Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX
Management plan for the 72-year-old woman with heart failure with preserved ejection fraction (HFpEF):
- Offer a loop diuretic to relieve symptoms of fluid overload, such as lower limb edema and exertional dyspnea, given the presence of congestive symptoms and signs of fluid retention.
- Continue the angiotensin-converting enzyme (ACE) inhibitor (lisinopril) to manage hypertension and potential renal protection, carefully monitoring renal function due to her estimated glomerular filtration rate (eGFR) of 35 mL/min/1.73 m2.
- Manage hypertension aggressively, as it is a major contributing factor to left ventricular hypertrophy and diastolic dysfunction, with amlodipine already prescribed; maintain careful blood pressure control.
- For type 2 diabetes mellitus (T2DM) with an HbA1c of 7.6%, continue metformin if tolerated and renal function permits; consider SGLT2 inhibitors if eGFR thresholds and licensing criteria are met to reduce heart failure hospitalizations and provide cardiovascular and renal benefits, though the eGFR of 35 mL/min/1.73 m2 suggests some SGLT2 inhibitors might still be usable.
- Arrange specialist referral for further assessment and ongoing management, particularly because of HFpEF diagnosis, elevated NT-proBNP, and diastolic dysfunction with E/e' ratio of 15, as symptomatic HFpEF requires specialist input if symptoms persist or worsen despite initial management.
- Develop a comprehensive care plan including education, symptom monitoring (e.g., worsening fatigue, dyspnea, or edema), and access to a specialist heart failure multidisciplinary team.
- Avoid long-term home oxygen therapy unless comorbidities such as COPD justify it.
- Regularly monitor renal function, electrolytes, and heart failure symptoms, adjusting medications according to tolerance and evolving clinical status.