Case #1 Answers:
This patient probably has hypertensive heart disease resulting in diastolic dysfunction. Cardiac output, especially during exercise is limited by the abnormal filling characteristics of the ventricles leading to pulmonary congestion, dyspnea and edema. This should be strongly suspected by the patient's sex, age, associated diabetes and HTN, the presence of an S4 and obesity. Mitral regurgitation (secondary to remodeling), renal disease and ischemia need to be considered. Other etiologies of volume overload should be excluded (meds, diet, compliance, etc.).
Stage C: probable structural heart abnormality (LVH) and symptomatic heart failure
The patient has uncontrolled hypertension and should be a focus of therapy. The target diastolic blood pressure, especially in a patient who is diabetic is below 80 mmHg.
Echocardiogram or MUGA, CBC, lytes, BUN, CR, U/A, ECG, CXR. Patients with diabetes have a high incidence of heart disease and CAD should be evaluated.
The treatment of diabetes in patients with heart failure is complicated because metformin is contraindicated in all patients with "heart failure requiring pharmacologic treatment" because of the increased risk of potentially lethal lactic acidosis. Thiazolidinediones are not recommended for patients with "NYHA class III or IV status" because these agents expand intravascular volume and may exacerbate heart failure (Masaudi F. JAMA 2003;290:81-85). If angiography is anticipated, metformin must be discontinue prior to the procedure to avoid potential lactic acidosis.
a. Control risk factors (HTN, CAD, DM) with the emphasis on the BP control
b. Modifications of lifestyle
c. Avoidance of NSAIDS because of their sodium retentive properties and nephrotoxicity particularly in diabetics.