CASE DISCUSSION 4 : HEART FAILURE

K.mounika

Roll no 86

I have been given this case to solve in an attempt to understand the topic of patient clinical data analysis and to develop competency in reading & comprehending clinical data including history,clinical findings,investigations & come up with a diagnosis & treatment plan

My analysis of this case is found in the link below

https://86kethavathmounika.blogspot.com/2020/05/k.html

Original links

https://madhur116.blogspot.com/2020/05/on-1452020.html?m=1

http://hitesh116.blogspot.com/2020/05/elog-14th-may-2020.html

CHIEF COMPLAINTS IN CHRONOLOGY ARE :-

1.Fever

2.Shortness of breath

3.B/L pedal edema

4.Generalised weakness

1.FEVER - with chills,high grade,relieved on  anti malarial medication

    Propable causess:-

   a)malaria

  b)pulmonary infection

  c)bacterial endocarditis

  d)meningitis/viral infections

2.DYSPNEA -SINCE 2 WEEKS

  -initially NYHA grade3,after treatment grade 2

  - h/o paroxysmal noctural dyspnea

DYSPNEA CAUSES

PATHOPHYSIOLOGY

DYSPNEA DUE DISEASES OF RESPIRATORY SYSTEM

1)BROCHIAL ASTHMA– The cause is chronic inflammation of the airways leading to variable airway obstruction. The patients complain of frequent attacks of shortness of breath, often at night as well.The precipitating factors can include respiratory irritation, allergen exposure, exercise, weather changes, and (respiratory tract) infections. Auscultation reveals expiratory wheezes due to obstruction. Spirometry shows a decrease in both the forced expiratory volume at one second (FEV1) and the peak expiratory flow (PEF), both of which may be normal in the asymptomatic interval between episodes. The obstruction, & the symptoms, improve markedly after the inhalation of a bronchodilator drug. Episodes of acute dyspnea in a patient with asthma are called exacerbations. Tachypnea, wheezes, and a prolonged expiratory phase are typical clinical findings 

2)COPD

COPD is generally characterized by a fixed obstruction of the lower airways.

COPD – Chronic bronchitis is present, according to WHo, when cough and discharge have been present for at least 3 months in at least two consecutive years. In COPD, chronic inflammation leads to destruction of lung parenchyma and thereby to overinflation of the lungs and a decline in elastic restorative forces. COPD is usually characterized by a fixed obstruction of the lower airways. Pulmonary function tests and body plethysmography afford further diagnostic help. The Tiffeneau index (FEV1/IVC, where IVC is the inspiratory vital capacity) is typically under 0.7, and the residual volume may be elevated as an expression of overinflation of the lungs.  -

- Abnormally low CO diffusion indicates emphysema. A plain chest x-ray reveals flattened diaphragm shadows and often rarefaction of the pulmonary vasculature.

3)PNEUMONIA

Pleuritic pain, fever, and cough are typical symptoms of pneumonia. The physical findings include tachypnea, inspiratory rales, and sometimes bronchial breathing.

Pneumonia—Dyspnea is the main symptom of pneumonia primarily in patients over age 65 (ca. 80%) . Pleuritic pain, fever, and cough are typical accompanying symptoms. Examination reveals tachypnea, inspiratory rales, and sometimes bronchial breathing. Laboratory testing (inflammatory parameters; hypoxemia in arterial blood gas analysis, in severe cases), chest x-ray, and in some cases chest CT are diagnostically helpful.

4)INTERSTITIAL LUNG DISEASES—Patients report chronic shortness of breath and nonproductive cough, and they are often smokers . Examination reveals crackling rales at the bases, and sometimes also digital clubbing and hourglass nails.

Pulmonary function testing reveals low vital capacity (VC) and total lung capacity (TLC), a high normal Tiffeneau index, and reduced CO diffusion.

5)PULMONARY EMBOLISM—The clinical picture of acute pulmonary embolism is often characterized by dyspnea of acute onset. Patients often report pleuritic pain and sometimes have hemoptysis. Examination reveals shallow breathing and tachycardia. There is often evidence of a deep venous thrombosis of the lower limb as the source of the pulmonary embolism.

DYSPNEA DUE TO DISEASES OF CARDIOVASCULAR SYSTEM

1)HEART FAILURE as a cause of dyspnea

Aside from dyspnea, patients also have other symptoms including fatigue, lessened physical performance, and fluid retention. Both HFrEF and HFpEF are associated with low stroke volume.

Heart failure—Along with dyspnea, there are other symptoms including fatigue, diminished exercise tolerance, and fluid retention. The common causes are advanced coronary heart disease, primary cardiomyopathy, hypertension,Diabetes type 2 and valvular heart disease.In all types of congestive heart failure, the stroke volume and cardiac output are diminished

This might be the cause for pt presentation as 

     -2D ECHO revealed:EF-27%,IVC dilated(2.3cm)not collapsing,mild TR+,severe MR+,trivial AR+,dilated all chambers ,global hypokinesia,severe LV dysfunction,mild PAHT,no MS/AS,no PE/LV clot - which  suggest Left ventricular failure due to reduced ejection fraction

2)CORONARY HEART DISEASE—Dyspnea can also be a symptom of coronary stenosis, even if it is not a “classic” symptom . It can be present simultaneously with angina pectoris, or as the predominant or sole symptom of coronary heart disease, e.g., in a patient with diabetes mellitus.

Coronary heart disease

Exertional dyspnea may be an atypical sign of coronary heart disease.

Patients with dyspnea of unclear origin should be evaluated for possible coronary heart disease. The assessment includes conventional ergometry as well as stress tests in combination with imaging studies, such as stress echocardiography, myocardial perfusion scintigraphy, and stress magnetic resonance tomography.

        Dyspnea more typically arises as part of the constellation of symptoms in an acute coronary syndrome or myocardial infarction, as well as in cardiogenic shock as a consequence of low cardiac output.

3)VALVULAR HEART DISEASE– Among elderly patients in particular, valvular heart disease is a further possible cause of dyspnea. The most common valvular diseases are aortic valvular stenosis and mitral insufficiency. Typical findings of aortic valvular stenosis include diminished physical performance, episodes of collapse, syncope, and dizziness, and, sometimes, chest pain resembling angina pectoris. Auscultation often points to the diagnosis (a rough systolic heart murmur heard loudest parasternally over second intercostal space, with projection into the carotid arteries). Patients with mitral insufficiency present with signs of heart failure. The ECG often reveals atrial fibrillation due to volume overload of the left atrium. Here, too, auscultation points to the diagnosis (a holosystolic murmur over the cardiac apex, sometimes projected into the axilla). Echocardiography is the definitive diagnostic study.

 -AORTIC STENOSIS & MITRAL INSUFFICIENCY are most common causes of valvular heart diseases causing dyspnea

DYSPNEA DUE TO DISEASES OUTSIDE THE CARDIOVASCULAR & RESPIRATORY SYSTEM

*The WHO defines anemia as a hb value (<13 g/dL)in men or (12 g/dL) in women. There is no sharp threshold value of Hb below which anemic patients become dyspneic.

*Mental illnesses such as anxiety disorders, panic disorders, somatization disorders, or “functional complaints” should be regarded as diagnoses of exclusion after an extensive somatic work-up has been performed. Improvement of dyspnea with distraction or physical exercise may be a clue to a disturbance of this type.

* Iatrogenic (pharmacological) causes of dyspnea 

*Diseases of the ears, nose, and throat that affect the airways can also cause dyspnea. In disturbances of the upper airways, the main symptom other than dyspnea is stridor (expiratory in bronchopulmonary airway compromise, inspiratory in supraglottic airway compromise, biphasic in airway compromise at or just below the glottis). A rule of thumb states that dyspnea arises when the tidal volume is reduced by 30% . Possible causes include congenital malformations, infections, trauma, neoplasia, and neurogenic disturbances.

*Neuromuscular diseases that can cause dyspnea include muscle diseases such as Duchenne muscular dystrophy, myasthenia, motor neuron diseases such as amyotrophic lateral sclerosis, and neuropathies such as Guillain-Barré syndrome. In most cases, these diseases have other neurological manifestations aside from dyspnea.

3) PEDAL EDEMA(B/L) - up to knees,pitting type & progressive- frm 2wks

  Possible causes:

1)Heart failure:

2)Dilated cardiomyopathy (DCM) 

Valvular disease:  rheumatic disease, mitral stenosis and aortic disease were both considered, but auscultatory exam did not reveal any murmurs. The patient did not meet the Duke criteria for infective endocarditis.

3)Acute myocarditis (from HIV or other viral etiologies): Although this may have been the historical etiology of cardiac dysfunction, lack of acuity and absence of chest pain made this less likely as an acute presentation.

4)High output failure in setting of chronic anemia, thyrotoxicosis, or nutritional deficiency (eg, wet beriberi from thiamine deficiency): The patient appeared well nourished and without signs of thyroid dysfunction,and no anemia

5)Endomyocardial fibrosis: This also represents a local etiology of diffuse edema, but has no association with HIV.

6)Congenital disease: Eisenmenger syndrome can present at a later stage in life and does have increased prevalence with vertical transmission of HIV.

(7)Ischemia: Though this is the most common cause of heart failure.

(8)Cardiac tumors (eg, atrial myxoma or cardiac Kaposi sarcoma): These are rarely seen.

●Constrictive pericarditis/effusion: 
  *Infectious etiologies (tuberculin, fungal, parasitic, or HIV associated) predominate as causes of constrictive pericarditis.

 *Malignancy, such as lymphoma in the setting of HIV or autoimmune diseases, also was possible. In regard to constrictive disease, however, there was no evidence of pulsus paradoxus or Kussmaul sign upon examination. An auscultatory examination was notable for easily audible Korotkoff sounds without a rub, and an electrocardiogram (EKG) was unrevealing.

●Pulmonary hypertension: Etiologies considered include schistosomiasis, HIV, rheumatic disease, portal hypertension, and congenital cardiac disease

●Cirrhosis: Etiologies of cirrhosis common to include hepatitis B, alcohol use, aflatoxin poisoning (for hepatocellular cancer development), schistosomiasis, and granulomatous disease.However, physical examination revealed no stigmata of liver disease, and there was  only h/o occasional alcohol use. Serum albumin was checked to rule out other etiologies of hypoalbuminemia (eg, protein-losing enteropathy and kwashiorkor).

●Renal failure: Although the nephrotic syndrome and tubular/interstitial kidney disease can lead to volume overload, the patient showed no evidence of renal dysfunction. He continued to have excellent urine output with normal-appearing urine

●Thyroid diseases - very rare

PAST HISTORY: not significant

PERSONAL HISTORY:

 -Mixed diet

 -Appetite & bowel & bladder habitsregular

 -H/O Alcohol and smoking occasionally

GENERAL EXAMINATION:

- consious,coherent & cooperative,well built and well nourished

-vitals within limits

-No pallor,Icterus,cyanosis,clubbing,lymphadenopathy

Edema upto knees (grade2)

ON EXAMINATION:

-CVS: S1, S2heard

-RS: right ISA early inspiratory crepts +

-P/A:soft and non tender

CNS: 

High mental functions normal

Cranial nerves intact

Motor and Sensory system normal

No meningeal and cerebellar signs

ON EXAMINATION OF NECK:

-JVP: was found to be raised(20 cm of H2O)

visible in 45 degrees near clavicle and at 90 degrees

-USG abdomen:right moderate pleural effusion ,grade1 fatty liver,mild ascites

DIAGNOSIS: heart failure with reduced ejection fraction secondary to viral myocarditis with denovo DM type 2

QUESTIONS:-

(1) POSSIBLE ANATOMICAL LOCATIONS FOR DYSPNEA ARE:

(2).PATHOPHYSIOLOGY OF  DYSPNEA & EDEMA IN HEART FAILURE:-

(3)INVESTIGATIONS DONE ARE:-

      -2D echo with doppler to asses ventricular function,size,wall thickness,wall motion & valve function

      - Echocardiography it hepls to define type & etiology of heart failure

      -others like CBP,BNP,serum electrolytes,BUN & creatinine,LFT,urine analysis,RBS,TSH,Arterial blood gas,lipid profile,cardiac troponins
(4) NON PHARMACALOGICAL TREATMENT:-
Life style cahnges - diet low in salt,fat,high fibre diet
Cessation of smoking & alcohol
Activity & exercise,weight reduction

(5)PHARMACOLOGOlCAL TREATMENT:-

  *Diuretics-furosemide,hydrochlorthiazide,metolazone

  *ACE inhibitors- captopril,lisinopril,enalapril

  *Angiotesin receptor blockers- losartan,valsartan

  *Beta blockers - bisoprolol,carvedilol

  * Aldosterone receptor antagonists -spironolactone

MECHANICAL CIRCULATORY SUPPORT

  - Intraaortic balloon pump(IABP)

  - Ventricular assist devices(VAD)

  - Cardiomyoplasty

  - Ventricular reduction

  - Transplant/artificial heart

COMMENTS:

1) What is reason for ascitis in this patient with heart failure?

2)What might be the  underlying mechanism for diaphragmatic muscle overwork leading to dyspnea in heart failure?

3)Is there any cause for right heart failure other than LVF?