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Congestive Heart Failure Presenting as Shortness of Breath

Joseph Carter

Abstract

The case being presented is one of congestive heart failure that was diagnosed in the emergency
department. The clinical history and diagnostic findings are discussed.

1. Introduction

Congestive heart failure is a severe cardiovascular disease that when left untreated can increase the
chances of death. It is very common in the United States and affects millions of people, especially
those over the age of 65 [1]. Emergency physicians should maintain suspicion of congestive heart
failure when patients show symptoms of pneumonia.

Risk factors for developing CHF are age, obesity, history of heart attacks, and congenital heart defects;
the main risk is age and it increases as people get older and the heart muscles weaken [2].

2. Case Presentation

An 88-year-old male presented due to a severe shortness of breath along with chronic weakness. He
stated that he was feeling light headed and checked his vitals which showed an abnormal heart rate
with low blood pressure and oxygen saturation. This led him to go to the emergency department. He
stated that he lives in an assisted living center and has difficulty walking and moving around so he
usually does not move a lot during the day. His past medical history was notable for atrial fibrillation.

Review of symptoms was positive for pulmonary system concerning patient's shortness of breath. The
patient denied fever, chills, chest pain, abdominal pain, nausea, vomiting, diarrhea, urinary systems, or
head ache. The patient had no allergies and his tetanus status was up to date.

Patient's vital signs were as follows: blood pressure 201/74 mmHg; pulse 69/min; SpO2 94%;
temperature 98.4 oF. On physical exam, he was alert and oriented to person, time, and place and in no
acute distress. However, during pulmonary exam rales were heard in the lungs.

Laboratory analysis revealed a normal white blood cell count and CBC was within normal limits. The
initial troponin tests were negative. Urinalysis showed no alarming abnormalities.

AP radiograph of the chest shows that the heart and pulmonary veins are dilated. There is a blurred and
indistinct pulmonary vasculature which indicates interstitial pulmonary edema (Figure 1).
Figure 2: AP chest radiograph demonstrating dilated heart and pulmonary veins (arrows).

At first, the patient's presentation was very concerning in the initial differential diagnosis for
pneumonia until lab analysis and chest x-ray showed that his shortness of breath was caused by
congestive heart failure. The patient was given Lasix for the edema. He was admitted to the hospital
and treated for the edema then given medication to take when at his nursing home.

3. Discussion

Congestive heart failure (CHF) is the collection of fluid in the lungs and extremities due to the heart's
inability to effectively pump blood through the blood vessels. Blood begins to build up in the vessels
which leads to an increased blood pressure in the body. The fluid from the blood is then pushed through
the capillary wall into the alveoli and reduces oxygen flow, causing shortness of breath. CHF can
happen due to different abnormalities. Systolic failure happens when the heart muscles are stretched
and cannot pump blood and often leads to a dilated left ventricle [3]. Diastolic failure happens when the
left ventricle cannot relax because it is stiff so blood entering the heart backs up and fluid causes the
heart tissues and surrounding veins to swell [4]. There are instances where it is difficult to distinguish
pulmonary edema (a symptom of CHF) from pneumonia, however, there are certain distinctions
between the two. Pneumonia is an inflammation of the lungs due to an infection that creates puss or
fluid which travels to the alveoli. On a chest x ray, pneumonia can cause a symmetric pattern that
simulates lung edema since E. coli and other bacteria can move rapidly across the lungs [3]. Pneumonia
also resides around the bronchus where harmful microorganisms reside. Pulmonary edema leads to
fluid flooding the alveoli as well but can lead to thickened pulmonary veins and CHF can cause the left
atrium to increase in size. The enlargement of the heart is a clear giveaway for CHF instead of
pneumonia. It is very important to differentiate between the two since both require different treatment
and can continue to target different parts of the body. If congestive heart failure is not properly
diagnosed and treated, there will be further damage to other organs such as the kidneys, liver, and lungs
because they all require oxygen which travels by blood flow. Therefore, it is imperative that CHF not
be dismissed as pneumonia or other lung diseases. Treatment of this condition is based on the type of
heart failure a patient has, but they are always given medication and may be put on a special diet with
some exercise. Prognosis for patients who are diagnosed early have a favorable outcome where not
only symptoms are treated but there is the possibility of the disease being reversed [5].

References
1. A. Bui, T. Horwich, and G. Fonarow (2011). Epidemiology and risk profile of heart failure.
Nature Reviews Cardiology, 8, 30-41. doi: 10.1038/nrcardio.2010.165

2. n.a. (2015, June 22) Who is at risk for heart failure? National Heart, Lung, and Blood Institute.
Retrieved from: http://www.nhlbi.nih.gov/health/health-topics/topics/hf/atrisk

3. H. Simon and D. Zieve (2012, May 28). Heart failure. University of Maryland Medical Center.
Retrieved from: http://umm.edu/health/medical/reports/articles/heart-failure

4. S. Ghanem, A. Gouda, H. Jahdali, and A. Khan (2009). Reading chest radiographs in the
critically ill (part II): radiography of lung pathologies common in the icu patient. Annals of
Thoracic Medicine, 4, 149-157. doi: 10.4103/1817-1737.53349

5. B. Berry (2016, Feb. 23). Early diagnosis of congestive heart failure can lead to better
outcomes. Ravalli Republic. Retrieved from:http://ravallirepublic.com/lifestyles/health-med-
fit/article_3df07a90-daa0-11e5-94b8-7ff39e27b2b2.html