Nephrotic Range Proteinuria and Acute Heart Failure

Case presentation: A 66-year-old woman with mild obesity, systemic hypertension and no history of previous treatment presented to our emergency department (ED) because of progressive exertional dyspnea and bilateral lower limbs swelling. At admission in the ED, arterial pressure was 188/86 mmHg, heart rate was 84 bpm and oxygen blood saturation was 96%. Physical examination confirmed bilateral symmetrical lower limbs pitting edema and bilateral rales at thoracic auscultation. Both laboratory and imaging findings were suggestive of acute decompensated heart failure (HF): BNP was 421 pg/mL and chest X-rays showed signs of congestion, mild pleural effusion and an enlarged cardiac shadow. Cardiac ultrasound revealed left ventricular concentric hypertrophy, mild left atrial enlargement and mild–moderate diastolic dysfunction (LVEF 60%, E/A 0.81, E/Eʹ 17, PAPS 30–40 mmHg). The patient was, thus, treated with intra-venous Furosemide and admitted to our Internal Medicine department with a diagnosis of “acute heart failure with preserved ejection fraction”.