What is the diagnosis and management plan for a patient with a history of normal myocardial perfusion study, normal ejection fraction (EF) with mild left ventricular hypertrophy (LVH) and impaired relaxation filling pattern, mild aortic valve calcification, and moderate mitral valve calcification, presenting with shortness of breath, 1+ to 2+ pitting edema, and currently taking Furosemide (Lasix) 20 milligrams (mg) daily?

From the Guidelines

The patient's current treatment plan, including increasing the Lasix dose to 40mg daily and implementing lifestyle modifications such as a low-salt diet and fluid restriction, is appropriate to manage signs of possible heart failure, including bilateral pitting edema and shortness of breath. The patient's recent myocardial perfusion study and echo results, which showed a normal EF but mild LVH with impaired relaxation filling pattern, mild calcification of the aortic valve, and moderate mitral calcification, suggest the presence of diastolic dysfunction and valve disease that require close monitoring and management. According to the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1, diuretics are recommended to improve symptoms and exercise capacity in patients with signs and/or symptoms of congestion, which is consistent with the patient's current treatment plan. Further evaluation, including BNP testing, repeat echocardiogram, and lower extremity ultrasound, will help clarify the underlying cardiac status and guide further management. The patient should also continue to follow a heart-healthy diet, engage in regular exercise as tolerated, lose weight, and manage vascular risk factors to reduce the risk of progression to more significant heart failure. Additionally, the patient's medication compliance and response to treatment should be closely monitored, and adjustments made as necessary to optimize outcomes. The 2009 focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults 1 also supports the use of diuretics and lifestyle modifications in the management of heart failure, and emphasizes the importance of monitoring and adjusting treatment based on patient response and clinical status. Key aspects of the patient's management plan include:

• Increasing the Lasix dose to 40mg daily for 4 days to address edema
• Implementing lifestyle modifications, such as a low-salt diet and fluid restriction
• Monitoring weight daily and adjusting fluid intake as needed
• Continuing CPAP therapy and managing vascular risk factors
• Following a heart-healthy diet and engaging in regular exercise as tolerated
• Losing weight and maintaining medication compliance
• Closely monitoring the patient's response to treatment and adjusting the management plan as necessary to optimize outcomes.

From the FDA Drug Label

Edema Therapy should be individualized according to patient response to gain maximal therapeutic response and to determine the minimal dose needed to maintain that response. The dose may be raised by 20 or 40 mg and given not sooner than 6 to 8 hours after the previous dose until the desired diuretic effect has been obtained. The dose of Furosemide tablets may be carefully titrated up to 600 mg/day in patients with clinically severe edematous states.

The patient's current dose of Lasix (Furosemide) 20 mg is being increased to 40 mg daily for the next 4 days, which is within the recommended dosing guidelines. The decision to increase the dose is appropriate given the patient's edema and shortness of breath. The patient's response to the increased dose should be closely monitored, and further adjustments can be made as needed to achieve the desired diuretic effect 2.

From the Research

Patient's Current Condition

• The patient underwent a myocardial perfusion study on 3/29/2022, which was normal.
• An echo study on 4/8/2022 showed a normal EF between 65-70% with mild LVH, impaired relaxation filling pattern, mild calcification of the aortic valve, and moderate mitral calcification.
• The patient's EKG showed a normal rhythm.
• The patient has 1+ to 2+ pitting edema in bilateral lower legs, with the left leg being more affected than the right.
• The patient is experiencing shortness of breath.

Treatment Plan

• The patient's Lasix dose has been increased to 40 mg daily for the next 4 days.
• A repeat BNP test and echocardiogram will be conducted to assess heart failure status.
• An ultrasound of bilateral lower extremity will be performed to rule out DVT.
• The patient has been advised to follow a low-salt diet, monitor their weight daily, restrict fluid intake to 1.5-2 L daily, and maintain a heart-healthy diet.
• Regular exercise, weight loss, CPAP therapy, medication compliance, and aggressive management of vascular risk factors have also been recommended.

Relevant Studies

• A study published in 2012 3 found that high daily doses of furosemide were associated with increased mortality in patients with chronic systolic heart failure.
• A systematic review and meta-analysis published in 2021 4 compared the effects of furosemide and other diuretics in the treatment of heart failure, and found that azosemide and torasemide caused significant reductions in brain natriuretic peptide (BNP) levels.
• A study published in 2023 5 discussed the combination of beta-blockers and ACE inhibitors in the treatment of cardiovascular diseases, highlighting their complementary actions on the sympathetic nervous system and renin-angiotensin-aldosterone system.
• A systematic review published in 2024 6 compared the efficacy and long-term outcomes of beta-blockers alone or in combination with ACE inhibitors in chronic heart failure, and found that combining these therapies provided an additive benefit in improving long-term survival and reducing heart failure-related hospitalizations.