Good

1. Case
Study
Associate Professor Dr Marjan

2. A 72-year-old man presents to the clinic
complaining of several weeks of
worsening exertional dyspnea.

3. Previously, he had been able to work in his garden and mow the lawn,
but now he feels short of breath after walking 100 feet. He does not
have chest pain when he walks, although in the past he has
experienced episodes of retrosternal chest pressure with strenuous
exertion. Once recently he had felt lightheaded, as if he were about to
faint while climbing a flight of stairs, but the symptom passed after he
sat down. He has been having some difficulty sleeping at night and
has to prop himself up with two pillows. Occasionally, he wakes up at
night feeling quite short of breath, which is relieved within minutes by
sitting upright and dangling his legs over the bed. His feet have
become swollen, especially by the end of the day.
History of present
illness

4. Past Medical History
He denies any significant medical history
Drug History
Takes no medications, and prides himself on the fact that he has not
seen a doctor in years
Social History
He does not smoke or drink alcohol

5. Physical examination
u He is afebrile, with a heart rate of 86 bpm, blood pressure of 115/92 mm Hg, and
respiratory rate of 16 breaths per minute.
u Examination of the head and neck reveals pink mucosa without pallor, a normal thyroid
gland, and distended neck veins.
u Bibasilar inspiratory crackles are heard on examination.
u On cardiac examination, his heart rhythm is regular with a normal S1 and a second
heart sound that splits during expiration, an S4 at the apex, a nondisplaced apical
impulse, and a late-peaking systolic murmur at the right- upper sternal border that
radiates to his carotids.
u The carotid upstrokes have diminished amplitude.

6. Congestive heart failure (CHF),
possibly as a result of aortic
stenosis.
Echocardiogram to assess the aortic valve area as
well as the left ventricular systolic function
What is the most likely
diagnosis?
What test would confirm the
diagnosis?

7. u The Framingham criteria for the diagnosis of heart failure consists of
the
concurrent presence of either two major criteria or one major and two minor criteria
Major criteria comprise the following:
• Paroxysmal nocturnal dyspnea
• Weight loss of 4.5 kg in 5 days in response
to treatment
• Neck vein distention
• Rales
• Acute pulmonary edema
• Hepatojugular reflux
• S 3 gallop
• Central venous pressure greater than 16
cm water
• Circulation time of 25 seconds or longer
• Radiographic cardiomegaly
• Pulmonary edema, visceral congestion, or
cardiomegaly at autopsy
Minor criteria (accepted only if they
cannot be attributed to another medical
condition) are as follows:
• Nocturnal cough
• Dyspnea on ordinary exertion
• A decrease in vital capacity by one
third the maximal value recorded
• Pleural effusion
• Tachycardia (rate of 120 bpm)
• Hepatomegaly
• Bilateral ankle edema

11. ECG
Among the ECG markers they may have…
u higher resting heart rate and other dysrhythmia (AF, … ),
u prolonged QRS duration,
u abnormal time to ID (Intrinsicoid deflection (ID) corresponds to the peak of the R wave,
“R-wave peak time”),
u left-axis deviation,
u abnormal QRS-T angle,
u left ventricular hypertrophy,
u ST/T-wave abnormalities, and
u left bundle-branch block were significantly associated with all HF events

12. HF r
EF
In HFrEF, cardiac output is reduced due to depressed myocardial
contractility, irrespective of the aetiology. This will result in the following
compensatory mechanisms:
u A higher ventricular end diastolic pressure - This is a compensatory
mechanism to increase stroke volume by the Frank Starling
mechanism.
u Neurohormonal activation of the:
 Sympathetic nervous system
 Renin-angiotensin-aldosterone system
 Vasopressin
There are effective medical and device therapies that have been shown
to have survival benefit in HFrEF.

13. HF p
EF
u About 50% of patients presenting with HF have normal systolic
function with predominantly diastolic dysfunction.
u Diastolic dysfunction leads to impaired left ventricular (LV) filling due to
decreased relaxation (during early diastole) and/or reduced compliance
(early to late diastole) leading to elevated filling pressures.
u These haemodynamic changes are accompanied by predominantly
signs of pulmonary and/or venous congestion and occasionally
systemic hypoperfusion as well.
u There is limited data available on therapies that improve survival in
HFpEF unlike those with HFrEF.

14. HF mr
EF
u Patients with HF mr EF have a clinical profile that are closer to those of
patients with HF p EF than those of HF r EF.
u This category of patients is poorly studied and their response to
therapies is unknown.
u Data seems to indicate that they have all cause readmission risk that
are higher than HF p EF.
u In addition, the 1-year mortality rate appeared comparable to HFrEF and
HFpEF after risk adjustments.

15. A 54-year-old woman presented with
shortness of breath (SOB)

16. shortness of breath (SOB) for 4 months that
progressed to an extent that she was unable to perform daily
activities.
She also used 3 pillows to sleep and often woke up from sleep due
to difficulty catching her breath
History of present
illness

17. Past Medical History
Her medical history included
hypertension, dyslipidemia, diabetes mellitus, and history of triple
bypass surgery 4 years ago
Drug History
aspirin, atorvastatin, amlodipine, and metformin
Social History
No significant social or family history was noted

18. Physical examination
u Physical examination showed bilateral diffuse crackles in lungs, elevated jugular venous
pressure, and 2+ pitting lower extremity edema
ECG
u showed normal sinus rhythm with left ventricular hypertrophy.
Chest x-ray
u showed vascular congestion.
Laboratory results
u showed a pro-B-type natriuretic peptide (pro-BNP) level of 874 pg/mL
Echocardiography
u dysfunction, mild mitral regurgitation, a dilated le atrium, and an ejection fraction (EF) of 33%.
How would you manage this case?

21. Aetiology
HF is not a complete diagnosis. It is important to identify the underlying
disease and the precipitating cause(s), if present, so that disease- specific
treatment can be initiated early. The common underlying causes of HF in
adults are:
u Coronary artery disease (CAD)
u Hypertension
u Dilated cardiomyopathy-idiopathic, familial
u Valvular heart disease
u Diabetic cardiomyopathy

22. Aetiology
Other causes of HF include:
u Congenital heart disease
u Cor pulmonale
u Pericardial disease: constrictive pericarditis,
cardiac tamponade
u Hypertrophic cardiomyopathy
u Viral myocarditis
u Acute rheumatic fever
u Toxic: Alcohol, cardiotoxic chemotherapy
e.g. doxorubicin, trastuzumab (Herceptin),
cyclophosphamide.
u Endocrine and metabolic disorders: thyroid
disease, acromegaly, phaechromocytoma.
u Collagen vascular disease: systemic lupus
erythematosis, polymyositis, polyarteritis
nodosa.
u Tachycardia induced cardiomyopathy eg
uncontrolled atrial fibrillation.
u Infiltrative cardiac disease e.g. amyloid,
hyper-eosinophilic syndrome.
u Miscellaneous.
u High output HF e.g. severe anaemia, large A- V
shunts/malformations.
u Peripartum cardiomyopathy.
u Stress (Takotsubo) cardiomyopathy.

24. Investigations