Cardiology

PCP submission

90-year-old male per home care RN, pt is having a lot of near-falls and low blood pressures but did not provide readings. BP in clinic today was 123/76 lying, 118/74 sitting, 104/64 standing. 

Echo 7/2020: EF 45-50%. Hypokinesia of the basal inferior wall(s). Mild AV regurg. Moderate MV regurg and calcification of the posterior leaflet. Mild TV regurg.

Echo 11/2017: EF 50% (up from 30-35% in 2015), grade 1 DD, mild MR, mild TR

Summary of last cardiology note (2 days ago) – Patient with worsening SOB on walking, when climbing stairs and at rest, which are relieved partially with bronchodilators and neb treatments. He denies CP, SOB, palpitations, dizziness, syncope, nausea, vomiting or abdominal pain, no PND, orthopnea, dysphagia, or leg claudication. He has gain 10 pounds. Effort tolerance is ½ block. ECG stable. 

Medication List: Advair, Albuterol, allopurinol, atorvastatin, carvedilol, colchicine, entresto, furosemide, mirtazapine, montelukast, tamsulosin

Given his age, comorbidities, and fall history, I would like to decrease some of his bp meds. Can you advise which med would be best to decrease and in general how you approach orthostatic hypotension picture with combined systolic-diastolic hf in older adults?

Specialist response

I would make the furosemide as needed for dyspnea/weight gain and keep the entresto and coreg at current dosing unless the BP continues to be at the low end causing issues. This would also help the most with his orthostatic issues if tolerated. If you need further adjustments, then probably cutting the entresto dosing to half would be reasonable. Thank you for using RubiconMD. Definitely let me know if I didn’t answer your question.