When the Heart Runs Out of Heartbeats

Abstract

A 50-year-old man was referred to the Advanced Heart Failure clinic at our institution for consideration of additional treatment options. He was diagnosed with heart failure (HF) 4 years earlier. Transthoracic echocardiography revealed a dilated left ventricle (LV) with an LV end-diastolic dimension of 5.5 cm, globally depressed ejection fraction (EF; estimated at 30%), and moderate mitral regurgitation. Complete blood cell count, urinalysis, and liver function tests were normal. Screening for hemochromatosis, human immunodeficiency virus, rheumatologic disease, and amyloidosis was performed and was negative. He did not have a family history of cardiomyopathy or sudden cardiac death. Coronary angiography revealed no evidence of obstructive coronary artery disease. Right heart catheterization demonstrated a right atrial pressure of 15 mm Hg, pulmonary artery pressure of 41/21 mm Hg, pulmonary capillary wedge pressure of 20 mm Hg, and cardiac index of 2.3 L ⅐ min ؊1 ⅐ m ؊2 . He was started on evidence-based therapies for HF. An implantable cardioverter-defibrillator was placed for primary prevention of sudden cardiac death after no improvement in his EF. He was not considered a candidate for cardiac resynchronization therapy because his QRS duration was 100 milliseconds. He had progressive HF symptoms despite maximal medical therapy and was hospitalized 3 times during the 6 months before referral for acute decompensated HF. The doses of angiotensin-converting enzyme inhibitor and ␤-blocker had been recently reduced by his cardiologist secondary to lightheadedness and fatigue accompanied by hypotension. His medical history was remarkable for hypertension and dyslipidemia. He reported adherence to his prescribed medications that included carvedilol 6.25 mg twice daily, lisinopril 5 mg daily, spironolactone 25 mg daily, and furosemide 40 mg daily.Dr Rogers: It is timely to refer this patient for advanced HF therapies because these therapies improve functional status and long-term prognosis of patients with refractory HF. 1 Referral is appropriate not only for potential heart transplantation or mechanical circulatory support (MCS) but also for medical management of persistent functional class III and IV symptoms. 2 The clinical history suggests that this patient has an idiopathic nonischemic cardiomyopathy with persistent symptomatic HF. He has been treated with angiotensinconverting enzyme inhibitors and ␤-blockers, therapies that form the cornerstone of treatment to delay or halt the progression of cardiac dysfunction and improve mortality. Aldosterone antagonists are also recommended for patients with New York Heart Association class III to IV HF secondary to reduced LVEF (Ͻ35%). Diuretic therapy, although not associated with improvement in outcomes, is recommended to restore and maintain normal volume status. 3 In this case, the history of frequent hospitalizations and reductions in neurohormonal antagonists doses for hypotension are markers of poor prognosis and suggest that the illness is progressing despite opt...

Role of Biomarkers for the Prevention, Assessment, and Management of Heart Failure: A Scientific Statement From the American Heart Association

“…Similarly, at time of dis-charge, risk assessment can identify patients who may derive the greatest benefit from palliative care services, referral for consideration of advanced HF therapies, or enrollment in disease management programs. 153 Thus, biomarker-guided prognostication may aid resource allocation.…”

Neurohormonal Blockade and Clinical Outcomes in Patients With Heart Failure Supported by Left Ventricular Assist Devices

“…P atients with stage D heart failure (HF) have limited life-prolonging therapeutic options other than left ventricular assist devices (LVADs) and cardiac transplant. 1 As few patients can undergo transplant and outcomes with mechanical circulatory support have greatly improved, the population of patients with durable LVADs is increasing. 2 However, data on the use of pharmacotherapy beyond the use of anticoagulation to prevent thrombotic events are limited.…”

Definition and Classification of Heart Failure

“…Physical examination, laboratory testing, multimodality imaging, and cardiopulmonary exercise testing are pivotal for the definition of refractory heart failure. These patients commonly have rapid clinical deterioration and may require inotropic agents to augment cardiac performance [34,35].…”