From the Guidelines
The next step for a patient with shortness of breath on exertion despite negative stress test and echocardiogram, who has hypertension, hyperlipidemia, and obstructive sleep apnea, should be to optimize management of existing conditions, particularly hypertension, as poorly controlled hypertension can contribute to symptoms even without overt cardiac dysfunction, as recommended by the American Heart Association 1. Given the patient's history of hypertension, hyperlipidemia, and obstructive sleep apnea, it is crucial to ensure that their blood pressure is well-controlled, with a target BP of <130/80 mm Hg, or even lower if possible, to <120/80 mm Hg, as suggested by the American Heart Association 1.
- The patient's medication regimen should be reviewed to ensure they are on appropriate medications, such as diuretics, ACE inhibitors (or ARBs), β-blockers, and aldosterone receptor antagonists, which have been shown to improve outcomes for patients with hypertension and heart failure 1.
- Additionally, the patient should be encouraged to make lifestyle modifications, such as sodium restriction and a closely monitored exercise program, to help manage their hypertension and overall health 1.
- It is also essential to ensure the patient is using their CPAP device consistently for OSA management, as untreated sleep apnea can contribute to exertional dyspnea.
- Further testing, such as pulmonary function tests (PFTs) with diffusion capacity and possibly a chest CT scan, may be necessary to evaluate for underlying pulmonary causes of dyspnea that cardiac testing hasn't identified.
- Blood tests, including complete blood count, comprehensive metabolic panel, BNP, and thyroid function tests, should be ordered to rule out anemia, kidney disease, subclinical heart failure, or thyroid disorders.
From the Research
Patient Profile
- History of hypertension (HTN)
- History of hyperlipidemia (HLD)
- History of obstructive sleep apnea (OSA)
- Stress test and echo negative
- Patient still experiences shortness of breath (SOB) on exertion
Considerations
- Despite a negative stress test and echo, the patient's symptoms and medical history warrant further evaluation 2, 3
- The patient's history of HTN, HLD, and OSA increases their cardiovascular risk 4
- The presence of SOB on exertion may indicate underlying cardiovascular disease or other conditions that need to be investigated
Next Steps
- Consider further diagnostic testing, such as cardiac catheterization or coronary computed tomography angiography, to rule out coronary artery disease 2, 3
- Optimize management of HTN, HLD, and OSA to reduce cardiovascular risk 4
- Evaluate the patient's exercise capacity and consider exercise stress testing with additional monitoring, such as electrocardiography, to enhance the predictive value of the test 3