What is the appropriate diagnostic workup and treatment for a patient with newly diagnosed heart failure, presenting with hypertension, bilateral edema, and swelling?

Inpatient Workup and Management for Newly Diagnosed Heart Failure

For this 45-year-old woman with newly diagnosed heart failure, bilateral edema, and hypertension, you should immediately obtain a comprehensive laboratory panel, 12-lead ECG, chest X-ray, and echocardiogram with Doppler, while initiating diuretic therapy for volume overload and assessing for underlying coronary artery disease. 1

Immediate Clinical Assessment

Physical Examination Priorities:

• Assess volume status systematically: Check for jugular venous distension, hepatojugular reflux, peripheral edema (bilateral lower extremities and sacral), pulmonary rales, and third heart sound (S3 gallop) 1
• Measure orthostatic blood pressure changes to evaluate volume status and guide diuretic therapy 1
• Document weight, height, and calculate BMI as baseline for monitoring response to therapy 1
• Evaluate functional capacity: Assess her ability to perform activities of daily living and quantify dyspnea severity 1
• Obtain detailed substance use history: Specifically ask about alcohol consumption, illicit drug use (especially cocaine or methamphetamines), chemotherapy exposure, and alternative therapies that may be cardiotoxic 1

Essential Diagnostic Testing

Laboratory Workup (Order Immediately): 1

• Complete blood count (to exclude anemia as contributing factor)
• Comprehensive metabolic panel including serum electrolytes (sodium, potassium, calcium, magnesium)
• Blood urea nitrogen and serum creatinine with estimated GFR
• Fasting blood glucose and hemoglobin A1c
• Lipid profile
• Liver function tests (AST, ALT, bilirubin, albumin)
• Thyroid-stimulating hormone
• Urinalysis
• BNP or NT-proBNP if diagnosis remains uncertain after initial evaluation, though with clear bilateral edema and hypertension, this may be confirmatory rather than diagnostic 1, 2

Cardiac Imaging and Testing (Perform Within 24 Hours):

• 12-lead ECG: Essential to assess for arrhythmias (especially atrial fibrillation), conduction abnormalities, left ventricular hypertrophy, or evidence of prior myocardial infarction 1. A completely normal ECG makes heart failure unlikely (<10% probability), but abnormalities are common and support the diagnosis 1, 3

• Chest X-ray (PA and lateral views): Look for cardiomegaly, pulmonary venous congestion, interstitial edema, pleural effusions, and Kerley B lines 1. This confirms volume overload and excludes primary pulmonary causes of dyspnea 1

• Two-dimensional echocardiography with Doppler: This is the most critical test and should be performed urgently 1, 2, 3. It will:

  • Determine left ventricular ejection fraction (LVEF) to distinguish HF with reduced EF (HFrEF, LVEF <40-45%) from HF with preserved EF (HFpEF, LVEF ≥45-50%) 1, 3
  • Assess left ventricular size, wall thickness, and regional wall motion abnormalities 1
  • Evaluate valve function (especially for aortic stenosis, mitral regurgitation) 1
  • Assess diastolic function parameters if LVEF is preserved 3

Coronary Artery Disease Evaluation

Given her age (45 years) and hypertension, assess for coronary artery disease as the underlying etiology: 1

• If she has any chest pain or anginal symptoms: Coronary angiography should be performed unless she has contraindications to revascularization 1
• If she has no chest pain but has risk factors for CAD (hypertension, diabetes, smoking, family history): Coronary angiography is reasonable, as CAD is the most common cause of heart failure and she's relatively young for de novo heart failure 1
• Consider troponin I or T if there's any suspicion of acute coronary syndrome 1

Immediate Therapeutic Management

Volume Management:

• Initiate loop diuretics (furosemide) for symptomatic relief of bilateral edema and congestion 2. Start with IV administration in the inpatient setting for more predictable absorption and faster symptom relief
• Monitor daily weights, strict intake/output, and clinical signs of decongestion (resolution of edema, improved dyspnea, decreased jugular venous pressure) 2
• Monitor renal function and electrolytes closely during diuresis, especially potassium and magnesium 1

Blood Pressure Control:

• Her BP of 144/92 mmHg requires management, but avoid aggressive BP lowering initially if she has significant volume overload, as diuresis alone may improve BP
• Once volume status is optimized and LVEF is determined, initiate guideline-directed medical therapy based on whether she has HFrEF or HFpEF 2

Additional Testing in Selected Circumstances

Consider these tests if initial workup suggests specific etiologies: 1

• Screening for hemochromatosis (serum ferritin, transferrin saturation) if family history or clinical suspicion
• HIV testing in appropriate risk populations
• Rheumatologic panel (ANA, rheumatoid factor) if systemic symptoms suggest connective tissue disease
• Sleep study if history suggests sleep-disordered breathing
• Endomyocardial biopsy only if specific infiltrative disease (amyloidosis, sarcoidosis, myocarditis) is suspected and would change management 1

Critical Pitfalls to Avoid

• Don't delay echocardiography: This is the definitive test to confirm heart failure and guide therapy. Clinical assessment alone is insufficient 1, 3
• Don't assume the diagnosis without objective evidence: Bilateral edema and dyspnea can have multiple causes (venous insufficiency, pulmonary disease, renal disease). Echocardiographic confirmation of cardiac dysfunction is mandatory 1, 3
• Don't overlook reversible causes: At age 45, consider peripartum cardiomyopathy (if recent pregnancy), viral myocarditis, thyroid disease, alcohol-induced cardiomyopathy, or undiagnosed valvular disease 1
• Don't forget to assess for coronary disease: Even without chest pain, CAD evaluation is reasonable in this age group with new heart failure 1
• Monitor renal function closely: Aggressive diuresis can worsen renal function, especially if she has underlying cardiorenal syndrome 1

Disposition Planning

• Ensure hemodynamic stability before discharge
• Confirm adequate decongestion (resolution of orthopnea, reduced edema, stable weight)
• Initiate guideline-directed medical therapy based on LVEF determination (ACE inhibitors/ARBs and beta-blockers for HFrEF) 2
• Arrange close outpatient follow-up within 7-14 days with cardiology
• Provide patient education on daily weight monitoring, sodium restriction (<2-3g/day), fluid management, and when to seek urgent care 2, 3