What is the best course of treatment for a 57-year-old female patient with elevated blood pressure (hypertension), shortness of breath (dyspnea), and persistent cough, who denies chest pain, lightheadedness, and dizziness at present, but has experienced lightheadedness over the past few weeks?

Immediate Evaluation for Cardiac Failure in This Patient

This 57-year-old woman with elevated blood pressure, shortness of breath, persistent cough, and recent lightheadedness requires urgent evaluation for left ventricular failure, which should be the primary diagnostic consideration given this constellation of symptoms. 1

Critical Assessment for Left Ventricular Failure

Left ventricular failure should be strongly considered in patients above 65 years with orthopnea, displaced apex beat, and/or a history of myocardial infarction, hypertension, or atrial fibrillation. 1 While this patient is 57, her hypertension places her at significant risk for cardiac failure presenting with dyspnea and cough. 1

Immediate Diagnostic Steps

• Obtain B-type natriuretic peptide (BNP) or NT-proBNP levels immediately - BNP <40 pg/mL or NT-proBNP <150 pg/mg makes left ventricular failure highly unlikely and can effectively rule out this diagnosis. 1

• Perform focused cardiovascular examination looking specifically for:

  • Displaced apex beat 1
  • Presence of third heart sound (S3 gallop) 1
  • Rales on lung auscultation 1
  • Jugular venous distention 1
  • Dependent edema 1

• Obtain chest X-ray to assess for pulmonary venous congestion, cardiac enlargement, and to evaluate the persistent cough. 1

• Perform electrocardiogram to assess for cardiac involvement, left ventricular hypertrophy, or ischemia. 2

Blood Pressure Management Considerations

This patient's elevated blood pressure requires careful assessment but should NOT be aggressively lowered until cardiac status is clarified. 2, 3 The combination of hypertension with dyspnea and cough suggests either:

1. Hypertensive emergency with acute left ventricular failure - if evidence of pulmonary edema is present 2
2. Chronic hypertension with developing heart failure - requiring different management 1

If Hypertensive Emergency with Pulmonary Edema is Confirmed:

• Admit to ICU immediately for continuous blood pressure monitoring and parenteral therapy. 2, 3
• Target systolic blood pressure <140 mmHg immediately using IV nitroglycerin (5-10 mcg/min IV infusion, titrated by 5-10 mcg/min every 5-10 minutes). 2
• Avoid excessive acute drops in systolic BP (>70 mmHg) as this may precipitate acute renal injury, cerebral ischemia, or coronary ischemia. 2, 3

If Chronic Hypertension Without Acute Organ Damage:

• Initiate or optimize oral antihypertensive therapy with ACE inhibitor (such as lisinopril) or ARB, which are particularly beneficial in patients with heart failure. 4
• Arrange follow-up within 2-4 weeks to assess response to therapy. 2

Additional Differential Diagnoses to Consider

Pulmonary Causes

• Pneumonia should be suspected if new focal chest signs, tachypnea, pulse rate >100, or fever >4 days are present. 1

  • C-reactive protein (CRP) <20 mg/L makes pneumonia highly unlikely; CRP >100 mg/L makes pneumonia likely. 1
  • Chest X-ray should be performed if doubt persists after CRP testing. 1

• Pulmonary embolism should be considered given recent lightheadedness and dyspnea, especially if history of DVT, recent immobilization, or malignancy exists. 1

• Chronic airway disease (COPD) should be considered if the patient has a smoking history, wheezing, or prolonged expiration. 1

Cardiac Causes Beyond Heart Failure

• Refer to cardiology for cardiopulmonary exercise testing if breathlessness with exercise might be caused by other cardiac conditions such as pulmonary hypertension, cardiac dysrhythmias, or valvular disease. 1

• Pulmonary hypertension can present with dyspnea and cough and may show peripheral airway obstruction on testing. 1

Critical Laboratory Workup

• Complete blood count (hemoglobin, platelets) to assess for anemia or other hematologic abnormalities. 2
• Basic metabolic panel including creatinine, sodium, and potassium to evaluate renal function. 2
• Troponins if any concern for acute coronary syndrome given the hypertension and dyspnea. 2
• Urinalysis for protein and sediment to identify renal damage from hypertension. 2

Common Pitfalls to Avoid

• Do not assume asymptomatic severe hypertension is benign - the recent lightheadedness suggests possible end-organ effects and warrants thorough evaluation. 2, 3

• Do not aggressively lower blood pressure before ruling out acute cardiac pathology - patients with chronic hypertension have altered autoregulation and acute normalization can cause ischemic complications. 2, 3

• Do not dismiss the cough as simply related to ACE inhibitor use (if patient is on one) without ruling out cardiac and pulmonary causes first. 1

• Do not delay BNP/NT-proBNP testing - this single test can rapidly differentiate cardiac from pulmonary causes of dyspnea and guide immediate management. 1