Follow-up Note

Diagnosis

Arthur is a 68-year-old male diagnosed with HFrEF, T2DM, and essential HTN.

Arthur was last seen in the internal medicine clinic on September 12, 2024, following a hospital discharge on August 28, 2024, for an acute decompensated heart failure exacerbation. At that visit, Arthur was started on sacubitril/valsartan (Entresto®) 24/26 mg PO BID and bisoprolol 2.5 mg PO daily, alongside his home furosemide 40 mg PO daily and metformin 1,000 mg PO BID. An echocardiogram from August 26, 2024, demonstrated an LVEF of 35 % with mild global hypokinesis and no significant valvular disease.

Arthur presents today on October 24, 2024, for routine heart failure follow-up and medication titration. Arthur reports significant improvement in his exercise tolerance since the last visit and is now able to walk two blocks on level ground without SOB, placing him at NYHA Class II. He denies orthopnea, PND, chest pain, palpitations, or presyncope. We discussed his adherence to a 2 L daily fluid restriction and a low-sodium diet, which Arthur has been following strictly. Home weight logs show a stable dry weight around 82 kg, and home BP readings have averaged 128/76 mmHg without any symptomatic hypotension.

Physical Examination

Today at 10:15, BP is 124/74 mmHg, HR is 66 bpm and regular, RR is 14 breaths/min, temperature is 36.7 °C, SpO2 is 97 % on room air, and weight is 81.8 kg.

Arthur appears euvolemic and in NAD. JVP is flat at 2 cm above the sternal angle. Cardiovascular exam reveals a regular rate and rhythm, normal S1 and S2, and no S3, S4, or murmurs. Respiratory exam shows lungs are clear to auscultation bilaterally with no bibasilar crackles or wheezes. Abdomen is soft and non-tender, and the lower extremities show no pitting edema bilaterally with warm peripheral perfusion.

Blood work drawn on October 20, 2024, shows Na 139 mmol/L, K 4.4 mmol/L, Cr 98 µmol/L, and eGFR 68 mL/min/1.73m2, which remains stable compared to baseline. HbA1c is 7.1 %, and NT-proBNP has decreased to 450 pg/mL from 1,850 pg/mL during his August admission. A 12-lead ECG performed today shows normal sinus rhythm at 64 bpm with a known LBBB and no acute ischemic changes.

Arthur has compensated HFrEF, currently stable at NYHA Class II, responding well to guideline-directed medical therapy without signs of volume overload or renal impairment. His T2DM and HTN are well controlled on his current regimen.

Given his stable renal function, potassium, and blood pressure, we will up-titrate sacubitril/valsartan (Entresto®) to 49/51 mg PO BID and increase bisoprolol to 5 mg PO daily. We will also initiate dapagliflozin (Forxiga®) 10 mg PO daily to complete quadruple therapy for HFrEF and provide additional glycemic benefit, while continuing metformin 1,000 mg PO BID and furosemide 40 mg PO daily. Arthur will repeat a renal panel and electrolytes on November 07, 2024, to monitor for hyperkalemia or acute kidney injury following the medication adjustments. He is instructed to continue daily weight monitoring and will return to the clinic for a follow-up appointment in six weeks on December 05, 2024.

Arthur has been referred to the outpatient cardiac rehabilitation program at Toronto General Hospital and to a registered dietitian for ongoing heart failure and diabetic nutritional support.