One-liner#

Test condition is a common heart problem that primary care doctors manage with medication and lifestyle changes.

Quick nav#

Definition and epidemiology#

Diagnostic criteria#

Diagnosis requires two of the following: elevated blood pressure above 140/90, heart rate above 100, or chest discomfort.

Epidemiology#

Affects 10% of adults over age 50. Risk factors include obesity, smoking, and family history.

Pathophysiology#

Mechanism (clinical understanding)#

The heart muscle becomes stiff over time due to high blood pressure. This leads to reduced pumping efficiency and fluid backup.

How to explain to patients#

Think of your heart like a pump. When the pump gets stiff, it cannot move blood as well. This makes you feel tired and short of breath.

Clinical presentation#

Characteristic symptoms#

Patients report fatigue, shortness of breath with activity, and swelling in the legs. Symptoms worsen over weeks to months.

Physical exam findings#

Look for elevated JVP, bilateral leg edema, and crackles at lung bases. Document S3 gallop if present.

Red flags#

Chest pain at rest, severe shortness of breath, or confusion require urgent evaluation. Send to ED if oxygen saturation below 90%.

Diagnostic workup#

Initial evaluation#

Order BNP, CBC, CMP, and chest X-ray. BNP above 100 suggests heart failure. BNP above 400 makes heart failure very likely.

Confirmatory testing#

Echocardiogram shows ejection fraction. EF below 40% indicates reduced function. EF above 50% with symptoms suggests preserved function.

When to refer for specialist workup#

Refer to cardiology if EF below 35%, if symptoms persist despite optimal therapy, or if patient needs device evaluation.

What NOT to order#

Avoid routine cardiac catheterization without clear indication. Skip serial BNP testing in stable patients. Do not order stress testing in acute decompensation.

Treatment#

Goals of therapy#

Target blood pressure below 130/80. Aim for heart rate 60-70 at rest. Goal is symptom improvement and reduced hospitalizations.

Non-pharmacologic management#

Limit sodium to 2 grams daily. Weigh yourself each morning. Call if weight increases by 3 pounds in one day or 5 pounds in one week.

Pharmacologic management#

DrugDoseContraindicationsMonitoringCostNotes
Lisinopril2.5-5mg daily; titrate every 2 weeks; max 40mgAngioedema, bilateral RAS, pregnancyCr and K at 1-2 weeks$ genericFirst-line for reduced EF
Metoprolol succinate12.5-25mg daily; titrate every 2 weeks; max 200mgSevere bradycardia, heart blockHeart rate at each visit$ genericUse succinate not tartrate
Spironolactone12.5-25mg daily; max 50mgK above 5.0, Cr above 2.5K and Cr at 1 week then monthly$ genericAdd if EF below 35%

Patient counseling points#

Tell patients: “This medicine helps your heart pump better. You may feel dizzy at first. This usually improves in a few days. Take it at the same time each day.”

Monitoring and follow-up#

See patient in 2 weeks after starting new medication. Check labs at 1-2 weeks. Once stable, follow up every 3-6 months.

Patient education#

What is this condition?#

Your heart is a pump that moves blood through your body. When the heart gets weak or stiff, it cannot pump as well. This makes you feel tired and short of breath. Fluid can build up in your legs and lungs.

What you can do#

Weigh yourself each morning. Write down your weight. Eat less salt. Take your pills every day. Walk for 30 minutes most days. Rest when you feel tired.

When to seek care#

Call your doctor if you gain 3 pounds in one day. Call if you feel more short of breath than usual. Go to the ER if you have chest pain or cannot breathe.

Questions to ask your doctor#

Ask about your heart function number. Ask what medicines you should take. Ask how much salt you can eat. Ask when you should come back.

Prognosis and monitoring#

Expected course#

With treatment, most patients feel better in 2-4 weeks. Symptoms can be controlled for many years. Without treatment, symptoms worsen over months.

Monitoring parameters#

Check weight daily at home. Get labs every 3-6 months when stable. Repeat echo yearly or if symptoms change.

Complications to watch for#

Watch for worsening shortness of breath. Monitor for leg swelling. Check for irregular heartbeat. Report dizziness or fainting.

Special populations#

Elderly/geriatric#

In patients over age 65, start medications at lower doses. Avoid Beers criteria medications. Watch for falls due to low blood pressure. Consider cognitive effects of medications.

Chronic kidney disease#

Reduce ACE inhibitor dose if eGFR below 30. Avoid spironolactone if eGFR below 30. Monitor potassium closely. Consider nephrology referral if eGFR declining.

Other populations#

In pregnancy, avoid ACE inhibitors and ARBs. For patients with polypharmacy, review for drug interactions. Check for duplicate medications.

When to refer#

Specialist referral criteria#

Refer to cardiology if EF below 35%. Refer if symptoms persist despite optimal medical therapy. Refer for device evaluation if indicated.

Urgency levels#

Routine referral for stable patients needing optimization. Urgent referral within 1-2 weeks for new diagnosis with low EF. Emergent referral for acute decompensation.

Smartphrase snippets#

Stable/controlled: Heart failure with reduced EF, currently stable on GDMT. EF 35% on last echo with no recent hospitalizations. Continue current regimen and follow up in 3 months.

Worsening/uncontrolled: Heart failure with worsening symptoms despite current therapy. Weight up 5 pounds this week with increased leg edema. Will increase diuretic and recheck in 1 week.

New diagnosis: New diagnosis of heart failure based on symptoms and elevated BNP. Starting low-dose ACE inhibitor and ordering echo. Follow up in 2 weeks with labs.

  • Chest Pain — symptom-based approach to chest pain differential
  • Edema — evaluation of lower extremity swelling
Backward Hypertension Atrial Fibrillation Forward