What is the best management approach for an 82-year-old female patient with a history of hypertension (high blood pressure), hyperlipidemia (elevated lipids), coronary artery disease, paroxysmal atrial fibrillation, permanent pacemaker, heart failure with preserved ejection fraction, type 2 diabetes mellitus, chronic kidney disease stage IIIa, hypothyroidism, right hemiplegia after cerebral vascular accident, osteoarthritis, and peripheral neuropathy, presenting with new onset bilateral lower extremity edema and acute volume overload?

Management of Acute Volume Overload in an 82-Year-Old with HFpEF

Immediately increase the furosemide dose aggressively—the patient has clear acute decompensated heart failure with preserved ejection fraction (HFpEF) requiring urgent diuresis to prevent further morbidity from persistent volume overload, skin breakdown, and potential hospitalization. 1, 2

Immediate Diuretic Management

Increase furosemide to at least 80-120 mg daily (divided into twice-daily dosing) and continue escalating by 20-40 mg increments every 1-2 days until achieving a weight loss of 0.5-1.0 kg daily. 1, 3 The patient's 5+ kg weight gain over recent weeks with new weeping edema and discoloration represents dangerous volume overload that mandates aggressive intervention. 2

• The ACC/AHA guidelines explicitly state that diuresis should be maintained until fluid retention is eliminated, even if this results in mild-to-moderate decreases in blood pressure or renal function, as long as the patient remains asymptomatic. 1
• Excessive concern about azotemia leads to underutilization of diuretics and refractory edema—persistent volume overload not only perpetuates symptoms but compromises the safety and efficacy of other heart failure medications. 1
• Given her CKD stage IIIa, she likely requires higher doses than typical patients due to impaired drug delivery to renal tubules. 1

Switch to twice-daily furosemide dosing immediately (e.g., 60 mg at 8 AM and 40 mg at 2 PM) rather than once-daily administration to overcome the "braking phenomenon" where distal tubular hypertrophy develops with single daily dosing. 4, 3

Consider Sequential Nephron Blockade

If the patient does not achieve adequate diuresis (weight loss <0.5 kg/day) within 48-72 hours on increased furosemide, add metolazone 2.5-5 mg daily given 30 minutes before the morning furosemide dose. 4 This combination provides sequential nephron blockade and is the preferred strategy for diuretic resistance in HFpEF. 4

• Monitor serum potassium, sodium, and creatinine every 1-2 days when using combination diuretics to prevent dangerous electrolyte derangements. 4
• The synergistic effect of thiazide-type diuretics with loop diuretics can produce profound diuresis—patients must be monitored closely. 1, 4

Non-Pharmacologic Interventions (Critical and Non-Negotiable)

Enforce strict sodium restriction to ≤2 grams daily—this is non-negotiable and must be achieved before resorting to high-dose or combination diuretics. 4 Since the facility cannot provide a therapeutic low-sodium diet, arrange for:

• Detailed written dietary instructions with specific foods to avoid (processed meats, canned soups, restaurant food, bread, cheese)
• Family involvement to bring in low-sodium meals if feasible
• Daily dietitian consultation at the skilled nursing facility
• Consider transfer to a facility that can provide therapeutic diets if current facility remains unable to accommodate

Mandate strict leg elevation and compression therapy immediately. 1 The patient admits non-compliance with leg elevation and compression stockings—this must be addressed:

• Elevate legs above heart level for at least 2-3 hours three times daily
• Apply graduated compression stockings (20-30 mmHg) daily after morning diuresis
• Nursing staff must document compliance with these measures
• Non-compliance with these basic measures directly contributed to the current crisis

Implement daily weights at the same time each morning (after voiding, before breakfast) with a target weight reduction of 0.5-1.0 kg daily until reaching dry weight. 1, 4

Blood Pressure and Disease-Modifying Therapy

Target systolic blood pressure <130 mmHg using ACE inhibitors or ARBs plus beta-blockers once euvolemia is achieved. 2 Given her multiple comorbidities (CAD, prior stroke, diabetes, CKD), optimal blood pressure control is essential to prevent HF hospitalizations. 1, 2

Initiate an SGLT2 inhibitor (dapagliflozin 10 mg daily or empagliflozin 10 mg daily) immediately as first-line disease-modifying therapy for HFpEF, regardless of diabetes status. 2, 5 This is the single most important long-term intervention to reduce cardiovascular death and heart failure hospitalizations in HFpEF. 2

Monitoring and Red Flags

Monitor the following parameters every 1-3 days during aggressive diuresis:

• Daily weights (target: 0.5-1.0 kg loss daily until euvolemic) 1, 4
• Serum creatinine and BUN (accept mild increases if asymptomatic) 1
• Serum potassium and sodium (especially critical with combination diuretics) 4
• Blood pressure (accept mild decreases if asymptomatic) 1
• Oxygen saturation (currently stable at baseline) 2

Red flags requiring hospitalization:

• Worsening renal function with creatinine increase >0.5 mg/dL above baseline despite continued volume overload 1
• Development of hypotension with symptoms (dizziness, syncope) 1
• New dyspnea, orthopnea, or declining oxygen saturation suggesting pulmonary edema 1
• Failure to achieve weight loss after 3-5 days of aggressive outpatient diuresis 4
• Severe electrolyte abnormalities (K+ <3.0 or >5.5, Na+ <130) 4

Skin Care for Weeping Edema

The dark discoloration and serous weeping represent venous stasis dermatitis with high risk for skin breakdown and infection:

• Apply moisture barrier cream to affected areas
• Ensure compression stockings are applied correctly without creating pressure points
• Inspect skin daily for signs of cellulitis or ulceration
• Maintain meticulous hygiene of lower extremities

Medications to Avoid

Do not use non-dihydropyridine calcium channel blockers (verapamil, diltiazem) in this patient with HFpEF—they have negative inotropic effects and worse outcomes. 2 Review her medication list to ensure these are not present.

Avoid NSAIDs and COX-2 inhibitors, which block diuretic effects and worsen fluid retention. 1 This is particularly important given her osteoarthritis—use acetaminophen for pain control instead.

Prognosis and Goals of Care

Given her age (82), multiple comorbidities, recent hip fracture, and now acute HF decompensation, this represents a critical juncture. 1 HF hospitalizations in elderly patients carry a 50% readmission rate at 6 months and ominous prognosis. 1 Establish goals of care through shared decision-making with the patient and family, incorporating her functional status, cognitive status, and preferences for aggressive versus comfort-focused care. 2

The current presentation was precipitated by dietary and medical non-compliance following her hip fracture—addressing these modifiable factors is essential to prevent recurrent decompensation. 1