HEART RESERVE Clinical Conversations
HFpEF in Women
Narration: Lisa Zahakos, RPA-C · authorized saved voice
Runtime: 38:47 at normal speed

[0:00] Opening

Her ejection fraction is sixty-three percent. She still cannot finish the walk she used to enjoy. A reassuring number has not explained what changed.

Welcome to HEART RESERVE Clinical Conversations. I’m Lisa Zahakos, a physician assistant and founder of HEART RESERVE.

In this episode, we’ll follow Renee with unexplained breathlessness, Angela with a treatment decision, and Teresa after a hospitalization. These are fictional teaching cases for clinicians.

You can listen straight through, or use the chapters to return to a case. I’ll ask you to consider a few decisions and then walk through the reasoning. The activity page has the objectives, references and online questions.

This episode focuses on heart failure with preserved ejection fraction. The syndrome requires more than a pumping percentage: symptoms or signs must be connected to objective cardiac evidence. Ejection fraction categories, trial entry criteria and product indications are related but are not interchangeable. Under the 2022 U S guideline and historical trial terminology, heart failure with preserved ejection fraction refers to a left ventricular ejection fraction of at least 50 percent; heart failure with mildly reduced ejection fraction refers to 41 to 49 percent. The 2026 European Society of Cardiology guideline instead uses reduced ejection fraction for values below 50 percent and preserved ejection fraction for values of at least 50 percent, removing the separate mildly reduced category. Identify the guideline framework. These naming changes do not alter completed trials or U S product-label boundaries. Several trials and the finerenone heart-failure indication include left ventricular ejection fraction of at least 40 percent. Always read the actual study or label boundary.

The women’s-health focus is a reason to ask a fuller history and examine care gaps. It is not a claim that every woman has the same phenotype or that a medicine works better simply because the patient is a woman. Pregnancy history, blood pressure, metabolic disease, kidney health, function and access belong in one clinical story.

[2:02] Renee · The pumping number is preserved. Her walking is not.

Let’s begin with Renee.

Renee used to walk the school track while her daughter practiced. Over six months she has begun stopping after one lap. The report says left ventricular ejection fraction 63 percent. She was told the result was reassuring. She wants to know why activity has become harder.

Presentation. Stable exertional dyspnea; no new chest pain, syncope or breathlessness at rest.

Context. body mass index 37 kilograms per square meter; hypertension; remote severe preeclampsia.

Available tests. left ventricular ejection fraction 63 percent; N T pro B N P 88 picograms per milliliter; full echo parameters not yet reviewed.

Clinical task. Keep the differential open and obtain the evidence needed to explain the symptom.

Begin with the change in her life.

Ask Renee to describe a usual day before and after the symptoms began. A comparison with her own baseline is more useful than asking only whether she can exercise. How far does she walk? Does she stop because of breathlessness, fatigue, chest discomfort, pain or fear of falling? Is the limitation reproducible? Has the pace of decline changed? Establish the timeline before interpreting any single result.

Then separate a stable outpatient problem from a potentially unstable one. New breathlessness at rest, chest pressure, syncope, severe hypoxemia or rapidly progressive symptoms require urgent assessment according to the presentation. The reassuring wording on an old echocardiogram must not override a new concerning symptom. Renee’s initial presentation is stable; that permits a structured evaluation, not a dismissal.

Ask about orthopnea, waking breathless, edema, weight change, palpitations, sleep-disordered breathing and exertional chest symptoms. Reconcile prescribed and nonprescribed medicines. Review blood pressure history, atrial fibrillation, kidney disease, diabetes, valve disease and previous cardiovascular testing. A description such as 'deconditioned' may eventually be reasonable, but it should not replace the assessment needed to support it.

What a preserved ejection fraction can, and cannot, tell you.

Ejection fraction is the proportion of end-diastolic ventricular volume ejected with a beat. It does not directly measure filling pressure, reserve during exercise or the total burden of a multisystem illness. A woman can have preserved left ventricular ejection fraction and still have a clinically important limitation in filling, vascular function or the response to exertion. Conversely, an ejection fraction of 63 percent is not evidence by itself that heart failure with preserved ejection fraction is present.

Read the entire echocardiogram in clinical context. Review chamber size, left atrial volume, wall thickness, tissue Doppler measurements, estimated filling-pressure indices, right-sided findings and valve assessment. Image quality and rhythm matter. A report of 'diastolic dysfunction' does not automatically establish symptomatic heart failure; an apparently normal resting study does not necessarily explain exertional symptoms.

Do not calculate a diagnostic score with missing inputs. Renee’s ejection fraction and N T pro B N P do not supply the information required for a complete H2FPEF or HFA-PEFF assessment. A score can organize uncertainty when used in the population and context for which it was designed. Its output should help decide the next step, not substitute for reasoning.

Here is the decision. Which information would most help determine whether Renee’s evaluation is on the right track?

Pause here if you would like a moment to think it through.

The best next step in this case is: Review the symptom trajectory, examination, full echo findings and competing causes.

These findings connect her functional change to a focused diagnostic plan.

Use biomarkers without letting them close the case.

Natriuretic peptides are useful, but obesity can lower their concentrations. An unflagged value is therefore less reassuring when the clinical question is heart failure with preserved ejection fraction in a woman with obesity and exertional symptoms. Other conditions, including atrial fibrillation and kidney dysfunction, can also alter interpretation. Use the actual value, units, assay and context rather than the laboratory flag alone.

A selected 2024 research cohort illustrates this problem. Among 78 volunteers with obesity and dyspnea, 65 percent were women. Forty qualified for invasive exercise testing; 24 were found to have heart failure with preserved ejection fraction. That is 60 percent of those tested and 31 percent of the full sample. Resting N T pro B N P and echocardiographic measures did not clearly separate the groups. These findings support a diagnostic concern; they are not a population prevalence estimate for all women with obesity.

For Renee, the practical response is to obtain the missing information and reconsider the competing explanations. It is not to diagnose heart failure with preserved ejection fraction from body mass index, start every heart failure medicine empirically, or reassure her solely because the laboratory result was not flagged.

Make the differential explicit.

heart failure with preserved ejection fraction is one explanation for breathlessness, not the only one. The first evaluation commonly includes a focused examination, ECG, appropriate laboratory testing and review of imaging. Testing should be selected to answer the clinical question: anemia, pulmonary disease, rhythm disturbance, ischemia, significant valve disease and other causes may need consideration. Obesity can coexist with each of these conditions.

Some disorders can resemble heart failure with preserved ejection fraction yet require a different diagnostic and treatment pathway. Clues to infiltrative cardiomyopathy, constrictive physiology or important valve disease should prompt directed evaluation. Do not label every thickened ventricle as ordinary hypertensive remodeling. Equally, do not send every patient with dyspnea for every advanced test; use the history and first-line findings to choose what will resolve the uncertainty.

Document both the leading hypothesis and the reason it remains uncertain. 'Possible heart failure with preserved ejection fraction; full echo and alternate causes under review' is more useful than a premature definitive diagnosis. That distinction also protects later treatment decisions from being based on a diagnosis that was never confirmed.

When resting data leave an intermediate probability.

The HFA-PEFF framework uses clinical assessment, echocardiographic and natriuretic-peptide evidence, functional testing when uncertainty remains, and a final search for the underlying cause. The H2FPEF approach estimates diagnostic likelihood from clinical and echocardiographic features. These tools answer related questions with different inputs; disagreement or an intermediate result is a reason to review the evidence, not average the scores.

In a symptomatic patient whose resting findings do not resolve the question, specialist assessment may lead to exercise echocardiography or invasive exercise hemodynamics. The choice depends on the remaining uncertainty, local expertise, feasibility and the patient’s circumstances. A normal resting pressure cannot necessarily answer what happens during the activity that produces symptoms.

Explain the purpose of the referral in the order: 'Persistent exertional dyspnea with obesity and hypertension, preserved ejection fraction, nondiagnostic resting assessment; please evaluate for heart failure with preserved ejection fraction and mimics.' Include the actual tests, symptom trajectory and question. This gives the receiving clinician a starting point and makes it easier to recognize whether the referral has answered the question.

Bring the history forward without overinterpreting it.

Renee remembers severe preeclampsia but has never been asked about it in a general medical visit. Record the condition and timing as part of her cardiovascular history. It may strengthen the prevention conversation, but it cannot establish the cause of her current dyspnea. Pregnancy complications are not interchangeable with a past diagnosis of peripartum cardiomyopathy, and neither should be inferred without evidence.

Ask what she understood from the earlier test: 'When you heard that the pumping percentage was normal, did you think that meant there could not be a heart problem?' Then correct the misunderstanding without creating unnecessary certainty: 'The pumping percentage is preserved. We still need to understand why activity has become harder. We are checking heart and nonheart causes.'

Close with a concrete plan: the next test or consultation, who tracks it, how she receives the result and which new symptoms change the urgency. If transportation or cost makes the planned test unrealistic, address that before ending the visit. The outcome of this encounter is an explained next step, not simply a referral entered in the chart.

Here is the decision. After reviewing the resting data, uncertainty remains. Which referral best communicates the clinical need?

Pause here if you would like a moment to think it through.

The best next step in this case is: Describe persistent exertional symptoms, available findings, alternatives and the question of exercise evaluation.

A focused referral makes the uncertainty and desired next decision clear.

The takeaway: Preserved ejection fraction and a low natriuretic peptide do not end the evaluation of persistent exertional symptoms. Confirm the syndrome, examine alternatives and track the next diagnostic step.

Before we move on, let’s apply that reasoning in more detail.

Test the reassurance: a worked diagnostic reveal.

Return to Renee after the complete resting evaluation. There is no major valve lesion, no clear anemia and no sustained tachyarrhythmia. A complete H F A peff assessment is intermediate. This does not turn a nondiagnostic study into a negative study. Her symptom occurs during exertion; a resting measurement may not reproduce the physiology causing it. The next question is which functional assessment can resolve the uncertainty and change management.

If specialist exercise echocardiography remains inconclusive or is not feasible, invasive exercise hemodynamics may be appropriate in a center with the required expertise. Explain what the additional test will answer, its burdens and the alternatives. Do not assume that everyone with obesity needs catheterization; persistent symptoms, the probability of disease and the consequences of the result drive the decision.

A 2025 study using selected outpatient diagnostic cohorts found that the usual N T pro B N P threshold of 125 picograms per milliliter had sensitivity of 82 percent when body mass index was below 35 and 67 percent when body mass index was at least 35. This supports caution about a low value in Renee. It does not establish a new universal threshold or a screening test for asymptomatic people. Atrial fibrillation and kidney dysfunction can raise concentrations, while obesity can lower them. A single laboratory flag cannot resolve those competing influences.

Before referral, state one sentence that states the clinical uncertainty and one that states the functional loss. Then attach the actual echo measurements, rhythm, biomarker value, blood pressure history and relevant testing. Ask the receiving team to report both the diagnostic conclusion and the next treatment or follow-up responsibility. A referral succeeds when its answer returns to the clinician and patient who need it.

[13:04] Angela · Relieving swelling is the beginning of the plan.

Now meet Angela. Her heart failure diagnosis has been confirmed.

Angela has confirmed heart failure with preserved ejection fraction. A diuretic helped her edema, but she still stops on the walk to her mailbox. She asks whether heart-failure medicines can help when she does not have diabetes.

Established diagnosis. heart failure with preserved ejection fraction confirmed after clinical and objective assessment; left ventricular ejection fraction 58 percent.

Current context. body mass index 35 kilograms per square meter; A one C 5.8 percent; no diabetes.

Safety starting point. E G F R 48 milliliters per minute per one point seven three square meters; potassium 4.6 milliequivalents per liter; review current volume status.

Patient goal. Walk to the mailbox with fewer stops; preserve strength and independence.

Match each treatment to the problem it is meant to solve.

Begin with current congestion, blood pressure, kidney function, rhythm, comorbidities, medication access and Angela’s goal. A drug that relieves fluid overload and a therapy that reduces future heart failure events may both have a role, but their purposes should be clear. Do not use improved edema as evidence that the overall risk has disappeared.

Contemporary heart failure with preserved ejection fraction care integrates heart failure-directed treatment with management of obesity, diabetes when present, hypertension, kidney disease, atrial fibrillation and coronary disease. The 2026 American College of Cardiology update incorporates newer evidence for S G L T 2 inhibitors, nonsteroidal mineralocorticoid receptor antagonists and incretin-based therapies within that broader approach. This is not a direction to give every agent to every patient in a fixed sequence.

Ask what Angela is already taking, what she has previously stopped and why. A medication list may contain an agent she never obtained or a dose she no longer uses. Explain the expected benefit in terms that match the evidence: symptoms, worsening heart failure events, hospitalization or another measured endpoint. Avoid promising an individual outcome from an average trial result.

S G L T 2 inhibition is not restricted to patients with diabetes.

In EMPEROR-Preserved, 5,988 participants with symptomatic heart failure and left ventricular ejection fraction above 40 percent received empagliflozin or placebo. The primary composite of cardiovascular death or heart failure hospitalization occurred in 13.8 percent versus 17.1 percent; the hazard ratio was 0.79 (95 percent confidence interval 0.69 to 0.90). The effect was largely driven by fewer heart failure hospitalizations and was observed with and without diabetes.

DELIVER tested dapagliflozin in 6,263 participants with left ventricular ejection fraction above 40 percent. Worsening heart failure or cardiovascular death occurred in 16.4 percent versus 19.5 percent, with a hazard ratio of 0.82 (95 percent confidence interval 0.73 to 0.92). The trials support heart failure treatment beyond glucose lowering. They do not show that one S G L T 2 inhibitor is superior to the other.

Angela’s absence of diabetes is therefore not a reason by itself to exclude an appropriate S G L T 2 inhibitor. Review the selected product’s heart failure indication, renal-use instructions, volume status, contraindications and access. Discuss genital infection symptoms, volume depletion and the possibility of ketoacidosis even without marked hyperglycemia. Provide individualized instructions for illness, fasting and procedures; empagliflozin’s label specifies withholding for at least three days before surgery or procedures associated with prolonged fasting, when possible.

Do not turn a monitoring conversation into a list the patient cannot use. Ask Angela which instruction she would follow if she were unable to eat or drink. Clarify whom she calls and when. Coordinate any diuretic adjustment with her volume assessment and the prescribing team rather than giving a universal instruction to reduce or stop it.

Here is the decision. Angela asks why a medicine commonly discussed for diabetes is being considered. Which answer is most accurate?

Pause here if you would like a moment to think it through.

The best next step in this case is: It is being considered for heart failure benefit; the evidence includes people without diabetes.

The indication and evidence should be explained in heart failure terms.

What the newer obesity trials actually establish.

STEP H F peff studied semaglutide 2.4 milligrams in 529 participants with obesity and heart failure with preserved ejection fraction without diabetes. At 52 weeks, the between-group improvement in Kansas City Cardiomyopathy Questionnaire clinical summary score was 7.8 points, and weight reduction was greater with semaglutide. The main lesson is improvement in symptoms, physical limitations and weight in the studied population. It was not a mortality trial.

SUMMIT studied tirzepatide in 731 participants with obesity and left ventricular ejection fraction of at least 50 percent. Cardiovascular death or worsening heart failure occurred in 9.9 percent versus 15.3 percent (hazard ratio 0.62, 95 percent confidence interval 0.41 to 0.95). Fewer worsening heart failure events drove the result; cardiovascular death alone was not shown to be reduced.

These trials ask different questions and cannot be used as a head-to-head ranking. Their effect sizes use different endpoints, populations and follow-up. Weight loss, symptom improvement and clinical event reduction should not be collapsed into a single claim that all incretin therapies do the same thing.

Current US product indications also matter. The reviewed Wegovy and Zepbound labels contain obesity-related indications; the reviewed Zepbound label also includes obstructive sleep apnea in adults with obesity. Neither should be described here as carrying a specific heart failure with preserved ejection fraction indication. A clinician may use a medicine for an approved obesity indication in a patient who also has heart failure with preserved ejection fraction, while discussing heart failure with preserved ejection fraction trial evidence accurately. Verify the current exact label at prescribing and at course release.

What belongs in an individualized obesity conversation.

Ask permission to discuss weight and the symptoms that matter to Angela. Her goal is not simply a lower number: she wants to reach the mailbox and manage her daily responsibilities. Discuss treatment options in the context of access, preferences, other conditions and the ability to sustain nutrition and function.

Review the selected agent’s contraindications, precautions and interactions. For semaglutide and tirzepatide, the relevant labeling includes the medullary thyroid carcinoma/multiple endocrine neoplasia type 2 contraindication and important gastrointestinal, gallbladder, pancreatitis and other precautions. This case is not a dose-escalation protocol. Use the product-specific prescribing information and the patient’s clinical context.

Ask whether nausea, food insecurity, dental problems or living alone interfere with intake. A registered dietitian can help individualize nutrition while protecting function. Do not assign a universal protein, fluid or sodium prescription from this vignette; heart failure symptoms, kidney disease and nutritional status can change what is appropriate. Adapt physical activity to stability, symptoms and ability, and revisit strength and daily function as weight changes.

At follow-up, ask what was obtained, what was tolerated and what changed. Include symptoms and a functional goal alongside weight, blood pressure and laboratory findings. A change in weight could reflect fluid, nutritional intake or intentional loss; interpreting it requires context.

Read mineralocorticoid receptor antagonist evidence without assuming a class effect.

Mineralocorticoid receptor antagonists are not interchangeable evidence packages. Spironolactone and eplerenone are steroidal mineralocorticoid receptor antagonists; finerenone is nonsteroidal. Receptor selectivity and pharmacologic properties differ, but a mechanistic difference does not establish comparative clinical superiority.

In TOPCAT, spironolactone did not significantly reduce the overall primary composite endpoint in the studied heart failure with preserved ejection fraction population. heart failure hospitalization was lower, and hyperkalemia was more frequent. Important regional differences complicate interpretation. Selected patients may still have reasons for a steroidal mineralocorticoid receptor antagonist, but the result should not be described as an unequivocally positive overall heart failure with preserved ejection fraction trial.

In FINEARTS H F, 6,001 participants with left ventricular ejection fraction of at least 40 percent were randomized to finerenone or placebo. The composite rate of total worsening heart failure events and cardiovascular death was lower with finerenone (rate ratio 0.84, 95 percent confidence interval 0.74 to 0.95). Cardiovascular death alone was not significantly reduced. Hyperkalemia was more frequent. Its current heart failure indication and monitoring requirements are addressed in Teresa’s case.

Do not compare TOPCAT and FINEARTS H F as though patients were randomized between spironolactone and finerenone. Do not stack two mineralocorticoid receptor antagonists without a specific specialist-directed reason and a careful safety review. The treatment decision should identify the indication, the evidence and the monitoring burden.

Separate a pooled analysis from a heart failure with preserved ejection fraction trial.

FINE-HEART pooled participant-level data from FIDELIO D K D, FIGARO D K D and FINEARTS H F. Its 18,991 participants span chronic kidney disease with type 2 diabetes and heart failure with mildly reduced or preserved ejection fraction. It is not a new head-to-head trial and is not a heart failure with preserved ejection fraction-only population. Its primary cardiovascular-death result did not reach statistical significance (hazard ratio 0.89, 95 percent confidence interval 0.78 to 1.01).

A 2026 sex analysis included 6,664 women, 35 percent of the pooled population. Women had a greater multimorbidity burden and were less likely to receive several commonly indicated CKM therapies at baseline. No evidence of treatment-effect heterogeneity by sex was found for the assessed finerenone outcomes. This supports attention to treatment access and equitable assessment; it does not establish a special female-only drug effect.

For Angela, close the treatment discussion by listing the clinical problem, the option chosen or deferred, the reason, the safety plan and her own goal. A defensible decision may include a reason not to use a therapy. Educational success is appropriate selection and follow-through, not the number of prescriptions or adoption of a particular brand.

Here is the decision. Angela reads that one trial improved symptoms and another reduced a composite event outcome. What should the clinician clarify?

Pause here if you would like a moment to think it through.

The best next step in this case is: Confirm each study’s population, endpoint and current product label before applying the result.

This avoids converting different evidence into an unsupported drug ranking.

The takeaway: Use heart failure evidence even without diabetes, distinguish symptom and event endpoints, and individualize obesity treatment. Compare each option with its own evidence and current label.

Before we move on, let’s apply that reasoning in more detail.

A treatment gap is a prompt to assess eligibility.

A US registry study published in 2025 examined 759,915 patients at 191 outpatient cardiovascular practices using records from July 2019 through June 2023. In the combined heart failure with mildly reduced ejection fraction/heart failure with preserved ejection fraction group, recorded S G L T 2-inhibitor prescribing reached 12.8 percent in the final quarter. Female sex was associated with lower prescribing across the overall heart failure cohort. This is a historical observational finding, not a current 2026 rate or proof that every untreated patient should receive a medicine.

Use the gap to improve the decision process: confirm the syndrome, assess clinical and product-specific eligibility, explain the expected benefit and limits, review safety and cost, and document the agreed plan. A balanced education program measures the quality of those decisions. It does not set a target for prescriptions of a particular product or assume that education alone removes insurance, laboratory or referral barriers.

For heart failure, empagliflozin and dapagliflozin are each given at 10 milligrams daily when appropriate, but their renal-use instructions are not identical. Dapagliflozin initiation is not recommended below an E G F R of 25 milliliters per minute per one point seven three square meters; empagliflozin heart failure studies enrolled patients down to 20 and did not enroll those below 20. Review the current complete label and clinical context rather than applying a single class cutoff. Assess volume status and correct depletion before initiation; the loop-diuretic plan may need adjustment.

Review genital symptoms, serious urinary symptoms, poor intake and the possibility of ketoacidosis without marked hyperglycemia. Both labels direct withholding for at least three days before surgery or procedures associated with prolonged fasting, when possible. Restarting requires clinical stability and resumed oral intake. Give the patient an actionable instruction and a contact route rather than an unexplained list of adverse effects.

Separate guidance, approval and the woman in front of you.

Evidence evolves after a course is written. The 2026 European Society of Cardiology guideline adds contemporary European recommendations across ejection fraction categories and discusses obesity therapies in symptomatic heart failure. US indication, dosing and safety decisions still require the current US product label and applicable US guidance. A guideline recommendation and a regulatory indication answer different questions.

In the STEP H F peff pooled sex analysis, health-status improvement with semaglutide was similar in women and men, despite greater weight reduction in women. A women-focused case therefore does not justify claiming a uniquely larger heart failure treatment effect in women. Explain the population studied and the outcome measured, and avoid turning a subgroup description into a superiority claim.

Build an individualized plan that also addresses blood pressure, atrial fibrillation when present, kidney health, sleep-disordered breathing, physical function, nutrition and access. Diuretics treat congestion; disease-modifying treatment and comorbidity management have distinct purposes. Neither weight loss nor relief of edema is a reason to stop asking whether the complete heart failure plan is appropriate.

[27:59] Teresa · The prescription is written. Who owns the next step?

For our last case, Teresa is going home with a changed treatment plan.

Teresa is home after a hospitalization for worsening heart failure. Her discharge list includes medication changes. A cardiology visit is planned, but she does not know who will review her next blood test.

Clinical context. Confirmed heart failure with preserved ejection fraction; left ventricular ejection fraction 55 percent; chronic kidney disease and type 2 diabetes.

At the stable follow-up. E G F R 42 milliliters per minute per one point seven three square meters; potassium 4.7 milliequivalents per liter.

Current task. Reconcile therapy and assess eligibility and safety before adding a mineralocorticoid receptor antagonist.

Coordination gap. Laboratory date and responsible result reviewer are not documented.

Reconstruct what is happening at home.

Ask Teresa to bring the medicines she is actually taking, or review them by a reliable remote method. Compare the hospital list, the outpatient record, pharmacy information when available and her account. Resolve duplicate therapies, stopped medicines that remain in the record and prescriptions that were never filled. Ask about supplements, salt substitutes and nonprescription agents as part of the safety review.

Do not interpret a missed dose as lack of interest without asking why. Cost, transportation, language, vision, manual dexterity and unclear instructions may all affect the plan. If the medicine is unaffordable, record the barrier and the action needed to address it. A plan that depends on a nonexistent supply is not an implemented treatment.

Review symptoms, volume status, blood pressure and the trajectory of kidney function. The decision to add treatment must consider stability and the existing regimen. This fictional stable follow-up is an opportunity to close the monitoring gap; it is not permission to initiate therapy in a patient with acute deterioration without reassessment.

Use the heart-failure label, not a remembered kidney schedule.

Finerenone’s current US labeling includes adults with heart failure and left ventricular ejection fraction of at least 40 percent. Baseline potassium and E G F R are required. Do not initiate when potassium is above 5.0 milliequivalents per liter; initiation below E G F R 25 milliliters per minute per one point seven three square meters is not recommended. Strong C Y P 3 A 4 inhibitors and adrenal insufficiency are contraindications. Review interactions and the entire regimen.

For the heart failure indication, starting and target doses depend on baseline E G F R, with subsequent decisions guided by potassium and kidney function. At Teresa’s stated baseline E G F R of 42, the label’s starting dose is 10 milligrams daily and target is 20 milligrams daily, subject to subsequent laboratory results and tolerability. Do not replace the heart failure dosing table with the chronic kidney disease-with-diabetes table.

The heart failure label calls for potassium and E G F R four weeks after initiation and four weeks after dose adjustment, then periodically. Clinical changes may require earlier assessment. Use the current label for exact hold, restart and adjustment rules. The course does not replace those tables or a clinician’s judgment.

Here is the decision. Teresa’s potassium is 4.7 and E G F R 42. After other eligibility and interaction checks, what completes a finerenone initiation plan?

Pause here if you would like a moment to think it through.

The best next step in this case is: Use the heart failure dosing instructions, arrange four-week potassium/E G F R testing, and name the reviewer and patient-contact process.

The dose, tests, owner and communication process belong together.

A laboratory order needs an owner.

'Repeat labs' is not a complete plan. Specify the tests, date, location and responsible reviewer. The reviewer needs a process for acting on abnormal values and contacting Teresa. The team also needs a way to detect a test that was not completed; a missing result is not a normal result.

For this case, the plan could read: 'Basic metabolic panel at four weeks after initiation, with potassium and E G F R review by the prescribing clinician; earlier clinical assessment if symptoms or intercurrent illness warrant. Nurse care coordinator checks completion and contacts the prescriber for missing or abnormal results. Results and instructions communicated to Teresa and documented.' The local team must assign real names and workable escalation thresholds.

Confirm that the testing site is reachable and the order can be used there. Give Teresa a short written summary of when to go and whom to call. With her permission, include a support person. If a dose changes, the laboratory date must change with it; otherwise the chart can appear complete while the relevant monitoring is missed.

Record that the result was reviewed and the patient informed. Sending a message into a portal that Teresa does not use may not complete the loop. Ask which contact method works for her and follow the organization’s privacy and communication policies.

Explain benefit and risk in the same conversation.

Teresa asks, 'Will this medicine keep me out of the hospital?' A useful answer respects both evidence and uncertainty: 'In a large trial, this treatment reduced the combined rate of worsening heart-failure events and cardiovascular death. It cannot promise that you will never need hospital care. We also need to watch potassium and kidney function.'

Use the relevant population and endpoint when explaining a result. FINEARTS H F included mildly reduced and preserved ejection fraction; it counted recurrent worsening-heart failure events as well as cardiovascular death. A rate ratio for total events is not an individual patient’s chance of avoiding every event. The trial’s lack of a significant cardiovascular-death result alone should not be hidden.

Ask Teresa to explain why the blood test matters. If she says it is only to see whether the drug is working, clarify the safety purpose. Hyperkalemia may not announce itself with a clear symptom. Monitoring is part of the treatment, even when she feels well.

Do not let the routine pathway absorb an emergency.

Now change the vignette. Teresa calls with new breathlessness at rest and chest pressure. This is a different decision from arranging the next routine blood test. Arrange emergency assessment; in the United States, severe or potentially life-threatening symptoms warrant calling 911. Do not ask her to wait for the scheduled visit or simply repeat an outpatient laboratory test.

For nonemergency worsening symptoms, the care plan should explain how to reach the clinical team and when same-day advice is needed. Any individualized weight or symptom action plan should be provided by the treating team. Do not invent a universal diuretic self-adjustment rule from this case.

Use teach-back while she is stable: 'If you develop chest pressure and cannot catch your breath at rest, what will you do?' Then ask whom she contacts for a nonemergency concern and when her next test and visit occur. Correct the plan in plain language rather than testing whether she can repeat clinical terminology.

Turn a handoff into a completed action.

A referral, order or discharge document is the start of a handoff. A completed handoff identifies the receiving clinician, the question to resolve, the current medicines and doses, recent results, pending tasks and the next contact. If no appointment is available, someone needs to address that gap rather than leaving an open-ended instruction to follow up.

Evidence from STRONG H F supports the value of structured, closely monitored care after acute heart failure, but the trial was not restricted to heart failure with preserved ejection fraction. Its exact titration approach should not be transplanted wholesale to every woman with preserved ejection fraction. The transferable lesson here is to design follow-up that actively checks treatment and safety.

For Teresa, the final note should make four things easy to find: what changed, what must be monitored, who will act and when she will hear from the team. At the next contact, confirm the test happened, the result was reviewed and the instruction reached her. The clinical outcome is not an order in the system; it is a patient who knows and can complete the next step.

Here is the decision. The four-week result is missing. Which response best closes the care gap?

Pause here if you would like a moment to think it through.

The best next step in this case is: Check whether testing occurred, resolve access barriers, arrange needed testing and ensure clinician review.

The team needs to track completion as well as interpret results.

The takeaway: Monitoring and coordination are treatment tasks. Pair every medication change with a test date, a responsible reviewer, a communication plan and clear symptom escalation.

Before we move on, let’s apply that reasoning in more detail.

A safety call that cannot wait for the next blood test.

Consider a separate development in Teresa’s story: after starting an S G L T 2 inhibitor she develops vomiting, poor intake, abdominal discomfort and breathlessness. Her home glucose is 146 milligrams per deciliter. This value does not rule out ketoacidosis associated with S G L T 2 treatment. Temporarily stop the medicine and arrange urgent clinical assessment for ketoacidosis, dehydration and other acute illness. Do not use a routine follow-up appointment or reassurance about the glucose value as the response.

For a stable finerenone heart failure candidate with E G F R 42 and potassium 4.7, the current label begins at 10 milligrams daily, after the remaining eligibility and interaction checks. The heart failure target associated with that baseline renal category is 20 milligrams daily, if the follow-up potassium, kidney function and full dose-adjustment instructions support titration. A target is not an instruction to start at the target. For baseline E G F R at least 60, the heart failure starting and target doses differ again.

Do not initiate finerenone with potassium above 5.0 milliequivalents per liter; initiation below E G F R 25 is not recommended. Check contraindications, including strong C Y P 3 A 4 inhibitors and adrenal insufficiency. Use the heart failure-specific table when laboratory values change. A newly prescribed interacting medicine, dehydration, falling blood pressure or an acute illness can make a previously appropriate plan unsafe and may require assessment before the scheduled four-week review.

Close the visit by asking Teresa to show how she will follow the plan: which medicine she is taking, when and where testing will occur, who will contact her, and which symptoms need immediate help. If a laboratory appointment or medication cannot be obtained, make the barrier visible to the responsible team. The plan is incomplete until it is feasible.

[38:19] Take it into practice

Before you go, bring the three cases back to one question: what will you do differently at the next visit?

Explain the symptom, use the endpoint the study actually measured, and give every monitoring plan an owner.

You’ll find the source references, transcript and clinical resources beside this episode. To record your answers and complete the learning activity, return to the activity page for the questions and brief evaluation.

This has been HEART RESERVE Clinical Conversations. I’m Lisa Zahakos. Thank you for listening.