• Understand when to refer HF patients for device therapy.
• Reduce morbidity by enrolling patients in HF disease management programs.

Terrence Shaneyfelt , MD
Associate Professor
Department of Medicine, Division of General Internal Medicine
University of Alabama School of Medicine
Birmingham, Alabama

The University of Alabama School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The University of Alabama School of Medicine designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The boards of nursing in many states, including Alabama, recognize Category 1 continuing medical education courses as acceptable activities for the renewal of license to practice nursing.

Heart failure (HF) is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. Medical therapies, such as angiotensin converting enzyme inhibitors, beta blockers, angiotensin II receptor blockers, and mineralocorticoid receptor antagonists have led to improvements in both symptom control and overall survival in patients with heart failure (HF) due to systolic dysfunction. Despite these advances morbidity and mortality rates remain high.

The first update in this two part series focused on standard HF therapies and the role of brain natriuretic peptide (BNP) measurement in the diagnosis and management of HF. This update will focus on more advanced topics of managing complications of HF.

A 65-year-old male with HF secondary to ischemic cardiomyopathy (LV ejection fraction 25%) returns to the office for follow-up. He reports feeling palpitations several days a week but has no other symptoms during these episodes. He is unsure how long they last. Baseline dyspnea with mild to moderate exertion is unchanged. He denies significant peripheral edema, PND or change in 2 pillow orthopnea. He is prescribed aspirin 81 mg daily, enalapril 20mg bid, furosemide 40 mg daily with sliding scale for weight gain of greater than 5 lbs, carvediolol 25 mg bid, and spironolactone 25mg daily. On physical exam, BP is 98/66 mm Hg, pulse is 55 bpm with occasional extrasystole, weight is 175 lbs (up one pound from last visit). Neck exam reveals no elevation in jugular venous pulsations; lung exam is clear bilaterally; cardiac auscultation reveals a regular bradycardic rhythm without murmurs or S3, an S4 is present at the apex; extremities have trace edema. Labs show normal renal function and electrolytes. An ECG in the office shows sinus bradycardia with occasional ventricular premature beats (VPBs) and previously noted Q waves in I, aVL, V4-6.

You obtain a 24-hour Holter monitor which shows the predominant rhythm to be sinus bradycardia. There are frequent VPBs along with several episodes of nonsustained ventricular tachycardia (NSVT). The patient experienced palpitations during most of these episodes and had one episode of lightheadedness.