Breathlessness, pedal oedema, pallor and declining function in a hypertensive, diabetic 70-year-old non-smoker — differential diagnosis and management

Heart failure (HF), chronic kidney disease (CKD) and anaemia often coexist and interact, so look for each.

HF, ischaemic or hypertensive. Ejection fraction (EF) classes are reduced (≤40%), mildly reduced (41–49%) and preserved (≥50%); preserved EF mainly affects older women with hypertension, diabetes and renal failure.

CKD with fluid overload and renal anaemia: diabetic or hypertensive kidney disease; nephrotic syndrome too. CKD may explain anaemia at GFR below 60 mL/min/1.73 m2, especially below 30.

Other anaemia: about a third of men and postmenopausal women with iron deficiency anaemia have underlying disease, usually gastrointestinal, and cancers may give no specific symptoms. Also consider coeliac disease, vitamin B12 or folate deficiency, plasma cell disorders and chronic disease. In older people causes are often multiple: ask about aspirin, NSAIDs, antiplatelets and anticoagulants.

Others: aortic stenosis; smoking-related lung disease (less likely in a non-smoker); thyroid disease; drugs such as calcium-channel blockers and thiazolidinediones.

Suspected HF: ECG, BNP or NT-proBNP, echocardiography, chest radiograph, full blood count, electrolytes, kidney, liver and thyroid function, HbA1c, ferritin and transferrin saturation.

Non-acute BNP <35 pg/mL or NT-proBNP <125 pg/mL makes HF very unlikely. Age, anaemia and CKD raise these peptides without HF and obesity lowers them; judge them with symptoms, signs and echocardiography.

Echocardiography shows EF, wall motion, valves and hypertrophy. Preserved-EF HF needs symptoms, EF ≥50% and objective diastolic dysfunction or raised filling pressure.

CKD means kidney injury (such as albuminuria ≥30 mg/gCr) or GFR <60 for over 3 months.

Anaemia: ferritin <15 µg/L is highly specific for iron deficiency, but inflammation can falsely normalise it. In HF deficiency means ferritin <100 µg/L, or 100–299 with transferrin saturation <20%; in pre-dialysis CKD, saturation ≤20% with ferritin ≤100 µg/L. Confirmed iron deficiency needs urinalysis, coeliac screening and gastroscopy plus colonoscopy (or CT colonography); most CKD patients still warrant this if fit.

Diuretics (Class I) relieve congestion at any EF; excess may cause hypotension and kidney deterioration.

Reduced EF: ARNI (or ACE inhibitor; ARB if intolerant), beta-blocker, mineralocorticoid antagonist (caution if eGFR <30 or potassium >5.0 mEq/L) and SGLT2 inhibitor (Class I).

Preserved EF: no treatment has clearly improved survival. SGLT2 inhibitors reduce HF admission or cardiovascular death (Class I), but raise urogenital infection risk and may add to volume depletion; ketoacidosis is rare. Treat comorbidities (Class I).

Cause: with hypertensive hypertrophy systolic 120–130 mmHg may help (Class IIa), avoiding overtreatment. Angiography if angina resists drugs. Symptomatic severe aortic stenosis needs surgical or transcatheter replacement.

Refer at G3b–G5, at G3a with albuminuria (A2–A3), or if function falls 30% or more within 3 months. Salt <6 g/day; in diabetic kidney disease, an SGLT2 inhibitor; BP <130/80 mmHg, watching for hypotension and dizziness.

HbA1c around <7.0%, individualised for comorbidity, frailty and hypoglycaemia. Avoid thiazolidinediones in symptomatic HF. In dehydrating illness consider withholding SGLT2 inhibitors, metformin and NSAIDs; diuretics and RAS inhibitors case by case, as stopping may worsen HF.

CKD: give iron if deficient. With erythropoiesis-stimulating agents (ESAs), do not aim for Hb 13 g/dL or more.

HF: ESAs are not recommended for anaemia without a specific cause (no clear benefit, more thromboembolism). IV iron is reasonable in iron deficiency anaemia (Class IIa); one large trial narrowly missed its primary endpoint but reduced HF admissions. Oral iron did not help in reduced EF.

Otherwise: oral iron, one tablet daily, continued about 3 months after Hb normalises; parenteral if it fails.

Exercise in all HF (Class I), supervised if frail or multimorbid (Class IIa), with multidisciplinary care and self-management (Class I). Screen for depression if suspected (20–40% in chronic HF) and cognition routinely.

Declining function: grade NYHA class; screen for frailty. In older people anaemia contributes to worse physical performance, cognition and frailty. Weigh endoscopy against frailty with the patient and family; in CKD base decisions on quality of life and prognosis.