The high-risk patient with heart failure with reduced ejection fraction: treatment options and challenges.

CASE A 65-year-old man with a medical history including coronary artery disease, hypertension, and chronic obstructive pulmonary disease (COPD) presents to the emergency department with a 2-month history of worsening dyspnea on exertion and mild edema. He now has dyspnea with mild exertion but is asymptomatic at rest. His mental status is clear, with no apparent cognitive dysfunction. The patient does not have ongoing angina. He discussed these symptoms with his primary-care physician and was given oral furosemide, but he continued to gain weight with continued dyspnea. His systolic blood pressure is 115 mm Hg, with normal heart rate and oxygen saturation. He has elevated jugular venous pulsation to 15 cm without an audible murmur or gallop. He is mildly cool to the touch, with normal pulses in his distal extremities and mild pitting edema. Laboratory studies reveal a serum sodium level of 130 mmol/l, blood urea nitrogen of 40 mg/dl, and creatinine of 1.4 mg/dl, resulting in an estimated glomerular filtration rate of 53 ml/min/1.73 m 2 , N-terminal pro-brain natriuretic peptide (NT-pro-BNP) of 5,500 pg/ml, uric acid of 8 mg/dl, total cholesterol of 170 mg/dl, and hemoglobin of 12 g/dl. The electrocardiogram indicates normal sinus rhythm, with no evidence of previous myocardial infarction. The QRS duration is 160 ms, with a left bundle branch block pattern. The transthoracic echocardiogram reveals a moderately dilated left ventricle with an internal diastolic dimension of 6.5 cm and ejection fraction of 25%. There is global hypokinesis and moder ate mitral regurgitation. The right ventricle is mildly dilated and minimally hypokinetic. There is grade 1 to grade 2+ tricuspid regurgitation. The inferior vena cava is mildly dilated at 2.1 cm, indicating that there is some degree of vascular congestion. The echocardiogram is otherwise normal. IDENTIFICATION OF HIGH-RISK PATIENTS The first challenge when treating patients with heart failure is appropriately risk stratifying the individual patient, because risk of mortality can vary widely depending on patient characteristics. Despite striking advances in medical therapy, the overall mortality rate remains 50% at 5 years after the initial diagnosis of heart failure. Hospitalization for heart failure is associated with a very poor prognosis, with 30-day and 1-year mortality rates of 10 and 22%, respectively. When the highestrisk patients were followed in the Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) trial, which was designed to assess the potential benefit of first-generation left-ventricular (LV) assist devices (LVADs), the 1-year mortality rate was as high as 75%. 2 Multiple risk scores that assess mortality risk in inpatient or outpatient settings have been developed. Each scoring system has particular strengths and weaknesses. The Seattle Heart Failure Model is applicable to the broadest array of patients because the model was derived and then validated in six cohorts of outpatients with LV systolic failure and varying severity of illness. 3 This model has been widely used. The variables with independent predictive power include New York Heart Association class, ischemic etiology, diuretic dose, ejection fraction, blood pressure, hemoglobin concentration, percentage of lymphocytes, and levels of serum sodium, uric acid, and cholesterol. This model appears to provide improved predictive power as compared with the Heart Failure Survival Score. The Heart Failure Survival Score was designed to predict survival in ambulatory patients in 1987, before the routine use of many of the current medications considered standard of care. 4 In our patient, the Seattle Heart Failure Score describes his