Should a 73-year-old female with shortness of breath (SOB) on exertion, pending echocardiogram referral, possible pericardial effusion on chest X-ray (CXR), and elevated B-type natriuretic peptide (BNP) be hospitalized despite the absence of distress, after initiation of Lasix (furosemide)?

From the Guidelines

This 73-year-old female patient should be hospitalized despite not being in acute distress, as the combination of shortness of breath on exertion, possible pericardial effusion on chest X-ray, and elevated B-type natriuretic peptide (BNP) suggests severe cardiac dysfunction requiring immediate inpatient management. The patient's symptoms and test results indicate a potential heart failure diagnosis, which should be primarily based on signs and symptoms derived from a thorough history and physical examination, as recommended by the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines 1.

The elevated BNP level is a key indicator of cardiac strain, and its measurement is recommended in patients being evaluated for dyspnea in which the contribution of heart failure is not known 1. Although the patient has been started on Lasix (furosemide), hospital admission is necessary for continuous cardiac monitoring, IV diuretic therapy with dose titration, daily assessment of fluid status, electrolyte monitoring, and expedited cardiac workup including the pending echocardiogram.

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, including adequacy of systemic perfusion, volume status, and contribution of precipitating factors and/or comorbidities 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 in which the contribution of heart failure is not known 1.
• Patients admitted with heart failure and with evidence of significant fluid overload should be treated with intravenous loop diuretics, with therapy beginning in the emergency department or outpatient clinic without delay 1.
• The effect of heart failure treatment should be monitored with careful measurement of fluid intake and output, vital signs, body weight, and clinical signs and symptoms of systemic perfusion and congestion 1.

Inpatient care enables prompt intervention for any deterioration, comprehensive evaluation of the underlying cardiac pathology, and initiation of appropriate heart failure therapy based on ejection fraction findings. Additionally, the possible pericardial effusion requires urgent echocardiographic assessment to rule out cardiac tamponade, which would necessitate immediate intervention. Outpatient management would be inadequate given these concerning findings despite the patient's current non-distressed appearance.

From the Research

Hospitalization Considerations

• The patient's symptoms, including shortness of breath (SOB) on exertion and possible pericardial effusion on chest X-ray (CXR), suggest acute decompensated heart failure, which is a leading cause of hospitalizations for elderly adults in the United States 2.
• Elevated B-type natriuretic peptide (BNP) levels also indicate heart failure, and this biomarker has been increasingly utilized in the setting of acute CHF since its approval in 2001 3.
• Despite the absence of distress, the patient's condition may warrant hospitalization to prevent rehospitalizations and improve survival, as acute heart failure is a major cause of urgent hospitalizations with high rates of death and rehospitalization after discharge 4.

Treatment and Management

• The initiation of Lasix (furosemide) is a common treatment for heart failure, but optimal management of patients with acute heart failure before discharge and in the early post-discharge phase is critical to prevent rehospitalizations and improve outcomes 4.
• Guideline-directed medical therapy, including the use of diuretics, ACE inhibitors, and beta-blockers, may improve both short- and long-term outcomes in patients with heart failure 2, 5.
• Early and intensive treatment for heart failure patients in the 'vulnerable phase' after hospitalization may be associated with lower rates of early readmission and mortality 6.

Risk Factors and Prognosis

• Delay of treatment initiation is associated with worse outcomes in heart failure patients, and time-to-treatment initiation is a modifiable risk factor 6.
• The patient's age and possible comorbid conditions may also affect their prognosis and treatment outcomes, highlighting the need for individualized care and management 2, 5.