Heart Failure Case Study: Mr. Smith – Pathophysiology and Management

Case Presentation

Patient: Mr. Smith, 55M
History: Hypertension, type 2 diabetes, hyperlipidemia, smoker, social alcohol
Chief Complaint: Progressive dyspnea on exertion, now at rest

Physical Exam Findings

• BP 160/90, HR 110 irregular (atrial fibrillation), RR 24, T 37.5°C
• Sitting upright, accessory muscle use
• No JVD (atypical – may be due to AF, rapid rate)
• Bibasilar crackles (pulmonary edema)
• S3 gallop (LV systolic dysfunction)
• No peripheral edema (acute presentation)

Key Labs/Imaging

• BNP/NT-proBNP: markedly elevated (not shown but expected)
• Echo: LVEF 30% → HFrEF (heart failure with reduced ejection fraction)
• CXR: Cardiomegaly, vascular congestion
• Labs: Mild renal impairment (Cr 1.2, BUN 25), hyperglycemia (140), dyslipidemia

Pathophysiology

Chronic pressure/volume overload (HTN, DM) → LV remodeling → systolic dysfunction → ↓ CO → neurohormonal activation (RAAS, SNS) → fluid retention, vasoconstriction → further remodeling. AF exacerbates by losing atrial kick, tachycardia-induced cardiomyopathy.

Guideline-Directed Medical Therapy (GDMT)

1. ACEi/ARB/ARNI: Lisinopril → target sacubitril/valsartan (ARNI preferred if tolerated).
2. Beta-blocker: Metoprolol succinate or carvedilol – start low, titrate up.
3. MRA: Spironolactone/eplerenone (if K⁺, Cr allow).
4. SGLT2 inhibitor: Empagliflozin/dapagliflozin – now class 1 for HFrEF regardless of DM.
5. Diuretic: Furosemide for congestion; titrate to euvolemia.
6. Rate control AF: Beta-blocker ± digoxin.
7. Anticoagulation: CHA₂DS₂-VASc ≥2 → DOAC.

Lifestyle

• Smoking cessation (critical)
• Sodium <2g/day, fluid restriction if hyponatremic
• Cardiac rehab (improves functional capacity, QoL)
• Weight loss if obese

Prognosis

With optimal GDMT + device therapy (ICD/CRT if indicated), 5-year survival ~75%. Regular follow-up, medication titration, and comorbidity control are essential.