What is the best management approach for a patient with Heart Failure with Reduced Ejection Fraction (HFrEF) presenting with Shortness of Breath (SOB)?

Key Questions for Patients with HFrEF and Shortness of Breath

When evaluating patients with Heart Failure with Reduced Ejection Fraction (HFrEF) who present with shortness of breath (SOB), it is essential to ask targeted questions that assess both the severity of heart failure and potential precipitating factors for decompensation. 1

Questions About Symptoms and Functional Status

• Ask about the onset, duration, and progression of shortness of breath (new vs. chronic, gradual vs. sudden worsening) 1
• Inquire about orthopnea (number of pillows needed to sleep comfortably) and paroxysmal nocturnal dyspnea 1
• Assess for exercise tolerance and functional capacity (NYHA classification) - how far can they walk before becoming short of breath? 1
• Question about peripheral edema - location, extent, and whether it's worsening 1
• Ask about chest pain, palpitations, or syncope that may accompany the shortness of breath 1
• Inquire about fatigue, weakness, or decreased ability to perform daily activities 1

Questions About Potential Precipitating Factors

• Ask about medication adherence, which is a major cause of hospital admission 1
• Question about dietary sodium and fluid intake that may precipitate acute heart failure 1
• Inquire about alcohol consumption and use of illicit drugs (especially cocaine and methamphetamine) 1
• Ask about recent use of medications that can worsen heart failure (NSAIDs, COX-2 inhibitors, calcium channel blockers, thiazolidinediones, and over-the-counter decongestants like pseudoephedrine) 1
• Question about recent infections or other acute illnesses 1
• Ask about thyroid function and symptoms of hypo/hyperthyroidism 1

Questions About Current Treatment

• Review current heart failure medications and recent changes to dosages 1
• Ask about diuretic use, dosing schedule, and response (urine output, weight changes) 1
• Inquire about daily weight monitoring and any recent weight changes 2
• Ask about blood pressure readings at home, especially if the patient has symptomatic hypotension 1
• Question about orthostatic symptoms when standing (dizziness, lightheadedness) 1

Questions About Comorbidities

• Ask about symptoms of sleep-disordered breathing or obstructive sleep apnea 2
• Inquire about symptoms of coronary artery disease (angina) 1
• Question about atrial fibrillation symptoms (palpitations, irregular heartbeat) 1
• Ask about symptoms of chronic kidney disease 1
• Inquire about diabetes control 1

Questions About Self-Management

• Ask about exercise habits and participation in cardiac rehabilitation programs 1, 2
• Question about salt restriction practices and dietary habits 2
• Inquire about the patient's understanding of when to seek medical attention for worsening symptoms 1
• Ask about support systems at home and ability to adhere to treatment plans 1

Physical Examination Focus Points

• Measure vital signs, with special attention to orthostatic blood pressure changes 1
• Check daily weight and compare to baseline or dry weight 1
• Assess for jugular venous distention, peripheral edema, and pulmonary crackles 1
• Listen for S3 gallop, murmurs suggesting valvular disease 1, 3
• Evaluate for hepatomegaly or ascites suggesting right heart failure 1

Laboratory and Diagnostic Considerations

• Review recent laboratory values (electrolytes, BUN, creatinine) 1
• Consider checking natriuretic peptide levels (BNP or NT-proBNP) 4
• Evaluate for iron deficiency, which may require supplementation 5
• Consider ECG to assess for arrhythmias or ischemic changes 4

Common Pitfalls to Avoid

• Don't assume SOB is always due to HFrEF decompensation - consider pulmonary, renal, or other cardiac causes 1
• Avoid discontinuing guideline-directed medical therapy (GDMT) for asymptomatic or mildly symptomatic low blood pressure 1, 2
• Don't overlook medication non-adherence as a common cause of decompensation 1
• Avoid focusing solely on diuretic therapy without optimizing disease-modifying medications 6, 7
• Don't miss the opportunity to initiate or optimize quadruple therapy (ARNI/ACEi/ARB, beta-blocker, MRA, SGLT2 inhibitor) during evaluation 7, 5