New York Heart Association Functional Classification of Heart Failure
Limitations of Physical Activity
Heart Failure Symptoms
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A 65-year-old man with a history of ischemic cardiomyopathy, congestive heart failure, diabetes mellitus, and chronic kidney disease presents to the emergency room with progressive dyspnea on exertion and weight gain for 8 days. Vitals signs are T 99.0, HR 110, BP 130/90, RR 24, SpO2 94% on room air. Physical examination reveals an S3 gallop, 2+ peripheral pitting edema, and marked jugular venous distention. Laboratory results show a serum creatinine of 1.2 mg/dL compared with the patient's normal baseline value of 1.1 mg/dL. The patient's chest radiograph is shown in Image A. A serum troponin is drawn and found to be 0.04 ng/mL. Which of the following medications is indicated first in the care of this patient?
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This patient is suffering an episode of acute decompensated heart failure. The patient's history of ischemic cardiomyopathy and CHF along with a negative troponin level point toward this diagnosis. This patient is volume-overloaded and requires a diuretic to decrease preload to his heart. Furosemide, a loop-diuretic, will decrease preload and is the best choice. (Note that the other drugs listed are used for chronic CHF management and/or in the case of CHF refractory to furosemide treatment.)
Acute decompensated heart failure is also known as acute congestive heart failure (CHF) exacerbation. Congestive heart failure is the inability of the heart to pump blood sufficiently to meet the metabolic demands of the body, or the ability to do so only at abnormally high cardiac filling pressures. In systolic heart failure, the heart cannot expel blood sufficiently, while in diastolic heart failure the heart cannot relax and fill with blood normally. Systolic heart failure is demonstrated by a decreased ejection fraction.
Vine reviews the etiologies and treatment of congestive heart failure: "Causes of congestive heart failure include hypertension, coronary artery disease, alcohol abuse and valvular heart disease...Medical management primarily consists of vasodilators, diuretics and inotropic agents."
The patient described in the question stem is based on the patient seen in the case report by Paul et al. who presented with acute decompensated heart failure and received 20 mg/hr IV furosemide on admission, followed by mitolazone and dobutamine on hospital day 2 in an attempt to increase diuresis.
Image A shows the classic appearance of a chest radiograph of a patient with CHF exacerbation. Note the pulmonary edema and cardiomegaly typical of this disease.
Answer 1: Enalapril is an ACE inhibitor that decreased mortality when used in the treatment of systolic heart failure. It is not the most appropriate first line agent for ADHF in this patient.
Answer 3: Dobutamine is sympathomimetic used in the treatment of heart failure, but furosemide is a more appropriate first line agent in this patient.
Answer 4: Hydralazine is used in the treatment of hypertension and is not the most appropriate first line agent in the treatment of this patient.
Answer 5: Dopamine is an ionotropic and chronotropic drug used in the treatment of heart failure. However, furosemide is a more appropriate first line agent in this patient.
Am Fam Physician. 1990 Sep;42(3):739-52. PMID: 2203240 (Link to Abstract)
Paul E H R, Camarda R, Foley LL, Givertz MM, Cahalin LP.
Cardiopulm Phys Ther J. 2011 Jun;22(2):13-8. PMID: 21637393 (Link to Abstract)
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A 60-year-old Caucasion male presents to your office complaining of shortness of breath on exertion. He undergoes an echocardiogram and is found to have an ejection fraction of 35%. Which of the following classes of drugs would decrease mortality in this patient?
Calcium channel blockers
The patient in the question stem has systolic heart failure as evidenced by his decreased ejection fraction. Beta blockers, angiotensin converting enzyme (ACE) inhibitors, and angiotensin receptor blockers (ARBs) have been shown to decrease mortality in the treatment of systolic heart failure. Spironolactone and eplerenone have additionally been shown to provide a mortality benefit.
Heart failure is the inability of the heart to pump blood sufficient enough to meet the metabolic demands of the body, or the ability to do so only at abnormally high cardiac filling pressures. In systolic heart failure, the heart cannot expel blood sufficiently, while in diastolic heart failure the heart cannot relax and fill with blood normally. Systolic heart failure is demonstrated by a decreased ejection fraction.
Answers 1-3 & 5: Although all of these drug classes may provide symptomatic relief in the treatment of systolic heart dysfunction, of the choices listed, only ACE inhibitors decrease mortality.
Average 4.0 of 2 Ratings
A 68-year-old male suffered a myocardial infarction two weeks ago. Since this incident, he has reported increased shortness of breath with both activity as well as when lying flat; he has also noted increased swelling in his ankles. Physical exam is significant for an S3 gallop on cardiac auscultation, bibasilar crackles on lung auscultation, and 2+ edema of the bilateral ankles. Which of the following sets of cardiac parameters would most likely be associated with this patient's current condition? (Cardiac index = CI; Systemic vascular resistance = SVR; Left ventricular end diastolic pressure = LVEDP)
Decreased CI, decreased SVR, increased LVEDP
Decreased CI, increased SVR, decreased LVEDP
Decreased CI, increased SVR, increased LVEDP
Increased CI, decreased SVR, increased LVEDP
Increased CI, increased SVR, decreased LVEDP
This patient is suffering from systolic heart failure. He would be expected to have a decreased cardiac index, increased systemic vascular resistance, and increased left ventricular end diastolic pressure.
Systolic heart failure is due to a weakened pumping function of the heart secondary to ischemic heart disease, chronic hypertension, or cardiomyopathy. This is in contrast to diastolic heart failure, which is characterized by the inability of the heart to sufficiently relax and fill with blood. Causes of diastolic heart failure may include hypertension leading to left ventricular hypertrophy, hypertrophic cardiomyopathy, amyloidosis, sarcoidosis, hemochromatosis, scleroderma, and fibrosis (either post-operative or radiation-induced).
Answer 1: Decreased systemic vascular resistance occurs due to systemic vasodilation, which may be a sequela of sepsis (most common), pancreatitis, cirrhosis, adrenal insufficiency, head injury, or beriberi.
Answer 2: Decreased LVEDP occurs in mitral stenosis.
Answers 4 & 5: Increased cardiac index may be seen in patients suffering from high-output cardiac failure; causes of this may include AV fistula, anemia, hyperthyroidism, beriberi, renal disease, hepatic disease, or sepsis.
Average 2.0 of 10 Ratings
A 69-year-old is hospitalized for worsening dyspnea at rest. Physical examination is notable for crackles at both lung bases and 2+ edema at the ankles bilaterally. Current medications include losartan, metoprolol, furosemide and spironolactone. An EKG and echocardiography are ordered. Which of the following results would serve as the best indication for placement of an implantable cardioverter defibrillator (ICD) in this patient?
Supraventricular tachycardia on EKG
Atrial fibrillation on EKG
Reduced diameter of aortic valve on echocardiography
Reduced left ventricular ejection fraction on echocardiography
Left ventricular hypertrophy on echocardiography
The single best indication for placement of an ICD in an adult is an ejection fraction less than 35%.
ICDs prevent sudden cardiac death from ventricular arrythmias. ICDs detect arrythmias and deliver a defibrillating shock to the heart to restore normal rhythm. ICDs are believed to be successful in terminating over 95% of ventricular arrythmias. Left ventricular systolic dysfunction, as indicated by an ejection fraction less than 35%, is currently the best indicator of benefit from ICD placement as primary prevention.
Turakhia reviews ICD placement. Patients with a history of myocardial infarction, coronary artery disease, cardiomyopathy, or heart failure, should have their ejection fraction evaluated. Other risk factors include nonsustained ventricular tachycardia, syncope, structural heart disease, and inherited heart failure or arrhythmia syndromes. Afflicted patients should discuss ICD placement with their cardiologist.
Ezekowitz et al. reviewed 12 randomized controlled trials with a total of 8,516 patients and concluded that ICDs reduced all-cause mortality for patients with left systolic dysfunction by 20%. The authors note that improved risk-stratification tools would be helpful in determining patients most likely to benefit from an ICD.
Illustration A shows a chest radiograph after placement of an ICD. The ICD generator lies in the upper left chest and the ICD lead in the right ventricle of the heart. Two opaque coils are present along the ICD lead.
Answer 1: Supraventricular tachycardia on EKG should be converted to sinus rhythm in the acute setting.
Answer 2: Atrial fibrillation indicates a need for anticoagulation therapy in patients with heart failure.
Answer 3: Aortic stenosis as a cause of heart failure is an indication for valve replacement.
Answer 5: Left ventricular hypertrophy is commonly seen in heart failure, but is not in itself an indication for ICD placement.
Am Fam Physician. 2010 Dec 01;82(11):1357-66. PMID: 21121520 (Link to Abstract)
Ezekowitz JA, Rowe BH, Dryden DM, Hooton N, Vandermeer B, Spooner C, McAlister FA.
Ann Intern Med. 2007 Aug 21;147(4):251-62. PMID: 17709759 (Link to Abstract)
Ezekowitz, ANIM 2007
A 69-year-old male presents to the emergency department with shortness of breath. The patient has presented three times this past month with similar complaints. The patient sees no primary care physician and is currently not taking any medications. The patient states his shortness of breath started when he was walking from his car to a local restaurant. His temperature is 99.5°F (37.5°C), pulse is 100/min, blood pressure is 130/90 mmHg, respirations are 18/min, and oxygen saturation is 96% on room air. On physical exam you note a fatigued appearing gentleman. Cardiovascular exam reveals an additional heart sound after S2. Pulmonary exam is notable for bilateral crackles. Abdominal exam reveals an obese abdomen without pain in any of the quadrants. Lower extremity pitting edema is noted bilaterally. Which of the following sets of lab values most likely corresponds to this patient's presentation?
High BNP, high ADH, high sodium, high potassium
High BNP, low ADH, normal sodium, low potassium
High BNP, high ADH, low sodium, low potassium
Low BNP, high ADH, low sodium, low potassium
Low BNP, low ADH, normal sodium, normal potassium
This patient is presenting with symptoms of congestive heart failure (CHF). The most likely laboratory abnormalities are elevated brain natriuretic peptide (BNP), high anti-diuretic hormone (ADH), low sodium, and low potassium.
As the ventricles dilate, they release BNP, a marker of CHF, and the kidneys tend to be underperfused leading to two key physiologic changes. First is the activation of the renin-angiotensin-aldosterone system, which serves to increase perfusion to the kidneys by increasing blood pressure, resulting in sodium and fluid retention at the expense of potassium (hypokalemia) and hydrogen (metabolic alkalosis). In addition, ADH is also increased to further increase perfusion, resulting in hemodilution and hyponatremia.
Answer 1: High BNP, high ADH, high sodium, and high potassium does not reflect the changes that would be seen in CHF. Though aldosterone serves to retain sodium, it also absorbs water. Thus, hypernatremia would not be seen.
Answer 2: High BNP, low ADH, normal sodium, and low potassium does not reflect the appropriate increase in ADH and subsequent decrease in sodium that would be seen in CHF.
Answer 4: Low BNP, high ADH, low sodium, and low potassium does not reflect the finding of elevated BNP that is classically found in the dilated ventricles of CHF.
Answer 5: Low BNP, low ADH, normal sodium, and normal potassium reflects the findings in a healthy patient.
Congestive heart failure (CHF) presents with crackles, JVD, ascites, edema, a S3 heart sound, fatigue, and shortness of breath, with common lab findings of elevated BNP, elevated ADH, low sodium, and low potassium.
Average 5.0 of 2 Ratings
heart sounds s3 third heart sound Graettinger WF, Weber MA. Left ventricular hyp...