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Clinical Approach: 60F with Hypertension, Dyspnea (1 day) + Pedal Edema (1 week)

Provisional Diagnosis

• Known systemic hypertension (SHTN) - the single most common cause of HF in women
• Acute dyspnea (suggests raised LVEDP / pulmonary congestion)
• Pedal edema for 1 week (suggests systemic venous congestion / right-sided or biventricular failure)

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Differential Diagnoses

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History to Elicit

• Orthopnea (how many pillows?) and paroxysmal nocturnal dyspnea (PND) - hallmarks of LV failure
• Exertional dyspnea - NYHA functional class
• Chest pain or palpitations
• Prior cardiac history, previous echo findings

• Onset, progression, symmetry of edema
• Ascites, right upper quadrant discomfort (hepatomegaly from RV failure)

• Duration of hypertension, BP control, current antihypertensives
• Compliance with medications

• Diabetes mellitus, dyslipidemia, CAD, smoking
• Alcohol use (dilated cardiomyopathy)
• Thyroid disorders, anemia

• Fever, weight loss (infective/malignant cause)
• Recent illness, URTI (viral myocarditis trigger)

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Physical Examination

Vital Signs

• BP (both arms - expect elevated), HR, RR, SpO2, temperature

General

• Respiratory distress, tripod positioning, ability to speak in sentences

Cardiovascular

• JVP elevation (>3 cm above sternal angle) - key sign of elevated venous pressure
• Apex beat - displaced laterally/inferiorly (LV dilatation) or sustained/heaving (LVH)
• S3 gallop - sign of volume overload / systolic dysfunction
• S4 gallop - sign of diastolic dysfunction (very common in hypertensive HF)
• Murmurs (aortic stenosis, mitral regurgitation as contributing causes)

Respiratory

• Bilateral basal crepitations (pulmonary edema)
• Pleural effusion (dullness at bases, reduced breath sounds)

Abdomen

• Hepatomegaly, hepatojugular reflux
• Ascites (in severe RV failure)

Extremities

• Pitting pedal/ankle edema - grade and extent (ankle, leg, thigh)
• Peripheral perfusion - warm (high output) vs cold (low output - cardiogenic shock)

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Investigations

Immediate / Bedside

Bloods (Urgent)

Imaging

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Management

Immediate (Emergency Stabilization)

1. Position: Sit upright (reduces venous return, eases dyspnea)
2. Oxygen: Target SpO2 94-98%; consider NIV (BiPAP) if severe respiratory distress / pulmonary edema
3. IV Access + cardiac monitor + continuous SpO2
4. IV Furosemide (Loop diuretic - first-line for congestion):
   • 40-80 mg IV stat (if diuretic-naive); double usual oral dose if already on diuretics
   • Onset of action ~30 minutes IV; monitor urine output
5. BP Control: If severely hypertensive (e.g. SBP >180), use IV nitrates (GTN infusion) - reduces preload and afterload; avoid rapid drops
6. Morphine: Use cautiously (only if very distressed) - reduces sympathetic drive and anxiety; can cause respiratory depression

Acute Oral / Short-term

Long-term GDMT (Guideline-Directed Medical Therapy) - "Fantastic Four" for HFrEF

1. ACE inhibitor / ARB / ARNI (Sacubitril-Valsartan if tolerates, superior to ACEi alone in HFrEF)
2. Beta-blocker (Carvedilol, Bisoprolol, or Metoprolol succinate)
3. MRA (Spironolactone or Eplerenone)
4. SGLT2 inhibitor (Dapagliflozin or Empagliflozin - reduces HF hospitalization and CV death)

If HFpEF (preserved EF): management is primarily diuretics for symptom relief + aggressive BP control (<130/80 mmHg), + SGLT2 inhibitor (Dapagliflozin - now evidence-based for HFpEF too).

Blood Pressure Target

• Target BP <130/80 mmHg (ACC/AHA 2017 guidelines for HTN + HF)
• Avoid over-diuresis / hypotension which worsens renal perfusion

Monitoring

• Daily weight (flag if >1.5-2 kg increase over 2 days - adjust diuretic)
• Daily urine output
• Serum creatinine + electrolytes (K+) within 1-2 weeks of starting/escalating diuretic or ACEi
• Repeat echo at 3-6 months to assess LV remodeling response

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NYHA Classification (for prognosis and management stratification)

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Key Points Summary

• A 60-year-old hypertensive woman with dyspnea + pedal edema = heart failure until proven otherwise
• Distinguish HFpEF vs HFrEF with echocardiography - this guides long-term treatment
• BNP/NT-proBNP and echo are the most important investigations
• Acute management: sit up + oxygen + IV furosemide
• Look for and treat any precipitating factor (ACS, arrhythmia, infection, medication non-compliance, dietary indiscretion - high salt intake)
• Long-term: 4-drug GDMT (ACEi/ARNI + beta-blocker + MRA + SGLT2i) for HFrEF; aggressive BP control + diuretics + SGLT2i for HFpEF

Sources: Goldman-Cecil Medicine (9780323930345), Fuster and Hurst's The Heart 15th Ed. (9781264257560), Tintinalli's Emergency Medicine (9781260019933). Dosing tables from Goldman-Cecil Medicine, p. 3077-3083.