History
This 60-year-old man had coronary atherosclerosis, left bundle branch block (LBBB) with a QRS duration of 154 ms, peripheral vascular disease, and cardiomyopathy. He sought an opinion regarding management of his cardiomyopathy, which was diagnosed 10 years previously after he went to a local emergency department with chest tightness and shortness of breath. A coronary angiogram was performed that showed total occlusion of his right coronary artery, with no other significant coronary disease. His left ventricular ejection fraction (LVEF) at that time was 40%. He was managed medically, his symptoms improved markedly, and he returned to his baseline functional capacity. He was riding his bicycle regularly, working full time as a high school teacher, and doing heavy housework without difficulty. Approximately 2 years earlier, he noticed a decline in his exercise tolerance and developed intermittent dyspnea on exertion. His medical regimen was optimized, but he had no improvement in his symptoms. His LVEF was noted to have declined to 32%. A workup for ischemia was negative, and given his underlying LBBB and New York Heart Association (NYHA) class III symptoms, he was then referred for a biventricular pacemaker and treated with cardiac resynchronization therapy (CRT). Despite an optimal medical regimen and CRT, he had progressive dyspnea on exertion and worsening functional capacity. He reported development of lower extremity edema over the past 6 months and had frequent episodes of congestion. He required hospitalization five times in the previous 6 months for treatment of acute decompensated heart failure. His most recent two-dimensional echocardiogram revealed an LVEF of 29%, mild right ventricular dysfunction, and a moderately dilated left ventricle with mild mitral regurgitation. He has orthopnea that requires four pillows and frequently sleeps in a recliner. After his most recent hospitalization, he was enrolled in a home telemonitoring program, but did not experience improvement in his symptoms. He is obese and was recently diagnosed with sleep apnea, for which he uses continuous positive airway pressure at night.
Comments
The patient had chronic heart failure with progressive worsening in symptoms despite an optimized medical regimen. His volume status was difficult to manage over the past year, even with the addition of home telemonitoring. He should be counseled about the importance of sodium restriction, medication, and dietary compliance. Given his obesity, his volume status might be difficult to assess, and evaluation of his hemodynamics by right catheterization would be helpful in establishing his true volume status. He might require advanced therapies for heart failure in the near future, including heart transplantation or a left ventricular assist device, and consideration should be given for other novel therapies that might assist in symptom management. Controlling volume status will help delay disease progression.
Current Medications
The patient was taking carvedilol 25 mg twice daily, lisinopril 40 mg daily, torsemide 80 mg twice daily, metolazone 2.5 mg as needed for weight gain of more than 5 lb in 48 hours, spironolactone 25 mg daily, digoxin 0.125 mg daily, atorvastatin 20 mg daily, and aspirin 81 mg daily.
Current Symptoms
The patient reported orthopnea for the previous 2 weeks and noted chronic lower extremity edema over the past 6 to 7 months. He was unable to walk more than 20 feet without significant dyspnea.
Physical Examination
Comments
The patient’s body habitus limited the sensitivity of the examination. The combination of the presence of an S3 gallop, a murmur of tricuspid regurgitation, and lower extremity edema suggested he was volume overloaded and likely had a component of both left and right heart failure.
Laboratory Data
