Our patient's treatment

Our patient's treatment already includes triple therapy with an ARNI, a beta blocker and a diuretic. As a first step in enhancing his therapy, salt was rigidly restricted. He was advised that alcohol must be avoided. Changes in his medicines were addressed one drug at a time.

Our patient's diuretic was first increased to provide relief of his symptoms and signs of congestion. He had a ten-pound weight loss and felt better. His serum electrolytes remained normal. His ARNI was gradually increased to a full therapeutic dose. A beta blocker was added to his regimen after confirming that his volume status and blood pressure were stable. He was started at a low dose and titrated upward cautiously. He further improved with additional weight loss. His blood pressure was 90/60 mmHg with no symptoms of postural hypotension.

The goal of treatment is not determined by the patient's therapeutic response, but by pre-specified target dose or side effects. For instance, in the presence of recurrent dyspnea, diuretics should be adjusted rather than stopping beta blockers. On the other hand, if the clinical deterioration is due to hypoperfusion or requires positive inotropic intervention, beta blocker should be temporarily stopped.

Additional optimal heart failure therapy includes administration of a mineralocorticoid antagonist, such as spironolactone, for patients with NY Heart Association class II to IV heart failure. In appropriate patients, consideration may also be given to resynchronization therapy with biventricular pacing. All patients with left ventricular ejection fraction of less than 35% on optimal medical therapy for at least three months, should be advised of the mortality benefits of an intracardiac defibrillator.

Despite maximal medical therapy including the addition of spironolactone and the use of a biventricular pacemaker defibrillator, our patient's symptoms recurred and progressed, with the development of dyspnea at rest. Further in-hospital medical treatment was not successful.