What is the diagnosis and treatment for a patient with orthopnea, shortness of breath (SOB), cough, and peripheral edema?

Diagnosis: Acute Decompensated Heart Failure

This patient's presentation of orthopnea, shortness of breath, cough, and peripheral edema is classic for acute heart failure (AHF), specifically the "warm and wet" profile characterized by congestion without hypoperfusion. 1

Clinical Diagnosis

The constellation of symptoms and signs establishes the diagnosis:

• Orthopnea (inability to lie flat due to breathlessness) is a hallmark symptom of left-sided heart failure and indicates elevated left atrial pressure 1
• Peripheral edema (feet swelling) reflects systemic venous congestion from right-sided involvement 1
• Cough and shortness of breath result from pulmonary congestion and increased intrapulmonary shunting 1

Key diagnostic findings to confirm on examination include: elevated jugular venous pressure, bilateral pulmonary rales (crackles), displaced cardiac apex, presence of S3 gallop, and bilateral lower extremity edema 1. The absence of these signs does not exclude heart failure, but their presence strongly supports the diagnosis 1.

Immediate Diagnostic Workup

• Chest radiography to identify pulmonary venous congestion, interstitial edema, and cardiomegaly 1, 2
• Electrocardiogram to detect arrhythmias, ischemia, or conduction abnormalities 1
• B-type natriuretic peptide (BNP) measurement—normal levels make heart failure unlikely 2
• Echocardiography is the diagnostic standard to assess left ventricular ejection fraction and distinguish systolic from diastolic heart failure 2
• Laboratory tests: renal function (creatinine, BUN), electrolytes, complete blood count to exclude anemia, and troponin if acute coronary syndrome is suspected 1, 3

Treatment Algorithm

Immediate Management (First 24 Hours)

Position the patient upright or semi-seated immediately to decrease venous return and improve ventilation 3.

Oxygen therapy:

• Administer supplemental oxygen only if SpO₂ <90% or PaO₂ <60 mmHg, targeting saturation of 95% 1, 3
• Avoid routine oxygen in non-hypoxemic patients as it causes vasoconstriction and reduces cardiac output 1

Non-invasive positive pressure ventilation (CPAP or BiPAP):

• Apply immediately in patients with respiratory distress to reduce intubation rates and mortality 1, 3
• Use BiPAP if hypercapnia or acidosis is present, particularly with COPD history 1

Pharmacological Treatment

Intravenous loop diuretics (Class I recommendation):

• Initial dose: 20-40 mg IV furosemide for diuretic-naive patients 1
• For patients already on oral diuretics, give at least the equivalent of their oral dose IV 1
• Administer as intermittent boluses or continuous infusion based on clinical response 1
• Monitor closely: urine output, symptoms, renal function, and electrolytes 1

Intravenous vasodilators (if systolic BP >90 mmHg):

• Consider for symptomatic relief and congestion reduction (Class IIa recommendation) 1
• Nitroglycerin: Start sublingual 0.4-0.6 mg every 5-10 minutes, then transition to IV at 5 mcg/min, titrating upward 3
• Particularly beneficial in hypertensive heart failure 1
• Monitor blood pressure frequently during administration 1

Avoid inotropic agents (dobutamine, dopamine, levosimendan) unless the patient is hypotensive (SBP <90 mmHg) or has signs of hypoperfusion, due to safety concerns 1.

Monitoring Requirements

• Continuous monitoring of heart rhythm, blood pressure, heart rate, and oxygen saturation for at least 24 hours 3
• Daily assessment of renal function (creatinine, BUN) and electrolytes 3
• Arterial blood gas if severe pulmonary edema or COPD history present 3

Long-term Management After Stabilization

Once acute decompensation is controlled:

• ACE inhibitors (e.g., lisinopril starting at 2.5-5 mg daily) reduce mortality and improve symptoms in heart failure 4
• Beta-blockers (e.g., metoprolol succinate) improve survival but should be initiated cautiously after stabilization 5
• Identify and treat precipitating factors: acute coronary syndrome, hypertensive emergency, arrhythmias, valvular disease, medication non-compliance, dietary indiscretion, infection, anemia, or thyroid dysfunction 1

Critical Pitfalls to Avoid

• Do not delay diuretic therapy while awaiting diagnostic confirmation—clinical diagnosis is sufficient to begin treatment 1
• Avoid excessive oxygen in non-hypoxemic patients, especially with COPD, as it may worsen ventilation-perfusion mismatch and cause hypercapnia 1
• Persistent orthopnea after treatment indicates inadequate response and predicts higher hospitalization rates and worse outcomes—these patients require more aggressive therapy 6
• Classic signs may appear late—absence of rales, edema, or elevated JVP does not exclude severe cardiac impairment 1