Exertional dyspnea of cardiac etiology

Specialty: Cardiovascular.

• cardiovascular exertion dyspnea
• shortness of breath when walking of cardiac origin

Why it occurs

• Left heart failure (with reduced, preserved or moderately reduced ejection fraction)
• Chronic ischemic heart disease (dyspnea as anginal equivalent of exertion)
• Significant aortic or mitral valve disease
• Hypertrophic or obstructive cardiomyopathy
• Group 2 pulmonary arterial hypertension (secondary to left heart disease)

Initial workup

Two-dimensional transthoracic echocardiogram with Doppler to characterize the valve anatomy, quantify the LVEF and evaluate the presence of diastolic dysfunction (E/e' ratio, left atrial volume); Stress electrocardiogram (ergometry) or cardiopulmonary exercise test (CPET) to differentiate dyspnea of ​​cardiac origin from that of respiratory origin; Quantitative serum determination of NT-proBNP; Chest x-ray.

Standard management

• Furosemide — loop diuretic indicated for the management of symptoms of venous congestion and volume overload; 20 to 40 mg once daily orally, adjusting according to clinical evolution
• Bisoprolol — selective beta-1 beta blocker to reduce heart rate, prolong diastolic filling and improve myocardial efficiency; start with 1.25 to 2.5 mg per day orally
• Ramipril — ACEI to reduce systemic afterload and adverse myocardial remodeling; 2.5 to 10 mg per day orally
• Empagliflozin (SGLT2i indicated to reduce hospitalizations for heart failure and improve exercise capacity; 10 mg once daily orally).