Longstanding DM, insulin and new finding of HF
Lucy is a 48-year-old woman with 18 years of type 2 diabetes. She had gestational diabetes with each of her pregnancies, but with her third pregnancy the diabetes never went away. She took metformin for a long time, but then later medications were added, including glimepiride. In the last two years, she has taken insulin glargine (U100) 48 units daily. She reports that she had achieved target glycemic management early on but has had a harder time for the last 10 years.
In the last month, she has noticed increased swelling in both of her legs (no trauma or inciting event) and has gained 11 pounds without a clear change in diet. She thought this must be her thyroid as she was also feeling more tired than normal. However, her CBC and thyroid function were normal. A depression screen was normal.
Past Medical History: Type 2 diabetes diagnosed in 2001, hyperlipidemia diagnosed in 2001, hypertension diagnosed in 1998, nonalcoholic fatty liver disease 2008,
Medications: Enalapril/hydrochlorothizide 10/25 mg once daily, simvastatin 40 mg daily, ASA 81 mg daily, metformin 1000 mg bid, glimepiride 4 mg bid, U100 glargine 48 units once daily. No supplements.
Social History: Works in an accountant’s office. Has commercial insurance. She is married and has three children with a grandchild on the way. No tobacco or alcohol. No time for exercise. Has tried to lose weight by dieting in the past and failed. Her spouse complained she wasn’t eating enough.
Exam: BMI 31.5, BP 110/62, P 105, R 18, Pain 0/10
Vessels: JVP is elevated to 15cm
Heart: RRR, +S3, PMI widened and laterally displaced
Resp: Faint bibasilar inspiratory crackles
Extremities: 2+ edema to the mid-calf bilaterally, chronic venous stasis skin changes; normal monofilament exam, no lesions or ulcers on her feet
eGFR = 66 ml/min
HbA1c = 8.6%
Lipids: total cholesterol 206, HDL-C 28, TG 220, LDL-C 134 mg/dL
Urine albumin/creatinine ratio: 22mg/g
BNP: 5000 pg/ml
Echo: HFrEF. Moderate left ventricular enlargement, left ventricular ejection fraction 34%, mild right ventricular enlargement with mild dysfunction, moderate mitral regurgitation, mild tricuspid regurgitation
You diagnose her with heart failure with reduced ejection fraction.