Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 68-year-old man is evaluated at a follow-up appointment. He has a 7-year history of heart failure secondary to ischemic cardiomyopathy. Over the past 6 months, he has had three hospitalizations for exacerbations of his heart failure. He currently has exertional dyspnea while getting dressed, and his maximal activity level is limited to riding to the store with his wife but staying in the car. Medical history is significant for disseminated prostate cancer treated with androgen deprivation therapy. Medications are aspirin, lisinopril, carvedilol, furosemide, digoxin, spironolactone, rosuvastatin, and leuprolide. He is stable on his current medications.

On physical examination, blood pressure is 92/60 mm Hg and pulse rate is 80/min. There is no jugular venous distention. An S3 is heard on cardiac examination. The legs are cool to the touch; there is no edema.

Laboratory studies are significant for a serum sodium level of 132 mEq/L (132 mmol/L) and serum creatinine level of 1.8 mg/dL (159 µmol/L).

Which of the following is the most appropriate management?

A. Add metolazone
B. Cardiac transplantation evaluation
C. Evaluation for left ventricular assist device placement
D. Home inotropic therapy

MKSAP Answer and Critique

The correct answer is C. Evaluation for left ventricular assist device placement.

This patient should be evaluated for placement of a left ventricular assist device (LVAD). He has end-stage heart failure manifested by extreme limitations of activity, multiple hospitalizations, poor kidney function, diuretic dependence to maintain fluid balance, and hypotension. The two possible options for therapy in a patient with this degree of heart failure are placement of an LVAD and heart transplantation. Because of his diagnosis of disseminated prostate cancer, however, the patient is not a candidate for transplantation. LVADs are indicated either as a bridge to heart transplantation or as destination therapy in selected patients who are not candidates for transplantation. Newer LVAD devices are smaller and easier to maintain than earlier versions, making their long-term use as destination therapy possible. Although this patient might otherwise be a candidate for transplantation, his diagnosis of disseminated prostate cancer is an absolute contraindication because of the required long-term posttransplant immunosuppression. However, placement of an LVAD would be an appropriate consideration in this patient if he is expected to survive for longer than 1 year.

Other contraindications to cardiac transplantation include medical problems associated with a reduced life expectancy (rheumatologic disease, severe pulmonary disease, liver failure), fixed severe pulmonary hypertension, diabetes mellitus with end-organ manifestations, age greater than 65 to 70 years, severe peripheral arterial or cerebrovascular disease, and advanced kidney disease. Although several of these factors are also associated with poorer outcomes with LVAD use (such as advanced age and degree of comorbid disease), assist devices are a viable option for treatment in patients who are clearly not candidates for transplantation.

Metolazone inhibits sodium reabsorption in the distal tubule and may be particularly effective in inducing diuresis when used in combination with a loop diuretic in patients with volume overload who have not responded adequately to high doses of a loop diuretic. However, this patient does not have signs of volume overload (no jugular venous distention or edema) and therefore would not be expected to benefit from the addition of metolazone to his current regimen.

Home inotropic therapy is associated with a mortality rate of approximately 90% at 1 year and should be considered as a palliative care option only. Use of this therapy is associated with worsening heart failure, infection, and arrhythmias. In a patient who is a candidate for either LVAD or heart transplantation, this should not be considered as an alternative therapy. Occasionally, patients require supportive inotropic therapy until they receive a transplant. This should be managed by their transplant cardiologist.

Key Point

• Placement of a left ventricular assist device is an option for patients with end-stage heart failure who are not candidates for heart transplantation.

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