What is the best course of treatment for a 72-year-old female (F) patient with sudden onset dyspnea, elevated N-terminal pro b-type natriuretic peptide (NT Pro BNP), concentric left ventricular hypertrophy (LVH) with preserved contractility on 2-dimensional echocardiogram (2D echo), hypertension, and no history of diabetes or chronic kidney disease (CKD)?

Management of Acute Heart Failure with Preserved Ejection Fraction (HFpEF)

This 72-year-old woman with sudden dyspnea, markedly elevated NT-proBNP (3934 pg/mL), concentric LVH with preserved contractility, and hypertension has acute decompensated HFpEF and requires immediate loop diuretic therapy to relieve congestion, followed by initiation of SGLT2 inhibitor therapy and aggressive blood pressure control. 1, 2, 3

Immediate Management (First 24-48 Hours)

Confirm the Diagnosis

• Your patient meets diagnostic criteria for HFpEF: NT-proBNP >125 pg/mL (hers is 3934 pg/mL, well above threshold), preserved LVEF on echo, symptoms of acute dyspnea, and structural heart disease (concentric LVH). 1, 2
• The markedly elevated NT-proBNP (3934 pg/mL) places her at high risk: each 500 pg/mL increase above baseline associates with 3.8% increased mortality risk, and her level predicts significant short-term morbidity. 1, 2
• Normal troponins are reassuring and exclude acute coronary syndrome as the primary driver, though troponin elevation would have added prognostic information. 1

Initiate Diuretic Therapy

• Start intravenous furosemide immediately to relieve congestion, as she presents with acute dyspnea suggesting volume overload. 1, 3
• Typical starting dose: 40 mg IV bolus, with dose adjustment based on prior diuretic exposure and renal function. 4, 3
• Monitor daily weights, strict intake/output, and assess for clinical decongestion (resolution of dyspnea, orthopnea, edema). 4, 3
• Check serum electrolytes (particularly potassium), creatinine, and BUN every 1-2 days during active diuresis to detect hypokalemia, hyponatremia, or worsening renal function. 1, 4

Critical Monitoring During Hospitalization

• Measure NT-proBNP at discharge: predischarge levels are the strongest predictor of 30-day readmission and 1-year mortality, superior to admission values or percent change. 1
• A predischarge NT-proBNP that fails to decrease by >30% from admission identifies patients at highest risk for readmission (HR 2.03) and death (HR 5.69 if increased by 30%). 1
• Repeat echocardiography is unnecessary unless clinical deterioration occurs. 1

Post-Discharge Medical Therapy

First-Line Pharmacologic Treatment

• Initiate SGLT2 inhibitor (dapagliflozin 10 mg daily or empagliflozin 10 mg daily) before discharge: this is the only medication class proven to reduce HF hospitalization and cardiovascular death by approximately 20% in HFpEF. 1, 3
• This recommendation applies regardless of diabetes status. 3

Blood Pressure Management

• Target systolic BP <130 mmHg: hypertension is the dominant driver of HFpEF, present in the majority of cases worldwide, and aggressive control is essential. 1, 5
• Continue or optimize antihypertensive regimen, which may include ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists. 5
• Note: These agents reduce NT-proBNP levels, potentially normalizing values in treated patients, but this does not indicate resolution of HFpEF. 2

Diuretic Maintenance

• Transition to oral loop diuretic (furosemide 20-40 mg daily or torsemide 10-20 mg daily) to maintain euvolemia. 3
• Educate patient on daily weight monitoring: >2 kg gain over 3 days warrants diuretic dose increase. 3
• Monitor potassium closely; supplement if <4.0 mEq/L, as hypokalemia exacerbates arrhythmia risk and may develop with chronic diuretic use. 4

Non-Pharmacologic Interventions

Exercise and Weight Management

• Prescribe structured exercise training: produces clinically meaningful increases in functional capacity and quality of life in HFpEF. 3
• Recommend diet-induced weight loss if BMI ≥30 kg/m²: obesity is a key HFpEF risk factor and weight loss improves outcomes. 1, 3
• Note: Obesity paradoxically lowers NT-proBNP levels for a given degree of cardiac dysfunction, so her elevated level despite unknown BMI suggests significant disease severity. 2, 6

Heart Failure Self-Care Education

• Provide education on medication adherence, dietary sodium restriction (<2 g/day), daily weight monitoring, and symptom recognition to prevent decompensation. 3
• Teach recognition of worsening HF signs: increased dyspnea, orthopnea, lower extremity edema, weight gain. 3

Prognostic Considerations and Follow-Up

Risk Stratification

• Her NT-proBNP of 3934 pg/mL places her in the highest risk category for adverse outcomes. 1, 2
• For each 100 pg/mL increase in BNP, relative risk of death increases by 35% over 1.5-3 years; her NT-proBNP equivalent suggests substantial risk. 2
• Schedule cardiology follow-up within 2 weeks of discharge given her high-risk NT-proBNP level (>2000 pg/mL equivalent). 2

Repeat NT-proBNP Measurement

• Recheck NT-proBNP at 1-3 months post-discharge to assess treatment response and guide prognosis. 1, 2
• Persistently elevated or rising levels indicate need for treatment intensification or consideration of advanced HF therapies. 1

Important Caveats

Age-Related NT-proBNP Interpretation

• At age 72, her NT-proBNP threshold for abnormality is >900 pg/mL (vs. >450 pg/mL if <50 years), so her level of 3934 pg/mL is unequivocally elevated even accounting for age. 2, 7

Avoid Common Pitfalls

• Do not withhold diuretics due to normal chest X-ray: up to 20% of AHF patients have near-normal chest radiographs, and clinical dyspnea with elevated NT-proBNP mandates diuretic therapy. 1, 2
• Do not delay SGLT2 inhibitor initiation: this is first-line therapy and should begin in-hospital, not deferred to outpatient setting. 1, 3
• Do not use beta-blockers as primary HFpEF therapy: unlike HFrEF, beta-blockers have not demonstrated mortality benefit in HFpEF and are reserved for rate control if atrial fibrillation develops or for blood pressure management. 5

Medication Effects on NT-proBNP

• ACE inhibitors, ARBs, and diuretics will lower her NT-proBNP over time, but persistently elevated levels despite therapy indicate ongoing risk. 2
• If she develops atrial fibrillation (common in HFpEF), NT-proBNP will increase independent of volume status. 2