How should I revise the emergency department medical decision‑making for a 69‑year‑old man with recent dual‑chamber implantable cardioverter‑defibrillator (ICD) placement who presents with orthostatic light‑headedness, new cough, mild lower‑extremity swelling, baseline elevated pro‑brain natriuretic peptide (BNP), and is taking torsemide and isosorbide mononitrate, given his history of heart failure with preserved ejection fraction (HFpEF), chronic obstructive pulmonary disease (COPD), asthma, pulmonary fibrosis, hypertension, diabetes mellitus, hypothyroidism, obstructive sleep apnea (OSA), and prior paroxysmal supraventricular tachycardia (PSVT)?

Medical Decision-Making Revision for 69-Year-Old Male with Recent ICD and Orthostatic Lightheadedness

Primary Assessment: Device-Related Complications vs. Volume Depletion

This patient's orthostatic lightheadedness 2 months post-ICD placement requires urgent device interrogation to exclude pacing-induced cardiomyopathy or inappropriate programming, while simultaneously evaluating for excessive diuresis given his torsemide and isosorbide mononitrate regimen. 1

Critical Device Considerations

• ICD interrogation is mandatory before discharge to assess pacing burden, as right ventricular pacing can worsen heart failure and cause dyssynchronous cardiac contraction, potentially explaining his orthostatic symptoms and new weakness 1
• The ACC/AHA guidelines emphasize that careful attention to ICD programming and pacing function is essential for all patients with low ejection fraction treated with an ICD, as devices have been associated with increased heart failure hospitalizations 1
• Document percentage of ventricular pacing – if >40%, this may be contributing to his symptoms and warrants cardiology consultation for potential CRT upgrade 1
• Evaluate for inappropriate ICD therapies or atrial arrhythmias (particularly atrial fibrillation), as his history of PSVT and amiodarone therapy places him at risk for breakthrough arrhythmias that could trigger lightheadedness 1

Volume Status and Medication Assessment

• His orthostatic symptoms strongly suggest volume depletion from excessive diuresis, particularly given torsemide 20 mg daily plus isosorbide mononitrate 15 mg daily – both vasodilators that can cause symptomatic hypotension 2, 3
• The FDA label for torsemide specifically warns that lightheadedness can occur, especially during initial therapy, and that inadequate fluid intake or excessive perspiration can lead to excessive blood pressure drops 2
• Obtain orthostatic vital signs (lying, sitting, standing at 1 and 3 minutes) to quantify postural changes – a drop in systolic BP ≥20 mmHg or diastolic BP ≥10 mmHg confirms orthostatic hypotension 2
• His pro-BNP of 1,423 is at baseline, suggesting he is not volume overloaded, making diuretic reduction reasonable 4, 3

HFpEF-Specific Management Gaps

• This patient has HFpEF (EF >55%) but is not on SGLT2 inhibitor therapy, which is now first-line treatment – consider adding dapagliflozin 10 mg daily or empagliflozin 10 mg daily, as these reduce heart failure hospitalizations and cardiovascular mortality by approximately 20% 5, 3
• His current regimen of sacubitril-valsartan is appropriate for HFpEF, but the addition of an SGLT2 inhibitor would provide incremental benefit 5, 3
• Torsemide should be reduced or held temporarily given his orthostatic symptoms and absence of volume overload on exam (no edema, stable pro-BNP) 2, 3

Pulmonary Evaluation

• His new cough with dry crackles and rhonchi at the right lung base, combined with COPD, asthma, and pulmonary fibrosis, requires differentiation between pulmonary infection, COPD exacerbation, and pulmonary congestion 4, 6, 7
• The urinalysis showing 2+ blood, 8 RBCs, and 10 WBCs with trace leukocyte esterase suggests possible UTI, which could be contributing to his malaise and weakness 4
• His negative influenza/RSV/COVID panel and lack of fever make viral infection less likely, but bacterial pneumonia or UTI remain considerations given the urinalysis findings 4
• Pulmonary hypertension is highly prevalent (83%) in HFpEF patients and strongly predicts mortality – his baseline dyspnea and pulmonary fibrosis place him at high risk 8

Rate Control Assessment for Atrial Arrhythmias

• If device interrogation reveals atrial fibrillation or atrial tachycardia, his current metoprolol 25 mg twice daily may be inadequate for rate control 1, 9
• For HFpEF patients with atrial fibrillation, beta-blockers or non-dihydropyridine calcium channel blockers are first-line for rate control, targeting resting heart rate <110 bpm 1, 9
• Amiodarone 200 mg daily is appropriate for rhythm control given his history of PSVT and multiple ablations, but requires monitoring for pulmonary toxicity given his underlying lung disease 1, 9
• Digoxin could be added if beta-blocker monotherapy fails to control rate, particularly useful for resting heart rate control in HFpEF 1, 9

Immediate Disposition Plan

Hold torsemide and reduce isosorbide mononitrate to 7.5 mg daily (half-tablet) until cardiology follow-up, as his orthostatic symptoms and euvolemic state suggest overdiuresis 2, 3

Mandatory ICD interrogation before discharge – if unavailable in ED, arrange urgent (within 24-48 hours) device clinic follow-up with explicit instructions to return immediately if syncope occurs 1

Start empiric antibiotic therapy for possible UTI given urinalysis findings (nitrofurantoin 100 mg twice daily for 5 days if GFR >30 mL/min) and send urine culture 4

Add SGLT2 inhibitor – prescribe dapagliflozin 10 mg daily or empagliflozin 10 mg daily as first-line HFpEF therapy 5, 3

Expedite cardiology follow-up to within 3-5 days (not 7-10 days) given recent ICD placement and new symptoms requiring device evaluation 1

Return Precautions

• Syncope or near-syncope – return immediately, as this may indicate device malfunction, ventricular arrhythmia, or severe orthostatic hypotension 1, 2
• ICD shock – return immediately for device interrogation 1
• Worsening dyspnea, orthopnea, or lower extremity edema – may indicate heart failure decompensation 3, 10
• Fever, productive cough, or chest pain – may indicate pneumonia or cardiac ischemia 4

Common Pitfalls Avoided

• Do not discharge without ICD interrogation or concrete plan for urgent device follow-up – pacing-induced cardiomyopathy can develop insidiously and worsen heart failure 1
• Do not continue full-dose diuretics in euvolemic patients with orthostatic symptoms – this perpetuates the problem and increases fall risk 2, 3
• Do not overlook SGLT2 inhibitor therapy in HFpEF – this is now standard of care with mortality benefit 5, 3
• Do not assume all dyspnea in HFpEF is cardiac – his multiple pulmonary comorbidities (COPD, asthma, pulmonary fibrosis) require parallel evaluation 6, 7, 8