Pulmonary Edema Secondary to Heart Failure
The most likely cause of this patient's symptoms is pulmonary edema (Option B), representing acute decompensation of chronic heart failure in the setting of multiple cardiovascular risk factors.
Clinical Reasoning
This elderly woman presents with the classic triad that points directly to heart failure with pulmonary congestion:
- Orthopnea (dyspnea worsened by lying down) is a hallmark symptom of elevated pulmonary capillary pressure and pulmonary edema 1
- History of ischemic heart disease (IHD), diabetes mellitus (DM), and hypertension (HTN) represents the highest-risk profile for developing heart failure 1, 2, 3
- Absence of chest pain argues strongly against acute coronary syndrome as the primary presentation 1
Why Pulmonary Edema is Most Likely
Pathophysiologic Basis
In elderly patients with established IHD, dyspnea frequently substitutes for typical anginal symptoms as the primary manifestation of cardiac dysfunction 1. The American Heart Association specifically notes that patients with coronary heart disease presenting with acute pulmonary edema are generally older than those manifesting typical anginal symptoms 1.
The European Society of Cardiology defines heart failure requiring: (I) symptoms of heart failure at rest or during exercise, (II) objective evidence of cardiac dysfunction, and (III) response to heart failure treatment 1. This patient fulfills criterion I with her orthopnea and progressive dyspnea.
High-Risk Profile
The combination of DM, HTN, and IHD creates a multiplicative risk for heart failure development 4, 3. A cohort study demonstrated that diabetes is the strongest predictor of incident heart failure in patients with ischemic heart disease, with hazard ratio of 2.04 (95% CI: 1.32-3.14) 3. When both DM and HTN coexist with IHD, the risk increases further to HR 2.57 (95% CI: 1.66-3.98) 3.
Orthopnea as a Distinguishing Feature
Orthopnea specifically indicates elevated pulmonary capillary pressure from left ventricular dysfunction 1. The American College of Cardiology lists orthopnea as a major criterion in the Framingham Heart Failure Diagnostic Criteria 1. This symptom occurs because recumbency increases venous return to an already failing heart, raising pulmonary venous pressure and causing interstitial pulmonary edema 1.
Why NOT Acute Coronary Syndrome (Option A)
The absence of chest pain makes acute coronary syndrome unlikely as the primary diagnosis 1. While elderly patients with IHD can present atypically, the progressive nature of symptoms over time (rather than acute onset) and the specific pattern of orthopnea point away from ACS 1.
The American Heart Association notes that although dyspnea can substitute for chest pain in elderly patients with acute MI, this typically occurs in the context of acute presentation, not progressive worsening 1. Additionally, normal vital signs argue against acute myocardial infarction, which typically presents with hemodynamic changes 1.
Why NOT Pulmonary Embolism (Option C)
Pulmonary embolism typically presents with acute onset dyspnea, not progressive orthopnea 1. The American Heart Association recommends rest for patients with thromboembolic disease until stable 1.
Key distinguishing features absent in this case:
- PE usually has sudden onset rather than progressive worsening
- Orthopnea is not a characteristic feature of PE
- The chronic nature of symptoms over time is inconsistent with acute thromboembolism
- No mention of risk factors specific to PE (recent surgery, immobilization, malignancy)
Critical Management Implications
This patient requires urgent evaluation for cardiogenic pulmonary edema 1. The American Heart Association states that shortness of breath at rest may suggest pulmonary congestion, and appropriate assessment for cardiogenic pulmonary edema is needed 1.
Immediate Assessment Should Include:
- Physical examination for signs of congestion: jugular venous distension, hepatojugular reflux, rales, S3 gallop, peripheral edema 1
- Chest radiography to assess for pulmonary edema 1
- Echocardiography to evaluate cardiac structure and function 1
- Natriuretic peptide levels (BNP or NT-proBNP) for diagnostic confirmation 1
Common Pitfall to Avoid
Do not dismiss progressive dyspnea in elderly patients with known IHD as simply "deconditioning" or "normal aging" 1. The American Heart Association emphasizes that elderly patients with IHD frequently present with dyspnea and worsening heart failure rather than typical angina 1. The presence of orthopnea specifically indicates pathologic cardiac dysfunction requiring treatment 1.
Answer: B. Pulmonary edema