Congestive Heart Failure:

Four CategoriesMay 27, 2009

M. LaCombe/MDFPRUNECOM

A 64 y.o. housewife from Moldova presents to the ER with the following symptoms:

•Anxiety•Dyspnea at rest•Dyspnea on exertion•Orthopnea and paroxysmal nocturnal dyspnea•Cough productive of pink, frothy sputum•Edema•Weakness•Lightheadedness•Abdominal pain•Malaise•Wheezing•Nausea

She speaks no English, and her daughter, whom she is

visiting, says that her mother gets little or no medical care

in Rudi Village, that the nearest good hospital with good doctors is in Bălţi to

the south.

Here Rudi Village, in northern Moldova

…and here is where Moldova is situated in

Eastern Europe:

You ask the daughter where exactly this

place is and she gets out the maps:

The patient is ethnic Ukrainian but also speaks a Moldovan

dialect of Romanian Her husband makes wine, for which Moldova is very

famous.

(the world’s largest winecellar is said to

be in Moldova)

There is not much else in the patient’s

history. She is on no medications, has had no surgeries, and no hospitalizations to speak of. All seven of her children were delivered at home.

On physical exam, the patient is visibly short of breath with a respiratory rate of 32, a HR of 114, a BP of 105/50, an O2 sat of 89%, and no fever. Her

neck veins are distended to the angle of the jaw when

she is sitting upright, and she has râles easily heard over her chest. Her heart sounds are muffled by the

respiratory noise.

She has 4+ pedal edema, and this is her

chest xray:

...and her EKG

Her laboratory studies show no abnormalities

save for a random blood sugar of 188.

What will you do next?

Yes, emergently treat, then admit her and

continue the workup. This is pretty

straight-forward. The chest xray shows

severe CHF.

Initial drug treatment?

Yes, a loop diuretic, preferably IV, but

what else?

You could use this mnemonic:

MOST DAMP

MOST DAMP

• M orphine• O xygen• S it up• T ournequets• D igoxin• A minophylline (no longer used)• M ercurhydrin (an ancient diuretic replaced by lasix)

• P hlebotomy (rarely, when the kidneys are gone)

Well, there, she feels better, smiles to show you her gold-capped tooth, and mumbles

something in Moldovan, which you take as “thank you

Doctor.”

The following morning her chest exam is largely normal, she has diuresed 2 liters, and now you clearly hear a third

heart sound, which your attending tells you is an S-3.

(http://www.wilkes.med.ucla.edu/Rubintro.htm)

What will you do now?

Yes, an echocardiogram. You don’t know why your

patient has congestive heart failure, which

is, after all a symptom, not a

disease.Here is her echo:

In diastole In systole

...so our patient has congestive heart failure due to

systolic dysfunction secondary to a dilated cardiomyopathy (DCM),

in this case, of unknown cause

(although the most common cause of DCM in the world is– Chagas

Disease)

Case #2: A 56 y.o. woman from Changning, China with shortness

of breath

She is here visiting her daughter, and speaks no

English

Her daughter however does supply some

history: the patient is a diabetic, is cared for by an

endocrinologist at the hospital there, and

receives quite excellent care.

You are curious about where your patient is from, and the daughter gets out the maps....

Changning is very near Shanghai

The Shanghai Skyline

The patient is on insulin twice daily, and takes two blood

pressure pills. One, her daughter believes, is a diuretic, and the

second is unknown.

The patient has been short of breath for six months, increasingly so,

and more so since arriving in Maine two

months ago. Her daughter notices her mother has become

sedentary because of such marked shortness of breath on exertion. The

patient has had no anginal equivalent whatsoever. Her

cholesterol profile has been normal.

The rest of the history is

unremarkable, save for some form of heart

disease in the patient’s mother and

grandmother.Her vital signs: BP

178/110, HR=78, RR=26, afebrile, O2 sat of

95%

On exam, she has no JVD, does have râles, quite prominent in the chest, and has a gallop

rhythmn:

(http://www.wilkes.med.ucla.edu/Rubintro.htm

)

Your attending tells you it is an S-4 gallop.

There is 2+ pedal edema.

This is her chest xray:

And this is her EKG:

Now what?

Yes, she has symptomatic CHF, and you will initially

treat with diuretics. Do you admit her?

YES!You don’t yet know the cause of the symptom, i.e. the CHF and it is incumbent upon you to

find out before sending her home.

So... What next?

Yes, an echo:

This patient has diastolic dysfunction causing her CHF and secondary to non-

obstructive hypertrophic

cardiomyopathy (HCM)

Yes, there are reported familial

HCM’s in China at a rate of 80 cases per

100,000 adults

In diastolic dysfunction, the

mainstay of therapy is beta blockers rather

than diuretics. Calcium channel

blockers with negative inotropicity (e.g. verapamil) are also

used.

So, now we have seen two broad categories of CHF, systolic and diastolic

dysfunction. Within these two categories are a great

many disease entities causing them, eg. Chagas

Disease and familial hypertrophic

cardiomyopathy. More common in the U.S. are

inflammatory and hypertensive

cardiomyopathies, respectively.

Case #3 is the reason why you do not send

home Case #2 prematurely.

A 55 y.o. Cree Indian from Winnipeg, Manitoba is visiting his son and comes to the ER short of

breath.

We all know where Winnipeg is, right?

The Winnipeg Skyline: a lot like downtown Augusta

Manitoba was a center for the aboriginal people of Canada

Cree Camp Ojibwe Wigwam

Assiniboine People

Major Segue:

Why bother with these geography lessons?

Four New Interns Are Coming From:

Inna AndrewsChisinau, Moldova Lily Li

Changning, China

Suhas Pinnaka Laxminagar, India

Kernjeet Sandhu Winnipeg, Canada

How nervous would you be if you were

starting an internship in central China right

now?

Your patient’s symptoms came on rather abruptly, today, and he has not

experienced them before.He was at a coffee shop in

Hallowell when someone asked him where Manitoba

was. He became so upset at the man’s ignorance, so

agitated in fact, that his shortness of breath would

not abate and he was brought to the ER.

His BP is 144/87, his pulse 94, his O2 sat on 2 liters is 99%, and he is afebrile. His RR presently is 18.His lung exam discloses a few râles, on cardiac exam you hear the S-4 you have

only just so recently learned about, and on chest

xray:

And this is his EKG:

He feels fine now, and back to normal, ready to go home. His

son agrees and prepares to take him home. His father,

the patient, who is a cheese-maker back home, wants to get

back to work.

What’s your next move, Doctor?

Well, yes, you can get an echo, and you’re in

luck. The tech is still around.

The patient’s EF is mildly, globally depressed, and

estimated at 40%. There are no other echo-abnormalities.

What now?

You MUST admit him, get serial enzymes, serial EKG’s because this patient’s CHF as a symptom may well be an anginal equivalent.

His enzymes prove normal, his EKG

completely normalizes, and his stress mibi

shows:

...so this patient has CHF secondary to stunned

myocardium secondary to ischemic heart disease.

There are two lessons here:

First: patients who quickly recover from CHF in the ER with minimal treatment may

be dangerously ill.

And second:

...even people of the First Nations can have

coronary artery disease.

Which leads us to Case #4 the 66 year man

from Laxminagar, India with shortness of

breath.Fortunately, he speaks excellent English. How

is your Hindi?

You ask where Laxminagar is.

Out comes the map:

And the pictures:

Your patient describes a heart murmur present for several years. He has had an echo back home, but cannot tell you the diagnosis.

His chest xray shows CHF, his EKG shows LVH, and when you

listen to his heart you hear:

A grade III/VI systolic murmur

http://www.wilkes.med.ucla.edu/Systolic.htm

His echo done here shows critical aortic stenosis, a probable

bicuspid aortic valve, and LVH

And so our man from India illustrates the fourth of the four

most common causes of CHF, that of valvular

heart disease.

To review then, systolic dysfunction, diastolic dysfunction,

ischemic heart disease, and valvular heart disease. We need a mnemonic

device, don’t we.

IMG’s might work

• I ischemic heart disease• M itral (i.e. valvular heart disease)

• G reat, i.e. LVH, i.e. diastolic dysfunction

• S ystolic dysfunction