Cardiology

PCP submission

55 y/o M with CHF, CKD and HTN coming for follow up after hospitalization on 1/4/2021 for SOB, DOE, respiratory failure.

Hospital records reviewed: 1/4/2022 HF with LVEF 40-50%. Prior to that his LVEF was 50-60% so he is deteriorating. This is the second time in 2 months that he has been hospitalized for similar problems. Had occasions where QT interval was prolonged. According to pt’s hospital discharge notes, he had elevated Kappa and Gamma light chain elevated electrophoresis study for which he was referred to Hematologist also advised 24 hrs Urine electrophoresis ( which is pending). 

During recent blood tests in the clinic, his serum proteins and CBC levels did not show anything – his WBCs was elevated 11.2 (repeat hospitalization and chronic comorbidities may be the cause). Labs also showed CKD stage 4. GFR 16 and creat 3.28, electrolyte levels were normal. Pt never been dialysed.

Is there anything else we can do while patient awaits to be seen by nephrologist and cardiologist?

Specialist response

Hi, thanks very much for your question. If this was my patient, there are a few things to consider especially given his new cardiomyopathy.

It is important he is on guideline medication therapy for the depressed EF so will outline those methods below first and then I will get into blood pressure control after. The medications I will suggest below should help with BP control. In patients with heart failure and depressed EF, carvedilol is the recommended guideline medical therapy as a beta blocker as it has the best mortality benefit in these patients, so I would consider titrate up the carvedilol to a maximum dose of 25 mg BID if this has not already been done. I would also consider switching his olmesartan to entresto. You can start entresto 24/26 mg BID and double the dose every 2 weeks until you reach the target dose of 97/103 mg BID. For diuretics he should be on aldactone. Finally, as you are probably already aware, it will be imperative to get him into see a cardiologist as soon as possible as they will want to continue to evaluate his EF over the next few months once he is started on aforementioned guideline therapy. If for any reason his EF continues to decrease and remains below 35%, despite optimal medical treatment, he will have to undergo evaluation for possible ICD placement. The timing of repeat ECHO and possible ICD evaluation in addition to continued management of his guideline medical therapy should be deferred to his cardiologist. In regards to blood pressure control I have a multimodal approach and will leave you with some of my approaches. As a first step I confirm the accuracy of blood pressure readings. I find home readings to be best. Formal 24-hr ambulatory monitoring can be considered in these scenarios, but generally I just have patients check their blood pressure 3-5 days a week and maintain a log. On days they check their blood pressure, I instruct them to do so in the morning before taking medications, and in the late afternoon before dinner. I have them collect two back to back measurements and I average them, this helps me to identify and exclude readings that may be obviously spurious.

Secondly and often alongside my first step I confirm that the patient does not have excess sodium intake in their diet from processed food, that they are not drinking excessive alcohol or coffee, and that they are not taking NSAIDs frequently. I have found that these are all not infrequent contributors to hypertension and there is good data in guidelines that screening for these contributors improve outcomes. (See: Carey et al. Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association. Hypertension. 2018;72(5):e53-90)

Third, I add additional anti-hypertensive agents. I am sure you are familiar with selection options and may have your own approach. In someone on a calcium channel blocker, I consider adding an ace inhibitor and diuretic as next potential steps, which I know he is already on and as suggested beforehand would consider switching the olmesartan to entresto which can be a strong anti hypertensive drug. Other thing to consider is the possibility of dialysis, as this can also help bring down elevated blood pressures and should be discussed with the nephrologist.

Fourth, if home blood pressure readings are still significantly elevated and there is no lifestyle factor that is clearly contributing, then I consider other diagnostic studies. Other than basic lab work, I check a TSH to ensure abnormal thyroid function is not contributing. There are 3 other considerations I have including, sleep apnea, primary aldosteronism, and renal artery stenosis. Hypertension guidelines generally agree sleep apnea is an important contributor and should be excluded in anyone with obesity, loud snoring, or daytime sleepiness. So I generally begin the secondary hypertension work up, when necessary, by screening for sleep apnea and testing if indicated. If sleep apnea is not present, I obtain a morning plasma aldosterone concentration (PAC) and plasma renin activity (PRA) to evaluate the aldo/renin (PAC/PRA) ratio which is usually greater than 20 in patients with primary hyperaldosteronism.

Lastly, in patients with known atherosclerotic disease such as coronary disease, I obtain a renal artery ultrasound earlier, but in the absence of known atherosclerotic disease, I obtain the other tests first, in the order I mentioned, and screen for renal artery stenosis afterwards if the other studies are negative. This approach is well supported by hypertension guidelines including the 2017 ACC/AHA joint recommendations. (See: Whelton et al. 2017 ACC/AHA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71:e13–e115).

In addition to the possibility of secondary hypertension above, a diagnosis of pseudo-resistant hypertension should be considered if and when high blood pressures persists despite the use of 3 anti-hypertensive agents. It is estimated that pseudo-resistant hypertension can be present in up to 50% of patients with uncontrolled blood pressure, and that it may be due to improper measurement, white coat effect, or poor medication compliance. (see: Klerman et al. Prevalence and characteristics of pseudohypertension in patients with resistant hypertension. J Am Soc Hypertens. 2013;7(6):467-70). I develop suspicion for pseudo-resistant hypertension especially when there are no signs of end organ damage despite a reported history of long-standing hypertension, such as no kidney disease and no abnormalities on ECG like left ventricular hypertrophy. You have asked some great questions. Heart failure patients can be complicated, so I applaud your investment in his care. Best of luck, thanks again for your question.