A 54-year-old woman wishes to establish care without specific complaints after her primary care physician retired. She stopped smoking (2 packs per day) 6 months ago after a close friend died of lung cancer. A radionuclide stress test two years ago was normal at 85% predicted heart rate with an LVEF 55%. She takes amlodipine for hypertension, and metformin for type 2 diabetes mellitus. She leads a sedentary lifestyle and does not note any functional limitations. Her blood pressure is 147/92 mm Hg and her pulse is 87 beats per minute. She is mildly overweight and has trace lower extremity edema. Her physical examination is otherwise normal.
Atenolol and glyburide are added to her medication regimen, and her blood pressure and glucose control improve by her next visit. Unfortunately, she returns several weeks later with new onset of shortness of breath with exertion and intermittent wheezing. She continues to sleep on two pillows for comfort. Her blood pressure is 137/84 and her pulse is 97 beats per minute. You are unable to appreciate any jugular venous distention or abnormal heart sounds, but you note mild wheezing bilaterally.
Based on the elevated level of BNP, your suspicion for heart failure is high.
The patient undergoes coronary angiography and is found to have a small right coronary artery with moderate disease not amenable to angioplasty or stenting. The left circumflex artery appears to be chronically occluded, and the mid-left anterior descending artery has a severe stenosis that is stented.
While evaluating the patient in the hospital, you discover that she started taking ibuprofen following a knee sprain. You recommend alternative analgesics that are less likely to affect her heart failure. She improves with heart failure treatment over the next few days, and is ready for discharge. Her blood pressure is 117/69 and her heart rate is 67. You review her blood chemistries and note that her serum sodium is 137 mmol/L, potassium 4.2 mmol/L, BUN 27 mg/dL, and creatinine 1.4 mg/dL.