What is the appropriate management for a 50-year-old male presenting with dyspnea (shortness of breath) on exertion, palpitations, and dry cough?

Management of 50-Year-Old Male with Dyspnea on Exertion, Palpitations, and Dry Cough

This patient requires immediate systematic evaluation to differentiate cardiac from pulmonary causes, with initial focus on excluding heart failure, coronary disease, and arrhythmias through ECG, chest radiography, BNP testing, and echocardiography. 1, 2

Immediate Diagnostic Workup

First-Line Testing (Obtain Immediately)

• 12-lead ECG to detect arrhythmias (given palpitations), ischemic changes, or chamber enlargement—this is rarely normal in cardiac disease and is essential to exclude acute coronary syndrome 1, 2
• Chest radiography to identify cardiomegaly, pulmonary congestion, pleural effusion, or alternative pulmonary pathology 3, 4, 1
• B-type natriuretic peptide (BNP) or NT-proBNP measurement: BNP <100 pg/mL or NT-proBNP <125 pg/mL effectively excludes heart failure, while BNP >100 pg/mL has 96% sensitivity for heart failure 4, 1
• Complete blood count and basic metabolic panel to assess for anemia, electrolyte abnormalities, and renal dysfunction 4

Physical Examination Priorities

• Cardiac auscultation for murmurs (valvular disease), extra heart sounds (S3 suggests ventricular dysfunction), or irregular rhythm (arrhythmia) 3, 4
• Jugular venous pressure assessment and examination for peripheral edema—though absence of edema does not exclude heart failure, particularly HFpEF 1, 2
• Respiratory examination for rales (pulmonary congestion) or wheezing (bronchospasm) 2
• Vital signs including oxygen saturation, blood pressure (drives treatment decisions), heart rate, and respiratory rate 2

Differential Diagnosis Framework

Cardiac Causes (Most Likely Given Triad of Symptoms)

• Coronary artery disease: Most common cardiac cause when myocardial oxygen supply doesn't meet demand during exertion 1
• Heart failure with preserved ejection fraction (HFpEF): Presents with dyspnea on exertion and requires EF ≥50%, elevated natriuretic peptides, and structural/functional cardiac abnormality 1
• Arrhythmias: Palpitations suggest supraventricular tachycardia, atrial fibrillation, or other rhythm disturbances that can cause dyspnea 3
• Valvular heart disease: Aortic stenosis or mitral disease causing elevated left atrial pressures 1
• Hypertrophic cardiomyopathy: Can present with dyspnea and chest discomfort, particularly concerning given palpitations 3

Pulmonary Causes

• Chronic obstructive pulmonary disease (COPD): Consider if smoking history present; assume COPD in patients over 50 with chronic breathlessness until proven otherwise 4, 1
• Asthma: "Chest tightness" is relatively specific for bronchoconstriction 1
• Interstitial lung disease: Progressive dyspnea with dry cough and bibasilar crackles; patients describe "air hunger" due to restrictive mechanics 1
• Pulmonary arterial hypertension: Can masquerade as asthma with dyspnea, dry cough, and palpitations 3

Second-Line Testing (If Initial Workup Non-Diagnostic)

• Transthoracic echocardiography to assess left ventricular systolic and diastolic function, valvular disease, right ventricular strain, and pericardial effusion 1, 2
• Pulmonary function testing/spirometry to differentiate obstructive from restrictive disease 1, 2
• CT chest if interstitial lung disease or pulmonary embolism suspected 1
• Cardiopulmonary exercise testing when diagnosis remains elusive or to differentiate cardiac from pulmonary limitation 3, 1

Critical Diagnostic Pitfalls to Avoid

• Do not rely on history and physical examination alone: While specificity is 96%, sensitivity is only 59% for cardiac causes 1
• Normal chest radiograph does not exclude cardiac disease: Nearly 20% of acute heart failure cases have normal chest X-rays 2
• Absence of peripheral edema does not exclude heart failure: Many HFpEF patients present without edema 1
• Do not assume single etiology: Dyspnea is multifactorial in approximately one-third of patients 2

Treatment Approach Based on Findings

If Cardiac Cause Identified

• Heart failure: Optimize diuretics (furosemide) for volume overload and afterload reduction; if systolic BP >140 mmHg with congestion, add vasodilators 4, 2
• Arrhythmias: Rate or rhythm control as appropriate; consider β-blockers if tachycardia-mediated 3
• Ischemic disease: Antiplatelet therapy, statins, β-blockers, and revascularization evaluation 4
• Valvular disease: Appropriate interventions based on severity 4

If Pulmonary Cause Identified

• COPD: Initiate bronchodilator therapy; if hypoxemic, target oxygen saturation 88-92% using 28% Venturi mask or 1-2 L/min nasal cannula to avoid CO2 retention 4
• Asthma: Bronchodilators and inhaled corticosteroids 4, 2
• Interstitial lung disease: Consider anti-inflammatory or antifibrotic therapy 4

Referral Indications

• Cardiology referral warranted to exclude alternative diagnoses, optimize guideline-directed medical therapy, and identify clinical trial eligibility 1
• Pulmonology referral if interstitial lung disease, pulmonary hypertension, or unexplained hypoxemia suspected 1
• Multidisciplinary dyspnea clinic when diagnosis remains elusive after comprehensive workup 1