A 62-Year-Old Male With Dyspnea at Rest and Lower Extremity Edema
Nida Hamiduzzaman, Seth Politano
What is the differential diagnosis for dyspnea at rest?
Differential diagnosis for dyspnea at rest can be caused by heart disease, renal disease, lung disease, or hematologic abnormalities. One must consider acute ischemia or heart disease as a cause of such. Fluid retention from chronic kidney disease, interstitial lung disease, chronic obstructive pulmonary disease, anemia, or bone marrow suppression due to malignancy or chronic infection should be considered as well.
What additional laboratory test would you order at this point?
You should order a B-type natriuretic peptide (BNP).
What is the role of BNP?
Serum levels of BNP and N-terminal-pro B-type natriuretic peptide (NTproBNP) increases in response to an increase in ventricular volume and pressure overload. NTproBNP has a longer half-life in the serum than BNP. The plasma half-life of BNP is estimated to be about 20 minutes. Both BNP and NTproBNP are used to help distinguish acute dyspnea caused by heart failure from other non-heart failure causes. Most patients with heart failure have values above 400 pg/mL.
What diagnostic tests are needed for evaluation of heart failure?
• ECG is indicated in all patients with acute heart failure or risk factors for heart disease. Look for ventricular hypertrophy, active ischemia, or arrhythmias.
• Echocardiography can show ventricular size and function, wall function abnormalities, and reveal valvular function.
• Stress testing is used to determine functional capacity, exercise-induced arrhythmias, and ventricular function.
• Coronary angiography is indicated if ischemic heart disease is suspected as a cause of heart failure.
What are risk factors for heart failure in this patient?
Risk factors for heart failure in this case include hypertension, diabetes, dyslipidemia, and history of smoking cigarettes. Other risk factors for heart failure are use of cardiotoxic substances, such as alcohol and cocaine, thyroid disorders, tachycardia, valvular disease, and coronary artery disease (CAD). In obese patients, sleep apnea should be ruled out as it can cause hypertension, which can lead to heart failure. Treatment for risk factors reduces the risk for heart failure.

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