What is the likely diagnosis and management for a patient presenting with orthopnea and bipedal pitting edema, suggestive of heart failure with possible left and right ventricular dysfunction?

Orthopnea and Bipedal Pitting Edema: Signs of Heart Failure

Orthopnea and bipedal pitting edema are classic signs of congestive heart failure, specifically indicating biventricular dysfunction with both left ventricular failure (causing pulmonary congestion and orthopnea) and right ventricular failure (causing systemic venous congestion and peripheral edema). 1

Clinical Significance of These Signs

Left Ventricular Dysfunction Manifestations

• Orthopnea reflects elevated left ventricular filling pressures causing pulmonary venous hypertension and pulmonary edema, forcing patients to sleep upright to reduce venous return to the heart 2, 1
• This symptom indicates fluid overload with high filling pressures and is associated with significantly higher hospitalization rates (64% vs 15.3%) when persistent 3
• Persistent orthopnea correlates with worsening or no improvement in left ventricular ejection fraction and requires aggressive management 3

Right Ventricular Dysfunction Manifestations

• Bipedal pitting edema reflects elevated right atrial pressure and systemic venous congestion from right heart failure 1, 4
• The presence of peripheral edema indicates advanced right-sided heart failure with elevated jugular venous pressure and hepatomegaly 1, 4
• Right ventricular dysfunction in left-sided heart failure is strongly associated with functional limitations and worsened survival 5

Diagnostic Approach

Immediate Evaluation Required

• Measure natriuretic peptides: BNP >100 pg/mL or NT-proBNP >300 pg/mL (if hospitalized) or >125 pg/mL (if ambulatory) confirms heart failure diagnosis 1
• Obtain echocardiography to assess both left ventricular ejection fraction and right ventricular function, evaluate structural/functional cardiac abnormalities, and guide therapy 1
• Perform ECG to evaluate for acute ischemia, arrhythmias, or prior myocardial infarction 6
• Order chest X-ray to assess for pulmonary venous congestion, interstitial edema, pleural effusions, and cardiomegaly 7

Physical Examination Findings to Document

• S3 gallop indicates ventricular dysfunction 1
• Jugular venous distension confirms elevated right-sided pressures 1, 4
• Hepatomegaly suggests advanced right-sided heart failure 1
• Pulmonary rales (crackles) at lung bases indicate pulmonary congestion requiring prompt diuretic therapy 7

Laboratory Assessment

• Liver function tests (transaminases, bilirubin) to confirm hepatic congestion from elevated right-sided pressures causing congestive hepatopathy 1
• Troponin to exclude acute coronary syndrome 6
• BUN/creatinine and electrolytes to assess renal function before initiating diuretics 2
• Complete blood count to evaluate for anemia as a contributing factor 2

Management Strategy

Immediate Treatment

• Administer oxygen therapy immediately to improve oxygenation 7
• Give intravenous loop diuretics (furosemide) promptly to reduce pulmonary congestion and systemic fluid overload 7, 8
• Consider intravenous vasodilators (nitroglycerin) unless systolic blood pressure <90 mmHg to reduce preload and afterload 7

Guideline-Directed Medical Therapy Based on Ejection Fraction

• For HFrEF (EF <40%): Initiate quadruple therapy including ACE inhibitor/ARB/ARNI, beta-blocker, mineralocorticoid receptor antagonist, and SGLT2 inhibitor 1
• For HFpEF (EF ≥50%): Initiate SGLT2 inhibitor as primary disease-modifying therapy 1

Monitoring Response to Treatment

• Serial lung examinations to assess resolution of rales 7
• Daily weights to monitor diuresis 2
• Natriuretic peptide monitoring: Aim for >30% decrease by day 5 and discharge value <1500 pg/mL for good prognosis 7
• Optimize diuresis while monitoring renal function and electrolytes 1

Critical Pitfalls to Avoid

• Do not attribute all symptoms to a single diagnosis prematurely - consider acute coronary syndrome, pulmonary embolism, or pneumonia as alternative or concurrent diagnoses 6
• Do not ignore right ventricular function on echocardiography, as RV dysfunction is strongly associated with mortality in left-sided heart failure 1, 5
• Do not delay echocardiography - it is essential for diagnosis and guiding therapy 1
• Do not provide inadequate diuresis - persistent congestion worsens outcomes 1, 9

Cardiology Referral Indications

Refer to cardiology for optimization of guideline-directed medical therapy, advanced diagnostic testing (including possible right heart catheterization), and consideration of device therapy (cardiac resynchronization therapy or implantable cardioverter-defibrillator) 1