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Internal Medicine

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Clinical Science

Abstract

Background: Heart failure (HF) is a significant health concern, resulting in more than 500,000 new cases, 1.9 million hospitalizations, and a cost of $31 billion in the US. HF treatment aims to decrease hospitalizations, improve quality of life, and extend survival through GDMT. Social determinants of health (SoDH) have been associated with poor outcomes and higher readmission rates in HF patients. Addressing SoDH is crucial for achieving health equity and improving overall population health outcomes, per the CMS Framework for Health Equity 2022-2023. In the Rio Grande Valley, immigration is a common SoDH. It is estimated that 100,000 people are undocumented, 81% uninsured. We now present a case that exemplifies the importance of addressing SoDH to improve HF outcomes and resource utilization in US healthcare.

Case: A 76-year-old former anesthesiologist from Mexico, undocumented and uninsured, presented to our ED with a complaint of worsening dyspnea. He endorsed orthopnea, PND, and bilateral LE edema. He had been admitted multiple times for the same reason. Chronic medical problems included ESRD on intermittent hemodialysis, HFrEF (EF of 25%), LFLG severe AS (AV gradient 24 mmHg, AVA 0.73 cm2, peak velocity 3.3 m/s), and chronic AF. Medications included metoprolol succinate, apixaban, bumetanide, sitagliptin, and insulin. Physical examination revealed increased JVD, bilateral crackles, S3, and bilateral LE pitting edema. POCUS of the lungs revealed bilateral B-lines across all lung fields. Patient was managed with hemofiltration. LifeVest was not recommended due to inability to follow through on a complex medical regimen. Sacubitril- valsartan was not recommended due to his LFLG severe AS and ESRD. He failed a previous AVR attempt. Recommendations were to continue fluid removal and beta-blocker as tolerated.

Conclusion: Our case highlights the challenges of limited healthcare access in our area due to psychosocial factors. Our patient met the criteria for GDMT for HF, however, he was not a candidate due to ESRD. Fluid management was complex due to LFLG severe AS. AVR pursued in another institution was unsuccessful. Renal transplantation was not feasible due to his social status. The complexity of this case lies within the patient’s medical diagnoses, limited management options, and psychosocial situation leading to suboptimal disease management and increased hospitalization risk. These psychosocial factors compounded the burden of managing his HFrEF, leading to decreased self-care motivation and poorer treatment adherence and care continuity. What is the right management for a patient with all odds against?

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Navigating Economic Constraints In The Management Of HFrEF - A Case Study of an Uninsured Patient

Background: Heart failure (HF) is a significant health concern, resulting in more than 500,000 new cases, 1.9 million hospitalizations, and a cost of $31 billion in the US. HF treatment aims to decrease hospitalizations, improve quality of life, and extend survival through GDMT. Social determinants of health (SoDH) have been associated with poor outcomes and higher readmission rates in HF patients. Addressing SoDH is crucial for achieving health equity and improving overall population health outcomes, per the CMS Framework for Health Equity 2022-2023. In the Rio Grande Valley, immigration is a common SoDH. It is estimated that 100,000 people are undocumented, 81% uninsured. We now present a case that exemplifies the importance of addressing SoDH to improve HF outcomes and resource utilization in US healthcare.

Case: A 76-year-old former anesthesiologist from Mexico, undocumented and uninsured, presented to our ED with a complaint of worsening dyspnea. He endorsed orthopnea, PND, and bilateral LE edema. He had been admitted multiple times for the same reason. Chronic medical problems included ESRD on intermittent hemodialysis, HFrEF (EF of 25%), LFLG severe AS (AV gradient 24 mmHg, AVA 0.73 cm2, peak velocity 3.3 m/s), and chronic AF. Medications included metoprolol succinate, apixaban, bumetanide, sitagliptin, and insulin. Physical examination revealed increased JVD, bilateral crackles, S3, and bilateral LE pitting edema. POCUS of the lungs revealed bilateral B-lines across all lung fields. Patient was managed with hemofiltration. LifeVest was not recommended due to inability to follow through on a complex medical regimen. Sacubitril- valsartan was not recommended due to his LFLG severe AS and ESRD. He failed a previous AVR attempt. Recommendations were to continue fluid removal and beta-blocker as tolerated.

Conclusion: Our case highlights the challenges of limited healthcare access in our area due to psychosocial factors. Our patient met the criteria for GDMT for HF, however, he was not a candidate due to ESRD. Fluid management was complex due to LFLG severe AS. AVR pursued in another institution was unsuccessful. Renal transplantation was not feasible due to his social status. The complexity of this case lies within the patient’s medical diagnoses, limited management options, and psychosocial situation leading to suboptimal disease management and increased hospitalization risk. These psychosocial factors compounded the burden of managing his HFrEF, leading to decreased self-care motivation and poorer treatment adherence and care continuity. What is the right management for a patient with all odds against?

 

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