Chronic Heart Failure Case File

https://medical-phd.blogspot.com/2021/04/chronic-heart-failure-case-file.html

Eugene C. Toy, Md, Michael d . Faulx, Md

Case 19
A 72-year-old man is seen in your clinic for dyspnea on exertion. Over the past week, he has
noticed worsening shortness of breath with moderate amounts of housework and when walking to
his car. He has also noticed difficulty falling asleep, so he has been sleeping in his recliner chair.
Two weeks ago, his children were in town and they ate out frequently at fast-food restaurants. The
patient has a history of hypertension, hyperlipidemia, and a myocardial infarction 3 years prior. His
medications are aspirin, lisinopril, and atorvastatin. On examination, he appears tachypneic but not
in respiratory distress. His temperature is 98.9°F, heart rate 94 bpm, blood pressure 134/74 mmHg,
respirations 24 per minute, and 02 saturation 93% on room air. Cardiac auscultation reveals a
regular rate and rhythm without murmurs or rubs. A low-pitched gallop is heart after the second
heart sound. There are wet crackles at the bases of both lungs bilaterally. The abdomen is soft
without organomegaly. The extremities are well perfused, and there is 1+ bilateral pedal and
presacral edema. Jugular venous distension is 12 cm. ECG shows sinus rhythm with Q waves in
V1-V4. Results of a complete blood count and chemistry panel are unremarkable.

 What is the most likely diagnosis?

 What is the best next diagnostic step?
 What is the best next step in therapy?

Answer to Case 19:

Chronic Heart Failure

Summary: A 72-year-old man with a history of hypertension, hyperlipidemia, and an old

myocardial infarction presented with worsening dyspnea on exertion. His exercise tolerance has
worsened after a week of eating high-sodium foods. He is mildly tachypneic on exam with
borderline low oxygen saturation. He has an S3 gallop, crackles, lower extremity edema, and
elevated neck veins on exam. An ECG reveals Q waves in the anteroseptal leads signifying an old
myocardial infarction.

 Most likely diagnosis: Acute heart failure exacerbation.

 Next diagnostic step: Echocardiography.
 Next step in therapy: Loop diuretics.

ANALYSIS

Objectives

1. Recognize the signs and symptoms of heart failure.

2. Know the diagnostic approach and common etiologies of systolic heart failure.
 3. Understand the medical and device management for chronic systolic heart failure.

Considerations
This 72-year-old man presented to clinic with worsening dyspnea on exertion and physical exam
findings of volume overload (wet profile) and heart failure. The first priority in the office should be
to assess his vital signs and tissue perfusion. Signs of low tissue perfusion (cold profile) are
hypotension, cold extremities, altered mental status, elevated creatinine, abnormal liver
transaminases, and an elevated lactate. Patients with abnormal tissue perfusion should be triaged to
a higher level of care. Our patient did not show signs of low tissue perfusion and falls into the
“warm and wet” category. Further categorization of heart failure into systolic or diastolic is an
important step and can be accomplished by echocardiography. Equally important is determining the
etiology of the heart failure. For our patient, systolic heart failure and ischemic cardiomyopathy are
the most likely scenarios given his old anterior myocardial infarction. Treatment centers around
relieving acute congestion, starting evidence-based medical therapy, and educating patients on diet
and lifestyle changes needed to prevent further exacerbations and improve mortality.

Approach To:
Chronic Heart Failure

DEFINITIONS

HEART FAILURE: A clinical syndrome characterized by shortness of breath or fatigue as a result

of underlying structural or functional heart disease.

CARDIOMYOPATHY: Disease or dysfunction of the myocardium. Cardiomyopathies are

commonly categorized as ischemic or nonischemic. Further classifications are based on ventricular
structure or etiology (dilated, hypertrophic, restrictive, Takotsubo, alcoholic, etc).

ORTHOPNEA: Shortness of breath in a recombinant position.

PAROXYSMAL NOCTURNAL DYSPNEA: Respiratory distress that awakens the patient from

sleep.