This document presents four cases of patients presenting with congestive heart failure (CHF) as a symptom and discusses the underlying causes in each case. The first case involves a woman from Moldova whose echocardiogram reveals dilated cardiomyopathy causing systolic dysfunction. The second case is a woman from China with diabetes who has diastolic dysfunction secondary to hypertrophic cardiomyopathy. The third case is a man from Canada whose CHF is caused by stunned myocardium from ischemic heart disease. The fourth case involves a man from India with critical aortic stenosis from a bicuspid aortic valve, illustrating valvular heart disease as a cause of CHF.

1. Congestive Heart Failure: Four Categories May 27, 2009 M. LaCombe/MDFPR UNECOM

2. 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

3. 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.

4. Here Rudi Village, in northern Moldova

5. … and here is where Moldova is situated in Eastern Europe:

6. You ask the daughter where exactly this place is and she gets out the maps:

8. The patient is ethnic Ukrainian but also speaks a Moldovan dialect of Romanian Her husband makes wine, for which Moldova is very famous.

9. (the world’s largest winecellar is said to be in Moldova)

10. 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.

11. 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.

12. She has 4+ pedal edema, and this is her chest xray:

14. ...and her EKG

15. Her laboratory studies show no abnormalities save for a random blood sugar of 188. What will you do next?

16. Yes, emergently treat, then admit her and continue the workup. This is pretty straight-forward. The chest xray shows severe CHF. Initial drug treatment?

17. Yes, a loop diuretic, preferably IV, but what else? You could use this mnemonic: MOST DAMP

19. 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)

20. What will you do now?

21. 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:

22. In diastole In systole

23. ...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)

24. Case #2: A 56 y.o. woman from Changning, China with shortness of breath She is here visiting her daughter, and speaks no English

25. 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.

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

27. Changning is very near Shanghai

28. The Shanghai Skyline

29. 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.

30. 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.

31. 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%

32. 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:

34. And this is her EKG:

35. Now what?

36. Yes, she has symptomatic CHF, and you will initially treat with diuretics. Do you admit her?

37. 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?

38. Yes, an echo:

39. 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

40. 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.

41. 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.

42. 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.

43. We all know where Winnipeg is, right?

44. The Winnipeg Skyline: a lot like downtown Augusta

45. Manitoba was a center for the aboriginal people of Canada Cree Camp Ojibwe Wigwam Assiniboine People

46. Major Segue: Why bother with these geography lessons?

47. Four New Interns Are Coming From: Inna Andrews Chisinau, Moldova Lily Li Changning, China Suhas Pinnaka Laxminagar, India Kernjeet Sandhu Winnipeg, Canada

48. How nervous would you be if you were starting an internship in central China right now?

49. 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.

50. 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:

52. And this is his EKG:

53. 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?

54. 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?

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

56. His enzymes prove normal, his EKG completely normalizes, and his stress mibi shows:

57. ...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:

58. ...even people of the First Nations can have coronary artery disease.

59. 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?

60. You ask where Laxminagar is. Out comes the map:

62. And the pictures:

63. 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:

64. 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

67. And so our man from India illustrates the fourth of the four most common causes of CHF, that of valvular heart disease.

68. To review then, systolic dysfunction, diastolic dysfunction, ischemic heart disease, and valvular heart disease. We need a mnemonic device, don’t we.