The Appropriate Steps in Heart Failure Management With The CardioNerds, Dr. Randall Starling

CardioNerds correspondents Drs. Akiva Rosenzveig and Jenna Skowronski, along with expert faculty Dr. Randall Starling, Cleveland Clinic, tackle the following hypothetical case study pertaining to heart failure management.

Mrs. M is a 65-year-old woman with non-ischemic dilated cardiomyopathy (LVEF 40%) and moderate to severe mitral regurgitation (MR) presenting for outpatient follow-up. Despite improvement overall, she continues to experience dyspnea on exertion with two flights of stairs and occasional PND. She reports adherence with her medication regimen of sacubitril-valsartan 97-103mg twice daily, metoprolol succinate 200mg daily, spironolactone 25mg daily, empagliflozin 10mg daily, and furosemide 80mg daily. A transthoracic echocardiogram today shows an LVEF of 35%, an LVESD of 60 mm, severe MR with a regurgitant fraction of 60%, and an estimated right ventricular systolic pressure of 40 mmHg. Her EKG shows normal sinus rhythm at 65 bpm and a QRS complex width of 100 ms.

What is the most appropriate recommendation for management of her heart failure?

To answer the question, the group refers to  Sections 7.4 and 7.5 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.