A breathless patient with a normal chest radiograph and a history of heart failure
A 72-year-old man with ischaemic cardiomyopathy (LVEF 30%) and hypertension presents with 5 days of progressive exertional breathlessness and a dry cough. He is on bisoprolol, sacubitril/valsartan, spironolactone, and furosemide. On examination: BP 112/70 mmHg, HR 88/min, SpO2 91% on room air, afebrile, JVP not raised, bibasal fine crackles, no oedema. Chest radiograph is reported as clear; ECG shows sinus rhythm with old inferior Q waves. BNP is 420 pg/mL (baseline 180). D-dimer is 1.2 mg/L FEU (normal <0.5). He has no leg swelling or pleuritic pain. Renal function is stable.
1. How would you approach the differential between decompensated heart failure and pulmonary embolism here, given the clear chest radiograph?
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Both are plausible and the two can coexist. Points that argue for decompensated heart failure: known LVEF 30%, rising BNP from baseline, bibasal crackles, no fever, and a clear CXR (which does not exclude pulmonary oedema, especially in a chronic heart failure patient). Points that argue for PE: breathlessness out of proportion to examination, hypoxaemia (SpO2 91%), elevated D-dimer, and a clear CXR - a clear CXR with hypoxia is a classic PE clue.
I would use the Wells score and age-adjusted D-dimer. His D-dimer (1.2 mg/L FEU) is above the age-adjusted threshold (age 72 → 0.72 mg/L), so it is not a rule-out. However, D-dimer is less useful in heart failure and in hospitalised/older patients - false positives are common. I would not stop at the D-dimer.
Next steps:
- CT pulmonary angiography is the test of choice if renal function allows (stable creatinine here). If contrast is a concern, V/Q scan is an alternative.
- Bedside echocardiography - assess RV size and function, TR jet, and inferior vena cava; a dilated, hypokinetic RV would push me toward PE and prompt urgent CTPA and consideration of thrombolysis if haemodynamically unstable.
- ECG and troponin - look for S1Q3T3, right axis, or TWI in V1–V4 (none described, but recheck).
- Treat heart failure concurrently - cautious diuresis if volume overloaded, but he has no oedema and a normal JVP, so I would not aggressively diurese before excluding PE (over-diuresis worsens RV preload).
The clear CXR should not reassure me - it is a recognised feature of PE and does not exclude pulmonary oedema.
2. The CTPA is negative. What is your working diagnosis and how do you optimise his heart failure therapy without destabilising him?
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With a negative CTPA, the working diagnosis is decompensated chronic heart failure with reduced ejection fraction, likely precipitated by something (infection, arrhythmia, non-adherence, ischaemia, or progression). I would look for the precipitant: ECG for AF, troponin for ischaemia, FBC/CRP and urine for infection, and a medication review.
Optimisation, cautiously:
- He is not overtly congested (normal JVP, no oedema, only bibasal crackles). Aggressive diuresis risks hypotension and renal impairment. I would use a modest increase in loop diuretic (e.g. furosemide dose review) guided by weight, symptoms, and renal function, rather than large IV boluses.
- Sacubitril/valsartan and beta-blocker: BP 112/70 is acceptable; do not up-titrate during acute decompensation. Reassess after stabilisation.
- Spironolactone: check potassium and renal function before continuing or adjusting; with stable renal function it can continue.
- Consider adding an SGLT2 inhibitor (dapagliflozin/empagliflozin) once euvolemic and stable - proven benefit in HFrEF regardless of diabetes.
- Iron studies - treat iron deficiency if present.
- Device therapy: reassess LVEF after ≥3 months of optimal therapy; if still ≤35% on optimal medical therapy, consider ICD/CRT.
- Education and follow-up - daily weights, fluid/salt advice, and early clinic review.
I would avoid NSAIDs and non-dihydropyridine calcium channel blockers, and recheck renal function and potassium after any diuretic change.