Managing heart failure

in primary care

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Using brain natriuretic peptide (BNP) to support a diagnosis of heart failure
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Case study: Heart failure

Irene Robinson is a 68-year-old woman who you see every six months due to her history of hypertension. At today’s appointment, you notice moderate swelling in her ankles and feet. She says that this began shortly after you last saw her, and has gradually increased over time. When questioned regarding any other symptoms, she says she does not feel “breathless” during her daily activities, but does confirm that she occasionally awakens at night due to shortness of breath, and has trouble sleeping unless she has a number of pillows. Irene also reports that she often feels fatigued.

Medical history

Hypertension
  • Identified after a routine blood pressure measurement when Irene was in her late thirties (155/90 mmHg at the time)
  • Treatment was not immediately initiated, but she has now been taking antihypertensives for a number of years
  • Generally well-controlled; however, short-term increases in antihypertensive dose have been required at times in the past which Irene puts down to periods of stress related to her employment
  • Most recent blood pressure was 140/80 mmHg six months ago

Osteoarthritis (hip)
  • Diagnosed when Irene was 60 years old
  • She uses ibuprofen to manage symptoms; she has not undergone any surgical treatment

Family history
  • Enalapril 5 mg, once daily
  • Ibuprofen 800 mg, twice daily as needed
    • Irene has been taking ibuprofen regularly over the past two years

Medicines
  • Her mother had coronary artery disease and died from myocardial infarction at age 62 years

Social history
  • Irene worked as a secondary school teacher, but retired recently
  • She is a lifelong non-smoker
  • She used to go aqua jogging with friends, but has stopped doing so over the past six months as she found the sessions increasingly difficult

Relevant examination findings:

  • BMI: 30.12 (height: 168 cm; weight: 85 kg)
  • Mild pitting oedema at the ankles
  • Auscultation: bibasilar crepitations (crackles) detected
  • Blood pressure: 148/85 mmHg (confirmed by repeat measurement)
  • Jugular venous pressure (JVP): raised
  • Heart rate: 90 bpm (regular rhythm)
  • ECG: evidence of left ventricular hypertrophy

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