EpistemisBendopnea
Specialty: Cardiovascular.
Why it occurs
- Congestive heart failure with reduced ejection fraction
- Heart failure with preserved ejection fraction
- Restrictive cardiomyopathy
- Constrictive pericarditis with hemodynamic compromise
- Severe mitral or aortic stenosis with retrograde pulmonary congestion
Initial workup
Quantitative serum determination of B-type natriuretic peptide (BNP) or the N-terminal fraction of pro-BNP (NT-proBNP); Two-dimensional transthoracic echocardiogram with color and tissue Doppler to evaluate left ventricular ejection fraction (LVEF), E/e' ratio to estimate left ventricular filling pressures, and pulmonary artery systolic pressure (PSAP); Anteroposterior and lateral chest x-ray to evaluate the cardiothoracic index, venocapillary congestion, Kerley B lines, and pleural effusion; Right heart catheterization with measurement of pulmonary artery occlusion pressure (POAP) and cardiac output by thermodilution in cases of diagnostic doubt.
red flags
Onset of dyspnea in less than 8 seconds of abdominal tilt, accompanied by signs of tissue hypoperfusion or shock of cardiogenic origin, such as acral coldness, livedo reticularis in the knees, altered alertness or lethargy, frank oliguria (<0.5 mL/kg/h), persistent arterial hypotension (SBP <90 mmHg), bilateral wet crackles suggesting acute lung edema, or jugular engorgement grade III/IV. These signs indicate extreme acute decompensation and require emergency medical attention.
Standard management
- Furosemide — loop diuretic for rapid reduction of preload and relief of pulmonary congestion; 20 to 80 mg intravenously depending on previous blood volume status and renal function, adjusting according to urinary volume and closely monitoring hydroelectrolyte balance.
- Sacubitril/Valsartan — neprilysin and angiotensin II receptor inhibitor, indicated in chronic heart failure with reduced LVEF to optimize stroke volume and reduce adverse remodeling; initial dose of 24/26 mg or 49/51 mg twice daily orally, with gradual escalation according to hemodynamic tolerance
- Empagliflozin — inhibitor of the sodium-glucose cotransporter type 2 (iSGLT2) that promotes osmotic diuresis and natriuresis by reducing preload and afterload; 10 mg once daily orally, monitoring glomerular filtration rate
- Spironolactone (mineralocorticoid receptor antagonist to mitigate myocardial fibrosis and improve survival; 12.5 to 25 mg once daily orally, monitoring serum potassium and creatinine).
Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.
- Area
- Cardiovascular
- Listed causes
- 5
- Treatment options
- 4