Management of Dyspnea with Preserved EF and Elevated Pro-BNP
This patient has heart failure with preserved ejection fraction (HFpEF) confirmed by elevated Pro-BNP (716 pg/mL) and symptoms, requiring immediate discontinuation of amlodipine, optimization of diuretic therapy with continued torsemide, and initiation of guideline-directed medical therapy including an ACE inhibitor or ARB. 1, 2, 3
Immediate Diagnostic Confirmation
Arrange urgent echocardiography within 2 weeks to fully characterize diastolic function parameters, valvular abnormalities, right ventricular function, and pulmonary pressures, as the Pro-BNP of 716 pg/mL exceeds diagnostic thresholds and indicates high probability of heart failure requiring specialist evaluation 2, 4, 3
Obtain comprehensive laboratory assessment including serum electrolytes, renal function (creatinine/eGFR), complete blood count, liver function tests, and thyroid function tests, as these are essential for guiding therapy and identifying confounders 1, 3
Perform 12-lead ECG to identify arrhythmias (particularly atrial fibrillation), ischemic changes, or left ventricular hypertrophy that could contribute to elevated natriuretic peptides 1, 2
Medication Management
Discontinue Amlodipine Immediately
Stop amlodipine as it is causing peripheral edema (a known adverse effect of calcium channel blockers) and provides no mortality benefit in heart failure 1
The swelling attributed to amlodipine is likely exacerbating symptoms and confounding the clinical picture of volume status 1
Optimize Diuretic Therapy
Continue torsemide for symptom relief as diuretics are recommended to reduce signs and symptoms of congestion in patients with heart failure, though they should be titrated to the lowest dose that maintains euvolemia 1
Adjust torsemide dose based on daily weights and symptoms of congestion, training the patient to self-adjust based on monitoring of symptoms/signs and daily weight measurements 1
Torsemide has advantages over furosemide including longer duration of action allowing once-daily dosing, higher bioavailability, and relatively more potassium-sparing effects 5, 6
Initiate Guideline-Directed Medical Therapy
Start an ACE inhibitor (such as enalapril 2.5 mg twice daily, targeting 10-20 mg twice daily) or ARB if ACE inhibitor not tolerated to manage underlying cardiac dysfunction and improve outcomes in HFpEF 1, 3
Consider beta-blocker therapy particularly if heart rate is elevated or if there is underlying coronary artery disease, as beta-blockers provide mortality benefit in heart failure 1
Evaluate for mineralocorticoid receptor antagonist (spironolactone or eplerenone) if symptoms persist despite initial therapy, though caution is needed with regular monitoring of potassium (must be <5.0 mmol/L) and renal function 1
Blood Pressure Management
Optimize blood pressure control aggressively as hypertension is a primary driver of HFpEF, using the ACE inhibitor/ARB as first-line therapy rather than calcium channel blockers 2, 3
Target blood pressure should be achieved through neurohormonal blockade rather than vasodilators that cause edema 1
Monitoring Strategy
Monitor daily weights with instructions to report weight gain >2-3 pounds in 1-2 days, as this indicates fluid retention requiring diuretic adjustment 3
Check renal function and electrolytes within 1-2 weeks after initiating ACE inhibitor/ARB and after any dose adjustments, as these medications can affect potassium and creatinine levels 1
Obtain serial Pro-BNP measurements at 3-6 month intervals to monitor treatment response, with a reduction >30% indicating good response to therapy and improved prognosis 2, 4, 3
Important Clinical Considerations
Age-Adjusted Interpretation
- Pro-BNP of 716 pg/mL is significantly elevated regardless of age, as it exceeds even the highest age-adjusted thresholds (>75 years: 1800 pg/mL for NT-proBNP) 2
Confounding Factors to Exclude
Atrial fibrillation can elevate natriuretic peptides independent of heart failure and requires ECG confirmation and potentially ambulatory monitoring if palpitations are present 1, 2
Renal dysfunction impairs natriuretic peptide clearance, making renal function assessment critical for interpretation 1, 2
Obesity (BMI >30 kg/m²) can lead to falsely lower Pro-BNP levels, so this level is particularly concerning if the patient is obese 2, 3
Common Pitfalls to Avoid
Do not attribute all symptoms to medication side effects without addressing the underlying heart failure, as the Pro-BNP elevation confirms cardiac dysfunction 2, 4, 3
Do not use diuretics alone without neurohormonal blockade, as ACE inhibitors/ARBs provide mortality benefit and disease modification beyond symptom relief 1
Do not restart calcium channel blockers for blood pressure control in this patient, as they worsen peripheral edema and provide no heart failure benefit 1