Management of HFpEF with Volume Overload at Discharge
For an older adult with HFpEF presenting with fluid overload, Pro-BNP ~1000 pg/mL, and normal troponin, initiate intravenous loop diuretics immediately to relieve congestion, then transition to oral diuretics at discharge with aggressive management of hypertension, atrial fibrillation, and other comorbidities that drive HFpEF progression. 1
Immediate In-Hospital Management
Diuretic Therapy for Congestion Relief
Start intravenous loop diuretics without delay in the emergency department or upon admission, as early intervention improves outcomes in decompensated heart failure. 1
If the patient is already on oral loop diuretics, the initial IV dose should equal or exceed their chronic oral daily dose to ensure adequate diuresis. 1
Titrate diuretic dose based on serial assessment of urine output, daily weights (measured at the same time each day), and clinical signs of congestion including jugular venous pressure, peripheral edema, and pulmonary rales. 1
Monitor daily serum electrolytes, blood urea nitrogen, and creatinine during active diuretic therapy to prevent electrolyte disturbances and worsening renal function. 1
Diagnostic Evaluation
Obtain urgent transthoracic echocardiography (within 2 weeks if not already done) to confirm preserved ejection fraction (≥50%), assess left atrial size, diastolic function, valvular disease, and right ventricular performance, as LVEF determination is critical for treatment decisions. 1, 2
Perform 12-lead electrocardiography to detect atrial fibrillation (which can raise BNP by 20–30%), left ventricular hypertrophy, or ischemic changes. 2
Identify and address precipitating factors including acute coronary syndrome (troponin is normal here, which is reassuring), severe hypertension, atrial/ventricular arrhythmias, infections, pulmonary emboli, renal failure, and medication/dietary noncompliance. 1
Interpretation of Pro-BNP ~1000 pg/mL
This Pro-BNP level of ~1000 pg/mL falls in the "gray zone" (400–2000 pg/mL) with sensitivity ~90% but specificity only 60–76% for heart failure, requiring confirmatory echocardiography before definitive diagnosis. 2
For patients >75 years, the age-adjusted NT-proBNP threshold is >1800 pg/mL, so a value of ~1000 pg/mL is below the highest age-adjusted cutoff but still warrants further evaluation. 2
BNP values may be lower in HFpEF; approximately 29% of symptomatic HFpEF patients with elevated pulmonary capillary wedge pressure have BNP ≤100 pg/mL, so this level does not exclude HFpEF. 2
Adjust interpretation for confounding factors: obesity (each BMI unit lowers BNP), chronic kidney disease (reduced renal clearance raises BNP), atrial fibrillation (markedly increases BNP), and age (baseline rises with age). 2
Discharge Management
Oral Diuretic Therapy
Transition from intravenous to oral loop diuretics (furosemide or torsemide) once clinical stability is achieved, with careful attention to dosing and electrolyte monitoring. 3
Prescribe a dose that maintains euvolemia based on the total IV diuretic requirement during hospitalization, typically converting IV furosemide 1:1 to oral furosemide or using torsemide at approximately half the furosemide dose. 1
Educate the patient on daily weight monitoring (same time each day, after voiding, before breakfast) and instruct them to contact their provider if weight increases by >2–3 pounds in 1 day or >5 pounds in 1 week. 1
Comorbidity Management (Critical in HFpEF)
Aggressively control hypertension with target blood pressure <130/80 mmHg using ACE inhibitors, ARBs, or ARNIs (sacubitril-valsartan), as hypertension is a major driver of HFpEF progression. 1, 4, 5
Manage atrial fibrillation with rate control (beta-blockers preferred) and anticoagulation if indicated, as AF is common in HFpEF and worsens outcomes. 1
Optimize diabetes control with target HbA1c <7% and consider SGLT2 inhibitors (dapagliflozin or empagliflozin), which reduce heart failure hospitalizations in HFpEF. 6, 7
Treat coronary artery disease if present, as ischemia can precipitate decompensation. 1
Address obesity through dietary counseling and weight loss programs, as obesity is a major risk factor for HFpEF and suppresses BNP levels. 2, 7
Medication Considerations for HFpEF
SGLT2 inhibitors (dapagliflozin 10 mg daily or empagliflozin 10 mg daily) are recommended for HFpEF patients, as the DELIVER trial demonstrated a 22% reduction in the composite of cardiovascular death, heart failure hospitalization, or urgent heart failure visits (HR 0.82,95% CI 0.73–0.92, p=0.0008). 6
ACE inhibitors, ARBs, or ARNIs are reasonable for blood pressure control and comorbidity management, though they have not shown mortality benefit specifically in HFpEF. 1, 4
Mineralocorticoid receptor antagonists (spironolactone or eplerenone) may be considered for blood pressure control and symptom management, though evidence in HFpEF is limited. 1
Beta-blockers are indicated for rate control in atrial fibrillation, blood pressure management, and treatment of coronary artery disease, but have not shown mortality benefit in HFpEF. 1, 8
Monitoring and Follow-Up
Schedule outpatient follow-up within 7–14 days of discharge to reassess volume status, review medications, check electrolytes and renal function, and reinforce self-care education. 1
Repeat Pro-BNP measurement at follow-up: a reduction of >30–50% signals adequate therapeutic response and is linked to better prognosis, while rising levels indicate treatment failure or disease progression. 2, 9
Serial Pro-BNP measurements track treatment response, with each 500 pg/mL increase in NT-proBNP associated with 3.8% higher mortality risk. 2, 9
Arrange echocardiography if not done during hospitalization to confirm HFpEF diagnosis and assess for structural heart disease. 1, 2
Patient Education and Self-Care
Sodium restriction to <2 grams per day to minimize fluid retention. 1
Fluid restriction to 1.5–2 liters per day if hyponatremia or severe volume overload is present. 1
Daily weight monitoring with clear instructions on when to contact the provider. 1
Medication adherence counseling, as noncompliance is a common precipitant of decompensation. 1
Recognition of early warning signs of decompensation (increasing dyspnea, orthopnea, weight gain, peripheral edema) and when to seek urgent care. 1
Common Pitfalls to Avoid
Do not rely solely on Pro-BNP for diagnosis or treatment decisions, as its specificity in the gray zone is limited (60–76%) and it can be elevated by non-cardiac conditions such as pulmonary embolism, sepsis, or chronic kidney disease. 2
Do not delay echocardiography, as LVEF determination is critical for selecting the appropriate treatment pathway (HFrEF vs. HFpEF). 2
Do not abruptly discontinue diuretics without ensuring the patient is euvolemic, as premature discontinuation leads to rapid readmission. 1
Do not overlook comorbidities (hypertension, diabetes, atrial fibrillation, obesity, renal dysfunction), as aggressive management of these conditions is the cornerstone of HFpEF treatment. 1, 4, 5
Do not expect tight correlations between Pro-BNP levels and hemodynamic parameters or ejection fraction, as BNP is a marker of wall stress but does not directly measure cardiac function. 2