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The American College of Physicians (ACP) established its evidence-based clinical practice guidelines program in 1981. The ACP clinical practice guidelines and guidance statements follow a multistep development process that includes a systematic review of the evidence, deliberation of the evidence by the committee, summary recommendations, and evidence and recommendation grading.


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A 40-year-old woman with nonischemic cardiomyopathy is evaluated 1 week after discharge from the hospital. She was hospitalized for dehydration associated with nausea, vomiting, and diarrhea, and complicated by acute kidney injury (peak creatinine level, 3.5 mg/dL [309.4 μmol/L]; baseline, 1.0-1.2 mg/dL [88.4-106.1 μmol/L]). Her symptoms and kidney injury resolved with supportive care, including hydration and withholding some of her medications.

The patient was diagnosed with nonischemic cardiomyopathy 5 years ago with a biventricular implantable cardioverter-defibrillator placed 3 years ago. Medications prior to admission included carvedilol, lisinopril, spironolactone, and as-needed furosemide. She currently feels well with only mild fatigue and shortness of breath with moderate activity (for example, ascending two flights of stairs; New York Heart Association class II symptoms). She does not experience lightheadedness or syncope. Current medications are carvedilol 3.125 mg twice daily and lisinopril 2.5 mg once daily.

On physical examination, the patient is afebrile, blood pressure is 110/80 mm Hg, pulse rate is 66/min, and respiration rate is 16/min. BMI is 20. The jugular vein is normal at the clavicle at a 45-degree incline. Cardiac examination reveals regular rate and rhythm, no S3 or S4, and a grade 2/6 systolic murmur at the apex. The chest is clear bilaterally. There is no peripheral edema.

Echocardiogram obtained in the hospital 1 week ago showed stable ejection fraction at 30%, with mild mitral regurgitation.

Laboratory studies:

B-type natriuretic peptide

120 pg/mL

Creatinine

1.4 mg/dL (123.8 μmol/L)

Potassium

4.5 mEq/L (4.5 mmol/L)

Sodium

135 mEq/L (135 mmol/L)

Q.

Which of the following is the most appropriate change in her medical therapy?

The most appropriate treatment for this patient with mild (New York Heart Association [NYHA] class II) systolic heart failure would be to restart the patient's spironolactone in addition to her baseline therapy of a β-blocker and an ACE inhibitor. Aldosterone antagonists have shown a clear benefit in mortality when used in selected patients with systolic heart failure. The proposed mechanisms of benefit include blockade of the direct effect of aldosterone on the myocardium and the preservation of serum potassium levels that may decrease the risk of ventricular arrhythmias. However, the use of aldosterone antagonists may lead to a significant increase in hyperkalemia, particularly in patients treated with an ACE inhibitor or angiotensin receptor blocker. In this patient, withholding angiotensin antagonist therapy in the presence of acute kidney injury was appropriate because of the diuretic effect and increased risk for hyperkalemia associated with spironolactone. However, current guidelines on heart failure treatment by the American College of Cardiology and American Heart Association indicate that treatment with an aldosterone antagonist may be used in patients with NYHA class II to IV symptoms and an elevated serum creatinine with a serum potassium level less than 5.0 mEq/L (5.0 mmol/L). As this patient's clinical status has stabilized with serum potassium below this level, she would benefit from restarting this medication with careful monitoring of the serum potassium level.

Furosemide and other diuretics are used to control symptoms of congestion and fluid overload in the management of heart failure but do not improve significant clinical endpoints such as survival. In this case, the patient has no signs of fluid overload on examination (central venous pressure is normal and there is no peripheral edema) and B-type natriuretic peptide level is only mildly elevated, which may be related to its reduced clearance due to persistent mild renal insufficiency. Therefore, daily use of a loop diuretic is not indicated.

Hydralazine in combination with a nitrate has been shown to be effective in treating symptomatic patients with heart failure, particularly in black patients. However, it is generally recommended for use in patients who remain symptomatic on optimal therapy with an ACE inhibitor or an ARB, β-blocker, and diuretics, or in those intolerant of an ACE inhibitor or ARB. In this patient who is otherwise clinically stable, adding these medications would not be indicated.

Decreasing the carvedilol would be appropriate in response to side effects such as bradycardia or symptomatic hypotension, but this patient does not exhibit those symptoms. β-Blockers do not necessarily need to be discontinued in patients hospitalized with decompensated heart failure unless there is severe hemodynamic compromise (impending or overt cardiogenic shock).

Key Point

  • Patients with mild systolic heart failure (New York Heart Association class II), an elevated serum creatinine, and serum potassium less than 5.0 mEq/L (5.0 mmol/L) should have an aldosterone antagonist added to their standard baseline therapy of a β-blocker and an ACE inhibitor.
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