Case Study: Lower extremity edema and heart failure in a middle-aged woman

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A 55-year-old obese woman with hypertension, diabetes, and scleroderma is referred for follow-up after a recent admission for new-onset heart failure.
A 55-year-old obese woman with hypertension, diabetes, and scleroderma is referred for follow-up after a recent admission for new-onset heart failure.

Case:

A 55-year-old obese woman with hypertension, diabetes, and scleroderma is referred for follow-up after a recent admission for new-onset heart failure. She presented to the hospital with shortness of breath on exertion that has progressed during the course of several months to resting dyspnea, increasing fatigue, and worsening lower extremity edema.

Two-dimensional echocardiography (ECG) was performed showing normal left ventricular (LV) systolic function, grade I diastolic dysfunction, right ventricular (RV) dilatation, and an estimated RV systolic pressure of 60 mm Hg.

She was diagnosed with diastolic left heart failure and World Health Organization group 2 pulmonary hypertension and was discharged after a course of intravenous diuretics with follow-up in your clinic. She continues to have dyspnea at rest despite some mild improvement of her lower extremity edema. She participated in a sleep study last year that demonstrated mild obstructive sleep apnea and has been adherent to continuous positive airway pressure (CPAP) therapy nightly.

On exam she has some mild crackles, a loud P2, and both systolic and diastolic murmurs. Review of the hospital chest radiograph reveals peripheral hypovascularity, RV enlargement, and prominent hilar pulmonary arteries. Electrocardiograph shows right axis deviation with evidence of right atrial enlargement and RV hypertrophy. Blood pressure is 145/88 mm Hg, and heart rate is 90 beats per minute.

What is the next best step in her management? 

  1. Start her on guideline-directed medical therapy for heart failure
  2. Start calcium channel blockers for pulmonary hypertension
  3. Referral for left heart catheterization to evaluate for coronary artery disease
  4. Referral for right heart catheterization for evaluation of pulmonary hypertension
  5. Referral for computed  tomography to rule out chronic thromboembolic disease

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