In a patient with ascites and bilateral lower‑extremity edema, should hypertensive heart disease‑related heart failure (NYHA class III) be considered as a differential diagnosis?

Hypertensive Heart Disease with Heart Failure (NYHA Class III) as a Differential Diagnosis for Ascites and Bipedal Edema

Yes, hypertensive heart disease-related heart failure (NYHA Class III) should absolutely be considered as a differential diagnosis in a patient presenting with ascites and bilateral lower extremity edema, as these are cardinal manifestations of the heart failure syndrome resulting from fluid retention and systemic venous congestion. 1

Clinical Presentation Consistent with Heart Failure

The combination of ascites and bipedal edema represents fluid retention from sodium and water accumulation, which is a hallmark sign of heart failure regardless of the underlying etiology. 1

• Peripheral edema is a typical but non-specific sign of heart failure that results from elevated systemic venous pressure and fluid retention. 1
• Ascites develops when right-sided heart failure leads to elevated central venous pressure, hepatic congestion, and increased intra-abdominal venous pressure. 2, 3
• These signs may occur even in the absence of classic left-sided symptoms like dyspnea, particularly when right ventricular dysfunction predominates. 2

Hypertensive Heart Disease as an Established Cause

Hypertension is one of the three most common causes of heart failure in Western populations (along with coronary artery disease and dilated cardiomyopathy), making hypertensive heart disease a high-probability diagnosis. 1

• Hypertensive heart disease progresses through diastolic dysfunction, left ventricular hypertrophy, and eventually heart failure with either preserved (HFpEF) or reduced ejection fraction (HFrEF). 4
• The pathophysiological sequence can lead to biventricular failure, where left ventricular diastolic dysfunction causes pulmonary hypertension and subsequent right heart failure, manifesting as ascites and peripheral edema. 2, 3

Diagnostic Approach to Confirm Heart Failure

To establish this diagnosis, you must document three essential elements: clinical syndrome, structural/functional cardiac abnormality, and elevated biomarkers. 5

Clinical Assessment

• Elevated jugular venous pressure is the most specific physical finding and the most important clinical evidence of a cardiac source of ascites. 2
• Look for hepatojugular reflux, S3 gallop, laterally displaced apical impulse, and cardiac murmurs (particularly mitral or tricuspid regurgitation from ventricular dilatation). 1
• Document NYHA Class III symptoms: comfortable at rest but marked limitation with less-than-ordinary activity. 1, 5

Objective Cardiac Testing

• Measure natriuretic peptides immediately: BNP >100 pg/mL or NT-proBNP >300 pg/mL supports heart failure diagnosis. 1, 5
• Obtain transthoracic echocardiography to assess left ventricular ejection fraction, chamber dimensions, wall thickness, diastolic function (E/e' ratio), and valvular abnormalities. 5
• Critical caveat: Normal LV systolic function on echocardiography does not exclude heart failure—you must also assess diastolic function, as HFpEF or isolated diastolic dysfunction can present with ascites. 2

Additional Workup

• 12-lead ECG may show left ventricular hypertrophy, strain pattern, or atrial enlargement. 1
• Chest X-ray to evaluate for pulmonary congestion, cardiomegaly, and pleural effusions. 1
• Laboratory tests: creatinine, BUN, electrolytes, liver function tests (often elevated from hepatic congestion), and TSH. 1

Differential Diagnosis Considerations

While heart failure is a strong consideration, you must systematically exclude other causes of ascites and edema:

• Hepatic cirrhosis: Check for stigmata of chronic liver disease, obtain liver function tests, albumin, and consider abdominal ultrasound with Doppler to assess portal vein patency. 1
• Nephrotic syndrome: Measure urine protein-to-creatinine ratio and serum albumin. 1
• Constrictive pericarditis or restrictive cardiomyopathy: Echocardiography with tissue Doppler and potentially cardiac MRI or catheterization. 1
• Malignancy with peritoneal carcinomatosis: Consider if weight loss, cachexia, or other constitutional symptoms present. 1

Common Pitfalls to Avoid

• Do not dismiss heart failure based solely on preserved ejection fraction—up to 50% of heart failure patients have HFpEF, which commonly presents with right-sided findings like ascites. 1, 2
• Do not overlook elevated central venous pressure on physical exam—this is the most important clinical clue distinguishing cardiac from non-cardiac ascites. 2
• Natriuretic peptides may be falsely low in obesity—borderline values should not exclude the diagnosis in obese patients with clinical signs of heart failure. 6
• Ascites from heart failure is typically a transudate, but biochemical analysis alone cannot definitively distinguish cardiac from hepatic causes—clinical context and elevated JVP are key. 2

Treatment Implications if Heart Failure Confirmed

Once hypertensive heart disease with heart failure is confirmed:

• Initiate loop diuretics (furosemide 20-40 mg IV for new-onset or equivalent to oral dose for chronic patients) to relieve congestion. 1
• Optimize blood pressure control with ACE inhibitors or ARBs targeting <130/80 mmHg. 6
• Add SGLT2 inhibitor (empagliflozin or dapagliflozin) if HFpEF confirmed, as this is the only class with proven morbidity benefit. 6
• Consider spironolactone if HFrEF or selected HFpEF patients with appropriate renal function and potassium levels. 1, 6
• Monitor closely for electrolyte disturbances, worsening renal function, and response to diuresis. 1