Management of Stage D Heart Failure

A 62 year old male with hypertension, hyperlipidemia, and ischemic cardiomyopathy with a left ventricular ejection fraction of 25% and a left ventricular end-diastolic dimension of 7 cm presented with 2 weeks of progressive weight gain, orthopnea, paroxysmal nocturnal dyspnea (PND), and dyspnea on exertion. Recent dose increase of outpatient diuretics did not provide relief of his symptoms. He was dyspneic with activities of daily living, had a poor appetite, and was frequently fatigued with occasional lightheadedness. He had no chest pain, palpitations or any other acute illnesses. He was adherent to medications, which included carvedilol, lisinopril, spironolactone, and torsemide. He underwent cardiac resynchronization therapy and defibrillator placement 2 years ago. This was his third admission to the hospital in the preceding 6 months.