Here’s another case: 49 yo woman w/obesity (BMI 46), HTN, OSA on CPAP, schizoaffective with new-onset HFpEF (leg swelling, dyspnea, ⬆️JVP, BNP 226 pg/ml, LVEF 65%). Low H2FPEF score = 4 (obesity, HTN meds, E/e’ = 10). What's the diagnosis? More info....
Hospitalized 6 months ago with psychotic break, treated with uptitration of anti-psychotics, now back to baseline mental status. 60-lb weight gain over past 6 mo. Also +lightheaded/dizzy. Here's the echo: 
More info: normal thyroid function, normal hemoglobin, no eosinophilia. She was taking lamotragine, risperidone, and citalopram for her schizoaffective disorder. RHC: RA 13, PA 37/24, PCWP 24, CO 9.2 L/min.
Answer: risperidone toxicity. Rapid weight gain was associated with NASH which ⬇️risperidone metabolism by liver. Citalopram also ⬇️risperidone metabolism. Both worsened weight gain. Obesity + NASH = high-output HF. ⬆️Risperidone = orthostatic hypotension.
Risperidone level checked and was ⬆️⬆️. It was weaned off with gradual weight loss and resolution of all symptoms. BNP returned to normal. Fluid overload resolved.
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