A 62-year-old woman is evaluated in the hospital prior to discharge. She was admitted 4 da… — USMLE Step 3

A $62$ -year-old woman is evaluated in the hospital prior to discharge. She was admitted $4$ days ago for progressive dyspnea on exertion, orthopnea, and severe bilateral lower extremity edema. She was diuresed successfully with intravenous furosemide and her volume status is now optimized. Prior to this admission, her baseline functional status was consistent with New York Heart Association (NYHA) Class III symptoms. Echocardiography performed during this admission revealed a newly reduced left ventricular ejection fraction of $25\%$ (down from $55\%$ $2$ years ago).

Her past medical history is significant for severe, erosive rheumatoid arthritis and paroxysmal atrial fibrillation. Her home medications include methotrexate, infliximab, folic acid, apixaban, and losartan.

The medical team plans to discharge her on a guideline-directed medical therapy regimen for her newly diagnosed heart failure with reduced ejection fraction (HFrEF), which will include the initiation of sacubitril-valsartan, carvedilol, and dapagliflozin. Her current vital signs are blood pressure $110/70 \text{ mmHg}$ , heart rate $68/\text{min}$ , and oxygen saturation $96\%$ on room air. Laboratory studies today show a serum creatinine of $1.1 \text{ mg/dL}$ and serum potassium of $4.2 \text{ mEq/L}$ .

Which of the following monitoring and treatment evaluation steps are strictly indicated for this patient over the next several months? (Select all that apply)

Discontinue infliximab and coordinate transition to an alternative non-tumor necrosis factor (TNF) inhibitor therapyAnswer
Obtain a basic metabolic panel to assess serum potassium and creatinine $1$ to $2$ weeks after dischargeAnswer
C
Order a serum B-type natriuretic peptide (BNP) level at the $2$ -week follow-up to monitor therapeutic efficacy
D
Ensure a $36$ -hour washout period after the final dose of losartan before administering the first dose of sacubitril-valsartan
Schedule a repeat echocardiogram in $3$ to $6$ months to evaluate the indication for an implantable cardioverter-defibrillatorAnswer

Answer

The strictly indicated steps are to discontinue the TNF-alpha inhibitor (infliximab), obtain a basic metabolic panel in 1 to 2 weeks to monitor for hyperkalemia and renal dysfunction, and schedule a repeat echocardiogram in 3 to 6 months to evaluate the need for an ICD.

The correct options (discontinuing the TNF-alpha inhibitor, assessing electrolytes

1

2

weeks after starting the ARNI, and repeating the echocardiogram in

3

6

months) reflect guideline-concordant management for newly diagnosed heart failure with reduced ejection fraction (HFrEF). TNF-alpha inhibitors like infliximab can exacerbate heart failure and are contraindicated in patients with NYHA Class III/IV symptoms. Initiating an ARNI such as sacubitril-valsartan requires monitoring of serum potassium and creatinine within

1

2

weeks due to the risks of hyperkalemia and renal impairment. Finally, a repeat echocardiogram after

3

6

months of optimally titrated medical therapy is strictly indicated to evaluate for left ventricular reverse remodeling; if the ejection fraction remains

\leq 35\%

, an implantable cardioverter-defibrillator (ICD) is indicated for primary prevention.

Step-by-Step Solution

Analyze the patient's current rheumatologic regimen against her new diagnosis of severe heart failure with reduced ejection fraction.

Infliximab is identified as a TNF-alpha inhibitor.

TNF-alpha inhibitors are strictly contraindicated in NYHA Class III/IV heart failure due to an increased risk of exacerbation and mortality.

Determine the necessary laboratory monitoring for the newly prescribed sacubitril-valsartan regimen.

A basic metabolic panel (BMP) is required in 1 to 2 weeks.

Sacubitril-valsartan can cause hyperkalemia and renal impairment, necessitating early lab monitoring after initiation or up-titration.

Evaluate the transition protocol from the patient's home blood pressure medication to sacubitril-valsartan.

No washout period is required.

The patient is taking losartan (an ARB). The 36-hour washout period is exclusively required when transitioning from an ACE inhibitor, not an ARB, due to the dual inhibition of bradykinin breakdown.

Identify the appropriate long-term procedural monitoring for newly diagnosed severe HFrEF.

A repeat echocardiogram should be scheduled in 3 to 6 months.

To assess for left ventricular reverse remodeling and evaluate if an implantable cardioverter-defibrillator (ICD) is indicated for primary prevention of sudden cardiac death.

Key Concept

Management of newly diagnosed severe HFrEF requires coordinating multi-system pharmacotherapy, recognizing absolute contraindications (e.g., TNF-alpha inhibitors), and navigating specific ARNI transition and monitoring protocols.

Estimated Time:2m 30s

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