60 yr old female known SHTN came with dyspnea for 1 day and pedal edema for 1 week

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Clinical Case Analysis: 60F with SHTN, Dyspnea (1 day) + Pedal Edema (1 week)

Most Likely Diagnosis

Acute Decompensated Heart Failure (ADHF) - most likely HFpEF (Heart Failure with Preserved Ejection Fraction) secondary to hypertensive heart disease.

The classic triad:

Known systemic hypertension - the primary underlying cause
Pedal edema for 1 week - gradual volume overload (backward failure)
Acute dyspnea for 1 day - acute decompensation with pulmonary congestion

This is the "Typical Hypertensive" ADHF phenotype - usually not volume overloaded as much as fluid redistributed, and elevated BP at presentation is the driver.

Pathophysiology

Chronic hypertension leads to:

Concentric LV hypertrophy - increased wall thickness, reduced compliance
Diastolic dysfunction - impaired LV relaxation and filling
HFpEF - elevated filling pressures despite preserved EF
Any precipitant (salt load, medication non-compliance, new arrhythmia) tips the patient into acute decompensation with pulmonary edema and peripheral fluid redistribution

History to Elicit

Cardiac symptoms:

Orthopnea (number of pillows), PND, bendopnea
Chest pain/palpitations (rule out ACS, AF as precipitant)
Previous similar episodes / prior HF diagnosis

Precipitating factors:

Medication non-adherence (antihypertensives, diuretics)
Dietary salt excess
Use of NSAIDs, thiazolidinediones, cold/flu preparations
Recent febrile illness or infection
Reduced urine output

Background:

Duration and control of hypertension
DM, CKD, CAD, valvular disease
Alcohol, smoking

Examination

Finding	Significance
BP (elevated or low?)	Hypertensive ADHF vs low-output state
HR, SpO2, RR	Hemodynamic severity
JVP elevated	Right-sided congestion
Basal crepitations	Pulmonary edema
S3 gallop	Ventricular dysfunction
Pitting pedal edema	Volume overload
Hepatomegaly	Congestion
Loud P2	Pulmonary hypertension

Investigations

Immediate:

ECG - LVH, arrhythmia (AF), ischemia
CXR - cardiomegaly, pulmonary venous congestion, Kerley B lines, pleural effusion
BNP / NT-proBNP - class I recommendation for diagnosis of acute HF; highly elevated in ADHF (BNP >100 pg/mL, NT-proBNP >300 pg/mL)
SpO2 / ABG - degree of hypoxia
CBC - anemia as precipitant
RFT (Creatinine, BUN, electrolytes) - cardiorenal syndrome (BUN >43 mg/dL and Cr >2.75 mg/dL are markers of worse prognosis)
LFT - hepatic congestion
Blood glucose, HbA1c - DM comorbidity
Troponin - rule out ACS as precipitant

Non-urgent:

Echocardiography - most important: assess EF (HFrEF vs HFpEF), LVH, diastolic dysfunction grading, valvular disease, wall motion abnormalities
Thyroid function (hyperthyroidism as precipitant)

Management

Phenotype Classification (This Patient)

Given known hypertension and this presentation, she most likely fits the "Hypertensive ADHF" phenotype (BP elevated, fluid redistribution rather than pure volume overload):

ADHF phenotypes and treatment approach - Harrison's Principles of Internal Medicine 22e

Step 1 - Immediate stabilization

Sit upright (reduces preload)
Supplemental O2 to maintain SpO2 ≥94%
Noninvasive ventilation (CPAP/BiPAP) if severe pulmonary edema / respiratory distress

Step 2 - Pharmacotherapy

Drug	Dose	Rationale
IV Furosemide	40 mg IV (or 1-2.5x oral dose)	First-line decongestant; bolus vs infusion - no clear difference in trials
IV Nitrates (GTN/nitroglycerine)	SL or IV infusion	Vasodilator of choice in hypertensive ADHF - reduces preload AND afterload, relieves dyspnea, lowers BP
IV Nitroprusside	If severe hypertensive emergency	More potent vasodilator for refractory hypertension

For diuretic resistance: add metolazone or chlorothiazide (sequential nephron blockade) - watch for hypokalemia
Avoid: ACEi/ARB/beta-blocker initiation during acute decompensation if hemodynamically unstable

Step 3 - Monitor response

Weight daily (surrogate for fluid status)
JVP, edema, pulmonary crackles normalization
Urine output >0.5 mL/kg/hr
Renal function (cardiorenal syndrome in ~30%)
Pre-discharge BNP/NT-proBNP - elevated level at discharge = high readmission risk

Step 4 - Address precipitants

Per Harrison's 22e, always identify and treat:

Medication non-adherence
Dietary indiscretion (salt)
Concurrent infection
AF or other arrhythmia
Myocardial ischemia (ECG, troponins, stress test)
Valvular disease (echo)

Discharge and Long-Term Management

Drug Class	Agent	Indication
ACE inhibitor/ARB/ARNi	Ramipril, Sacubitril-valsartan	BP control, neurohormonal blockade
Beta-blocker	Metoprolol, Carvedilol	After euvolemia achieved
MRA	Spironolactone	If HFrEF or HFpEF with persistent congestion
Loop diuretic	Oral furosemide/torsemide	Maintenance decongestion
SGLT2i	Empagliflozin/Dapagliflozin	Proven mortality benefit in both HFrEF and HFpEF

Salt restriction (<2g/day), fluid restriction, daily weight monitoring, and BP targets (<130/80 mmHg) are essential.

Differential Diagnoses to Consider

Diagnosis	Features distinguishing from HF
Pulmonary embolism	Sudden dyspnea, pleuritic pain, DVT, D-dimer, CTPA
Bilateral pleural effusion (non-cardiac)	Hepatic/renal cause; BNP normal
Pneumonia	Fever, cough, consolidation on CXR, WBC elevated
CKD with fluid overload	Uremic symptoms, frothy urine, very elevated creatinine
Hypertensive emergency with pulmonary edema	Severe HTN + organ damage

Key Prognostic Markers (ADHF)

Parameters associated with worse outcomes (Harrison's 22e):

BUN >43 mg/dL
Systolic BP <115 mmHg at presentation
Creatinine >2.75 mg/dL
Elevated troponins and natriuretic peptides
Residual congestion at discharge

The 30-day readmission rate for ADHF is nearly 25%, and 1-year combined CV events reach 50% - making thorough in-hospital management and post-discharge follow-up critical.

Sources: Harrison's Principles of Internal Medicine 22e; Brenner & Rector's The Kidney; Fuster & Hurst's The Heart, 15th Ed.

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