Skill Checkup: A 69-Year-Old Woman With Worsening Heart Failure and Iron Deficiency

Marco Guazzi, MD, PhD, Patrick Rossignol, MD


July 12, 2023

The Skill Checkup series provides a quick, case-style interactive quiz, highlighting key guideline- 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) and iron deficiency, requiring inotropic support. She is 1.68 m (5 ft 6 in), weighs 65.8 kg (145 lb) and has a body mass index of 23.4 kg/m2. Heart rate was 98 beats/min and regular, respiratory rate was 24 breaths/min, blood pressure was 100/50 mm Hg and temperature was 36.7°C (98.1°F).

An echocardiogram showed a left ventricular ejection fraction (LVEF) of 31%, a dilated left ventricle of 68 mm and moderate functional mitral regurgitation. No significant stenosis was seen on coronary angiography. Medical history included hyperlipidaemia and idiopathic dilated cardiomyopathy and a moderate chronic kidney disease (estimated glomerular filtration rate, 58 ml/min/1.73 m2). Once the patient's condition had stabilised, 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, dapagliflozin 10 mg once daily and furosemide 20 mg/24 h. Ambulatory uptitration of sacubitril-valsartan and carvedilol was limited because of symptomatic hypotension. Spironolactone was eventually not uptitrated owing to the occurrence of hyperkalaemia 5.6 mmol/L after an attempt to get it uptitrated.

Initially, the HF improved but the patient later presented with symptomatic deterioration. One month after discharge, she is experiencing marked limitation in activity, where less than ordinary tasks cause her to have palpitations/dyspnoea and fatigue. She is comfortable at rest. She, therefore, continued with the medication prescribed at an initial diagnosis. However, she had several episodes of worsening HF, which were managed with furosemide but did not require admission.


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