From the Guidelines
The best next step for this patient is both a hemodynamic stress echo and a cardiopulmonary exercise test. This 69-year-old woman presents with progressive exertional dyspnea and occasional dyspnea at rest, with no pulmonary cause identified despite appropriate workup. Her medical history includes hypertension and chronic kidney disease, and she has an elevated BNP of 365, suggesting possible cardiac dysfunction, as indicated by the 2023 ACC expert consensus decision pathway on management of heart failure with preserved ejection fraction 1. The hemodynamic stress echo would evaluate cardiac function during exercise, potentially revealing valvular disease, diastolic dysfunction, or pulmonary hypertension that might not be apparent at rest. The cardiopulmonary exercise test would complement this by providing objective measurement of exercise capacity, oxygen consumption, ventilatory efficiency, and can help distinguish between cardiac and pulmonary causes of dyspnea.
Together, these tests provide comprehensive evaluation of her cardiopulmonary system during exertion, which is when her symptoms primarily occur. Her medication regimen (atenolol, furosemide, losartan, and spironolactone) suggests treatment for heart failure and hypertension, making cardiac evaluation particularly important, as recommended by the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. The combination of these tests will provide the most complete assessment to guide further management of her symptoms. Additionally, monitoring disease progression with CKD and HF biomarkers, such as natriuretic peptide, is crucial, as suggested by the 2024 DCRM 2.0 multispecialty practice recommendations for the management of diabetes, cardiorenal, and metabolic diseases 1.
Some key points to consider in the management of this patient include:
- The diagnosis of heart failure is primarily based on signs and symptoms derived from a thorough history and physical examination, as stated in the 2009 focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults 1.
- Concentrations of B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) should be measured in patients being evaluated for dyspnea, as recommended by the 2009 focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults 1.
- The 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure suggest that natriuretic peptides have high sensitivity, and normal levels in patients with suspected AHF make the diagnosis unlikely, with thresholds of BNP < 100 pg/mL and NT-proBNP < 300 pg/mL 1.
Overall, the combination of a hemodynamic stress echo and a cardiopulmonary exercise test is the best next step for this patient, as it will provide a comprehensive evaluation of her cardiopulmonary system and guide further management of her symptoms.
From the Research
Patient Presentation
The patient is a 69-year-old woman presenting with progressive exertional dyspnea and occasional dyspnea at rest. Her past medical history includes treated hypertension, migraines, and chronic kidney disease. She is a lifetime nonsmoker and engages in regular physical activity by walking her dog nightly.
Vital Signs and Medications
Her vital signs are:
- Height: 162.5 cm
- Weight: 66.6 kg
- Heart rate: 56 bpm
- Blood pressure: 124/60 mmHg She is currently taking:
- Atenolol 25 mg daily
- Furosemide 40 mg daily
- Losartan 100 mg daily
- Spironolactone 25 mg daily
Diagnostic Findings
A pulmonary evaluation completed one month prior to her consult, including high-resolution CT chest and PFTs, was normal, with no pulmonary cause identified for her symptoms. Her lab results show:
- Hemoglobin: 12.0
- WBC: 7.7
- Platelets: 213
- Sodium: 139
- Potassium: 4.1
- BUN: 33
- Creatinine: 1.57
- BNP: 365
Next Steps
Considering her symptoms and diagnostic findings, the next steps could involve further cardiac evaluation to determine the cause of her dyspnea. The options include:
- Hemodynamic stress echo
- Cardiopulmonary exercise test
- Cardiac Rehab
- Both Hemodynamic stress echo and Cardiopulmonary exercise test
Rationale
Studies such as 2, 3, 4, 5, and 6 support the use of stress echocardiography and cardiopulmonary exercise testing in the diagnosis and management of heart failure, including heart failure with preserved ejection fraction (HFpEF). These tests can help identify hemodynamic and metabolic abnormalities, assess cardiac structure and function, and provide valuable information for risk stratification and guiding treatment.
Key points to consider:
- The patient's elevated BNP level suggests possible heart failure, which warrants further investigation.
- The absence of pulmonary causes for her dyspnea points towards a cardiac origin.
- Both hemodynamic stress echo and cardiopulmonary exercise test can provide complementary information about cardiac function and reserve.
- Guideline-directed therapy initiated early in the course of heart failure can improve clinical outcomes, as suggested by 5.
Given the patient's presentation and the information provided by the studies, both hemodynamic stress echo and cardiopulmonary exercise test are reasonable next steps to further evaluate her condition and guide management.