The Elusive Target of Congestive Heart Failure Treatment: delaying the Inevitable

Abstract

The patient is 72-year-old Caucasian male with history of type-2 diabetes mellitus, coronary artery disease with drug eluting stent, and congestive heart failure with ejection fracture of 40% was admitted to hospital with shortness of breath at rest. The patient noticed swelling of the legs for 4 weeks despite salt restriction and diuretics. His medications include Humalog (75/25) 20 units QD, frusemide 40 mg BID, metolazone 2.5 mg QD, spironolactone 12.5 mg QD, carvedilol 12.5 mg BID, Ramipril 10 mg QD, atorvastatin 40 mg QD, clopidogrel 75 mg QD, and aspirin 81 mg QD. His blood pressure was 100/60 mmHg, pulse 102 beats/ min, The patient had marked jugular venous distention, crackles at the lung bases, an S3 gallop, positive hepato-jugular reflux, and pitting edema up to the knees. His laboratory investigation showed sodium of 134 mEq/L, potassium of 3.8 mEq/L, chloride 90 mEq/L, bicarbonate 28 mEq/L, blood urea nitrogen 46 mg/L, creatinine 1.8 mg/L, with an estimated GFR of <60 mL/minute, and glucose of 100 mg/L. His HgbA1C was 7%. His urinalysis was significant for 2+ proteinuria. EKG showed tachycardia with nonspecific St and T wave changes, His weight was 98 kg.