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  • 1. Evaluation and Management of Congestive Heart Failure60 year old African American male previously in good health comes to clinic. Hecomplains of dyspnea on exertion. He is able to walk about 3 blocks without gettingshort of breath. Was able to climb 1 flight of stairs but can not go up a second flight ofstairs. Says he frequently wakes in the middle of the night short of breath. He has notnoticed any edema.On physical examination: General: A slightly overweight, African-American male with a BMI of 31. Vital Signs: BP: 130/80, P: 80 and regular, Respirations: 14 unlabored Heart exam: S1 and S2 within normal limits, he has no murmurs, rubs or gallops. PMI: 4th intercostal space anterior axillary line. Lungs: Clear except with some bibasilar rales. Extremities: Without deformities or edema.1. What is the patient’s likely diagnosis? What history/physical/lab findings are most helpful in establishing the diagnosis? what initial testing would you do?2. Enumerate the types of information that an echocardiogram will provide. Other information: Chest x-ray shows a slightly enlarged heart with vascular markings consistent with congestive heart failure. Echocardiogram shows left ventricular ejection fraction estimated at 30%. Patient has no regional wall motion abnormalities noticed and no valvular disease noted3. What NY Heart Association Class is he?4. Would you do any further diagnostic testing? If so, what tests?5. What treatment measures, including medications, would you start at this time and how would you then proceed?
  • 2. Answer KEY1. This clinical picture is suggestive of CHF. History and physical can be very suggestive although often not conclusive in the diagnosis of chf. Studies of adult patients presenting to the ER with dyspnea have established the usefulness of various history/physical/lab findings in this population for ruling chf in or out. Especially helpful in the history are: dyspnea on exertion if negative (100% sensitive; absence essentially rules out chf) and pnd if positive (80% specific; only 20% chance of no disease if positive). Orthopnea is slightly less specific (74%). History of MI has the best combined sensitivity/specificity/predictive value of any item in the history. In the physical exam: a) s3 is insensitive but highly specific, thus helpful if present. b) JVP and HJR are moderately specific and suggestive if present; rales and edema are somewhat less useful. (see table). c) Pulsus alternans if present is virtually pathognomonic of advanced chf. For labs: a) EKG is useful if normal (virtually rules out chf) and CXR is useful if pulmonary venous congestion or interstitial edema are present. b) BNP is a useful lab test for distinguishing dyspnea of cardiac from that of pulmonary origin. c) An echocardiogram is the definitive diagnostic study (although imperfectly sensitive in some studies).
  • 3. 2. a. The echocardiogram can estimate left ventricular function. b. It can show regional wall motion abnormalities. c. It can show undiagnosed valvular abnormalities. d. It can show pericardial effusion. e. It can sometimes demonstrate pulmonary artery hypertension.3. The patient has Class II heart failure. The New York Heart Association Classification: a. Class I – Asymptomatic b. Class II – Dyspnea at greater than 2 blocks and or greater than one flight of stairs. c. Class III – Dyspnea at less than 2 blocks and or less than one flight of stairs. d. Class IV – Dyspnea at rest.4. Yes. The patient clearly needs to be screened for diabetes, he does not have hypertension. Possibly treatable/reversible causes such as etoh, cocaine, anemia, thyroid disease, and nutritional deficiency (beriberi) should always be considered. The patient also needs to be screened for coronary artery disease. Guidelines suggest coronary arteriography if there is a history of angina or other evidence of ischemia. There is no clear recommendation for noninvasive imaging, but this may make more sense in asymptomatic patients as a survival benefit with revascularization is likely only if hibernating myocardium is present. This can be detected by technetium-sestamibi perfusion imaging, thallium imaging, or dobutamine echocardiography. More aggressive algorithms reflecting the common use of cardiac catheterization as a first test have been developed;
  • 4. But an initial noninvasive strategy in asymptomatic patients may be more defensible. The presence of hibernating myocardiuim would then be an indication for arteriography and CABG (vs PCI) would be considered in patients with poor left ventricular function who have significant left main disease, left main equivalent disease (≥70 percent stenosis of the proximal LAD and proximal left circumflex arteries), or proximal LAD stenosis with two or three vessel disease [46]. Among patients without any of these anatomic findings, the weight of evidence/opinion would be considered to be in favor of the efficacy of CABG (a weaker recommendation) in patients with poor left ventricular function who have a significant amount of viable, noncontracting, revascularizable myocardium.(at least 60% of myocardium viable with 25-30% of that hibernating). (2004 guideline, unmodified in 2005). Valvular disease as a contributing factor will be evident at echo if not before. Rarer causes of chf should be considered in the appropriate setting, such as infiltrative (hemochromatosis; amyloid in the setting of accompanying proteinuria; sarcoid if other evidence of disease); no cause will be evident in 50% of patients presenting with chf.5. Medications The patient has systolic dysfunction. All such patients should be instructed re salt avoidance and avoidance of medications likely to be harmful (nsaids, thiazolidinediones, metformin). Weight reduction is indicated in obese patients and a target should be to be within 10% of ideal body weight. Exercise is beneficial in patients with class II to III heart failure and is likely to be beneficial in this patient (once evaluation for ischemic heart disease is complete and appropriate treatment has been instituted). Unfortunately heart failure is not currently an insurance-covered indication for cardiac rehabilitation. In patients in overt HF, loop diuretics are used first line for relief of signs or symptoms of volume overload, such as dyspnea and peripheral edema; diuretics do not improve mortality. Given the lack of right ventricular findings and only mild rales, this patient probably does not need aggressive diuretic therapy at this time. Digoxin can also be helpful in the control of symptoms but also does not alter mortality and is unlikely to be necessary in this patient at present. Therapy aimed at mortality reduction should be begun in this patient. ACE inhibition is usually begun first, and is indicated in all stages of heart failure, including asymptomatic LV dysfunction (although beta blockade is likely equally important). The advantages of initial use of ACE inhibition is that it is unlikely to acutely worsen symptoms (which beta blockers may sometimes do). ACE inhibitors are generally titrated to the doses used in clinical trials showing efficacy in mortality reduction or greater (enalapril 20 mg bid or equivalent). ARBs are a viable alternative for patients who cannot tolerate Ace inhibitors. If the patient is stable on ACE inhibition, beta blockade should be initiated with an agent shown to be effective in mortality reduction if possible (carvedilol, metoprolol ER, bisoprolol). Patients to be started on beta blockade should be euvolemic. Doses should be started low and titrated up (to carvedilol 25 to 50 bid; latter dose in pts > 85 kg); for ER metoprolol target is 200 mg/day. Toleration of beta blockade may be limited by bp and hr. Patients who continue symptomatic on ace inhibitor or arb and beta blockade may benefit from the addition of nitrates/hydralazine (titrated to isdn 40 tid or ismo 40 to 120/day and hydralazine 100 tid). Spironolactone should be added to patients with moderate to severe systolic dysfunction (average EF in the rales trial was 25%) whose creatinine and potassium can be closely monitored. Aldosterone antagonists are not indicated in mild-moderate systolic dysfunction. Triple therapy with ace/arb/beta blockade is a viable option in patients with continuing symptoms on ace/beta blockade alone or hypertension on these agents alone (per CHARM-added). Based upon the SCD-HeFT trial, patients with ischemic or nonischemic cardiomyopathy, NYHA class II to III HF, and an LVEF ≤35 percent have a significant survival benefit from an implantable cardioverter-defibrillator (ICD) for the
  • 5. primary prevention of SCD. Thus if our patient remained symtomatic with EF as at firstmeasurement on medical therapy, an ICD would be indicated (SCD-HeFT). Cardiacresynchronization therapy is indicated in patients who are in sinus rhythm and have an LVEF≤35 percent, a prolonged QRS duration (≥120 msec), and moderate to severe symptoms(NYHA class III or IV HF) despite optimal medical therapy. This would not be an issue inour patient.Graphical summary of 2005 guideline (Circulation Sept 20, 2005); the only emendation wouldbe that beta blockade should be routine after ace inhibition rather than only if continuedsymptoms.