A 72-year-old man with fluid overload

A 72-year-old physically active man with a history of coronary artery disease and well-controlled hypertension developed gradual shortness of breath, initially with outdoor exertional physical activities and later with more usual activities. He also developed mild ankle and leg edema during the same time. He had no orthopnea, paroxysmal nocturnal dyspnea, or chest pain. His vital signs were normal, and he had no signs of heart failure except for mild lower extremity edema. He had normal sinus rhythm, no cardiomegaly on chest x-ray, and a left ventricular ejection fraction of 25%. A nuclear stress test showed mild myocardial ischemia not amenable to surgical interventions.

The patient was started on enalapril (Vasotec) 2.5 mg twice a day, carvedilol (Coreg) 3.125 mg twice a day, and furosemide (Lasix) 20 mg/ day. Several weeks later, his symptoms improved, and the diuretic was discontinued. The patient was advised to restrict his salt intake, check his weight daily, and take furosemide 20 mg/day as needed if he gained 2 to 3 pounds over 2 to 3 days. He has remained symptom free and stable on this regimen for more than 2 years.