What is the best course of treatment for a 60-year-old patient with elevated B-type Natriuretic Peptide (BNP) levels, bilateral pedal edema, and congestive heart failure (CHF) exacerbation?

Management of CHF Exacerbation with Elevated BNP and Bilateral Pedal Edema

The optimal treatment for this 60-year-old patient with CHF exacerbation, markedly elevated BNP (5649), and bilateral pedal edema should include immediate IV diuretic therapy followed by optimization of guideline-directed medical therapy (GDMT) including ARNI, beta-blockers, and mineralocorticoid receptor antagonists.

Initial Management

1. Acute Diuresis:

   • Administer IV loop diuretic (furosemide) to address volume overload
   • Dosing: If diuretic-naïve, start with 40mg IV; if on chronic diuretics, administer 1-2.5× their oral daily dose
   • Monitor urine output, daily weights, and fluid balance

2. Assess Hemodynamic Status:

   • Vital signs with particular attention to blood pressure
   • Oxygen saturation and need for supplemental oxygen
   • Signs of end-organ hypoperfusion

Diagnostic Evaluation

• The markedly elevated BNP (5649) confirms acute decompensated heart failure 1
• BNP >400 pg/mL is classified as "high" and indicates increased risk of adverse cardiac events 1
• Obtain echocardiography to assess:
  • Left ventricular ejection fraction (LVEF)
  • Chamber sizes
  • Valvular function
  • Diastolic function
  • Estimated filling pressures 2, 1

Optimization of Medical Therapy

For Heart Failure with Reduced Ejection Fraction (HFrEF):

1. First-line therapy:

   • ARNI (sacubitril/valsartan) is preferred first-line therapy for patients with HFrEF NYHA class II-III 1, 3
   • Start at low dose and titrate upward (24/26mg BID initially, target 97/103mg BID)
   • Do not administer within 36 hours of taking an ACE inhibitor 3

2. If ARNI contraindicated:

   • ACE inhibitor (e.g., lisinopril) or ARB if ACE inhibitor not tolerated 1

3. Additional therapies:

   • Beta-blocker (carvedilol, metoprolol succinate, or bisoprolol)
   • Mineralocorticoid receptor antagonist (spironolactone or eplerenone)
   • SGLT2 inhibitor (dapagliflozin or empagliflozin) 2, 1

For Heart Failure with Preserved Ejection Fraction (HFpEF):

1. Diuretics for symptom relief and volume management
2. Blood pressure control
3. Consider ARNI or spironolactone based on specific patient characteristics 2

Monitoring Response to Therapy

• Daily weights and vital signs
• Electrolytes and renal function within 1-2 weeks of starting therapy 1
• Follow-up BNP measurement in 1-2 months
  • A reduction >30% indicates good response 1
  • Patients whose BNP remains elevated (>250 pg/mL) despite treatment have significantly higher risk of readmission or death (72% at 6 months) 4
  • Patients whose BNP decreases to <250 pg/mL have better outcomes (12% event rate at 6 months) 4

Discharge Planning and Follow-up

• Ensure patient is euvolemic before discharge
• Schedule follow-up within 7-14 days
• Provide education on:
  • Daily weight monitoring
  • Sodium restriction (<2g/day)
  • Recognition of worsening heart failure symptoms
  • Medication adherence 1

Specialist Referral Considerations

Consider referral to heart failure specialist based on "I-NEED-HELP" criteria 2, 1:

• I: IV inotropes needed
• N: NYHA IIIB/IV or persistently elevated natriuretic peptides
• E: Ejection fraction ≤35%
• D: Defibrillator shocks
• H: Hospitalizations >1
• E: Edema despite escalating diuretics
• L: Low blood pressure, high heart rate
• P: Progressive intolerance or down-titration of GDMT

Prognostic Considerations

• Patients whose BNP levels increase during hospitalization have higher risk of death and readmission 5
• The combination of discharge BNP >360 pg/mL and a decrease <50% during hospitalization identifies the highest risk group (HR 5.97) 6
• Serial BNP measurements (admission, discharge, and follow-up) help identify patients at highest risk for poor outcomes 4