Congestive heart failure: Clinical sciences

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A 66-year-old man with a history of coronary artery disease, hypertension, and congestive heart failure presents to the clinic for a routine visit. Current medications include aspirin, atorvastatin, carvedilol, and losartan. The patient has had no recent hospitalizations and no symptoms other than mild dyspnea with daily activities. The patient’s weight has been stable. Temperature is 37.1°C (98.8°F), pulse is 66/min, blood pressure is 112/76 mmHg, respirations are 14/min, and oxygen saturation is 99% on room air. On examination, the lungs are clear and there is no lower extremity edema. Serum BNP today is 150 pg/dL, and transthoracic echocardiogram one year ago showed an ejection fraction of 55% and impaired left ventricular relaxation. Which of the following medications would potentially provide a mortality benefit if it was added to this patient’s medication regimen ?  

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Congestive heart failure, CHF, or the newer term, advanced heart failure, is a condition that occurs when the heart cannot pump or fill properly, leading to fluid accumulation in the lungs and other body tissues. It is a leading cause of morbidity and mortality worldwide. Based on the side of the heart that is affected, CHF can be classified as right-sided or left-sided heart failure.

Alright, the first thing to do when assessing a patient with signs and symptoms suggestive of CHF is to perform an ABCDE assessment to determine if they are stable or unstable. If the patient is unstable, stabilize their airway, breathing, and circulation, which might require intubation. Additionally, obtain IV access, administer supplemental oxygen, and put your patient on continuous vital sign monitoring.

OK, now that you’re done with acute management, obtain a focused history and physical exam, and order imaging, like Chest X-ray. History typically reveals fatigue, shortness of breath, dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea. On the flip side, a physical exam commonly reveals conversational dyspnea, rales, S3 heart sound, bilateral lower extremity edema, and jugular venous distention. Finally, a chest X-ray might show an enlarged cardiac silhouette and evidence of pulmonary congestion, such as a “batwing” or “butterfly” appearance from alveolar edema and Kerley B lines from interstitial edema.

Now, these findings should make you think of acute decompensated heart failure with pulmonary edema, so order B-type natriuretic peptide, or BNP for short; ECG; and a transthoracic echocardiogram, or TTE. BNP greater than 400; ECG findings associated with arrhythmias or ischemia, as well as TTE findings of ventricular dysfunction and valve abnormalities support the diagnosis of acute decompensated heart failure with pulmonary edema.

Sources

  1. "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines" Circulation (2022)
  2. "Evaluation and Management of Right-Sided Heart Failure: A Scientific Statement From the American Heart Association" Circulation (2018)
  3. "I have a patient with unintentional weight loss. How do I determine the cause?" Symptom to Diagnosis an Evidence Based Guide, 4th ed. (2020)
  4. "2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)Developed with the special contribution of the Heart Failure Association (HFA) of the ESC" Eur Heart J (2016)
  5. "How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Associations of the European Society of Cardiology" Eur Heart J (2007)
  6. "Acute decompensated heart failure update" Curr Cardiol Rev (2015)
  7. "Congestive Heart Failure" CDIM CORE MEDICINE CLERKSHIP CURRICULUM GUIDE, 4th ed. (2020)