What is the initial approach for a 79-year-old patient with heart failure presenting with cough and chest congestion?

Initial Assessment of a 79-Year-Old with Heart Failure Presenting with Cough and Chest Congestion

Your first priority is to determine cardiopulmonary stability—specifically assess for respiratory failure or hemodynamic compromise requiring immediate respiratory and cardiovascular support. 1

Immediate Triage Assessment

Assess mental status using AVPU (Alert, Visual, Pain, Unresponsive) as an indicator of hypoperfusion. 1 This rapid assessment determines whether the patient requires immediate ICU-level care versus emergency department evaluation.

Critical History Questions

Distinguish Acute Heart Failure from Alternative Diagnoses

• Duration and progression of symptoms: Acute worsening over hours to days suggests acute decompensated heart failure (ADHF), while gradual progression may indicate pneumonia or COPD exacerbation 2

• Fever presence: Fever with cough suggests infectious etiology (pneumonia) rather than pure cardiac decompensation, though both can coexist 2

• Orthopnea and paroxysmal nocturnal dyspnea: These are major Framingham criteria specific for heart failure and help distinguish cardiac from pulmonary causes 1, 3

• Recent medication adherence: Specifically ask about diuretic compliance, as non-adherence is a common precipitant of decompensation 4

• Dietary sodium intake: Recent dietary indiscretion can trigger acute decompensation 4

• Weight changes: Rapid weight gain (>2-3 kg over days) indicates fluid retention 5

Identify Precipitating Factors

• New cardiac ischemia: Chest pain, pressure, or anginal equivalents 1

• Arrhythmias: Palpitations, irregular heartbeat (atrial fibrillation is common in this age group) 5

• Medication changes: Recent initiation of NSAIDs, calcium channel blockers, or other nephrotoxic drugs 1

• Renal function changes: Decreased urine output or known chronic kidney disease 5

Essential Physical Examination Findings

Volume Status Assessment

• Jugular venous distension: Elevated JVP indicates elevated right heart filling pressures 1, 3

• Hepatojugular reflux: Apply pressure to right upper quadrant; sustained JVP elevation >3 cm indicates volume overload 1

• Peripheral edema: Assess ankles and sacrum (in bedridden patients) 3

• Weight measurement: Compare to baseline/dry weight 1

Pulmonary Congestion Assessment

• Bibasal rales/crackles: Fine inspiratory crackles indicate pulmonary edema, though absence does not exclude significant congestion 1, 6

• Pleural effusions: Dullness to percussion at lung bases (common in chronic heart failure) 1

• Respiratory rate and work of breathing: Tachypnea and accessory muscle use indicate respiratory distress 1

Cardiac Examination

• S3 gallop: Highly specific for volume overload and elevated filling pressures 1, 3

• S4 gallop: Suggests diastolic dysfunction 1

• Mitral regurgitation murmur: Extremely common in acute phase of heart failure 1

• Displaced apical impulse: Indicates cardiomegaly 3

Perfusion Assessment

• Blood pressure: Hypotension (SBP <90 mmHg) indicates cardiogenic shock requiring immediate intervention; hypertension (SBP >140 mmHg) is present in 60-77% of acute heart failure presentations 1

• Skin temperature and capillary refill: Cool extremities suggest poor perfusion 1

Immediate Diagnostic Testing

Mandatory Initial Tests

• Oxygen saturation: Pulse oximetry to assess oxygenation; arterial blood gas if severe respiratory distress to evaluate pO2, pCO2, and acid-base status 1

• ECG: Exclude ST-elevation myocardial infarction and assess for arrhythmias (atrial fibrillation), ischemic changes, or conduction abnormalities 1

• Chest X-ray: Assess for pulmonary venous congestion, pleural effusions, interstitial/alveolar edema, and rule out pneumonia (though normal in 20% of cases) 1

• BNP or NT-proBNP: Elevated levels support heart failure diagnosis (BNP >100 pg/mL in hospitalized patients, NT-proBNP >300 pg/mL), though levels may be normal in "flash" pulmonary edema 1

Laboratory Panel

• Complete blood count: Assess for anemia (can precipitate decompensation) 1, 5

• Serum electrolytes: Sodium, potassium (hypokalemia from diuretics, hyperkalemia from ACE inhibitors/ARBs) 1

• Renal function: Creatinine, BUN, eGFR (worsening renal function is adverse prognostic factor) 1, 5

• Cardiac troponin: Elevated troponin without ACS is common and indicates adverse prognosis 1

• Procalcitonin: If pneumonia suspected, helps distinguish bacterial infection from heart failure 1

• Liver function tests: Assess for hepatic congestion 1

Advanced Bedside Testing (If Available)

• Thoracic ultrasound: B-lines (lung rockets) indicate pulmonary edema with higher sensitivity than chest X-ray; can be performed faster than radiography 1

• Inferior vena cava ultrasound: Assess diameter and collapsibility to estimate right atrial pressure 1

Echocardiography Timing

Immediate echocardiography is mandatory only in cardiogenic shock or hemodynamic instability. 1 For stable patients, echocardiography should be performed after stabilization to assess ejection fraction, valvular function, and diastolic parameters 1. This is especially important in de novo heart failure presentations 1.

Key Pitfalls to Avoid

• Do not assume normal chest X-ray excludes heart failure: Nearly 20% of acute heart failure patients have normal chest radiographs 1

• Do not dismiss cough as purely cardiac: Pneumonia must be excluded, particularly with fever and elevated inflammatory markers 1, 2

• Do not overlook gout in elderly heart failure patients: Hyperuricemia from chronic diuretic use can cause acute gout attacks mimicking infection with fever and elevated inflammatory markers 2

• Do not aggressively diurese without monitoring renal function: Elderly patients with CKD are at high risk for worsening renal function with excessive diuresis 5