Skill Checkup: A 69‐Year‐Old Woman With Acutely Worsening Heart Failure

Marco Guazzi, MD, PhD


March 21, 2022

The Skill Checkup series provides a quick, case-style interactive quiz highlighting key guidelines- and evidence-based information to inform clinical practice.

A 69-year-old woman from Brussels, Belgium, was admitted to the hospital with acutely worsening heart failure (HF) requiring inotropic support (New York Heart Association [NYHA]) class 4). She was 5 ft 6 in, weight 145 lb (65.8 kg), BMI 23.4. Heart rate was 98 beats/min and regular, respiratory rate 18 breaths/min, blood pressure 100/50 mm Hg, temperature 98.1 °F.

An echocardiogram showed a left ventricular ejection fraction of 31%, a dilated left ventricle (68 mm), and moderate functional mitral regurgitation. No significant stenosis was seen on coronary angiography. Medical history included hyperlipidemia and idiopathic dilated cardiomyopathy. Once the patient's condition had stabilized, treatment for HF with reduced ejection fraction (HFrEF) was initiated, which consisted of sacubitril-valsartan 49 mg-51 mg, carvedilol 3.125 mg twice daily, spironolactone 25 mg/24 h, and furosemide 20 mg/24 h. Ambulatory uptitration of sacubitril-valsartan and carvedilol was limited because of symptomatic hypotension.

Initially, the HF improved to NYHA class II, but the patient later presented with symptomatic deterioration to NYHA class III-IV. One month after discharge, she remained in class III. She therefore continued with the medication prescribed at initial diagnosis. However, she had several episodes of worsening HF which were managed with furosemide but did not require admission.


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