Breathlessness in a young woman

Published on 10/04/2015 by admin

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Last modified 10/04/2015

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Problem 28 Breathlessness in a young woman

David Platts

A 28-year-old woman presented to the emergency department following and 3-day history of a dry cough, ankle swelling and progressively worsening shortness of breath. At presentation, the patient was severely breathless at rest. She had had an acute viral-like upper respiratory tract infection 6 weeks earlier.
On examination, she looks unwell and is in respiratory distress. Her heart rate was 110 bpm in sinus tachycardia, blood pressure 100/60 mmHg, respiratory rate 24 and oxygen saturations 92%. The jugular venous pressure was elevated at 8 cm. Praecordial examination revealed a displaced, volume loaded apex beat, a soft S1, normal S2 and an S3 with a 3/6 pansystolic murmur. Respiratory examination revealed reduced breath sounds in the left base with fine inspiratory crackles to the mid zones. There was mild pitting oedema in the ankles. You think she has acute heart failure.

Q.1

What further questions should be asked to help obtain a diagnosis?

There is no other medical or surgical past history. The patient is a non-smoker and non-drinker. She has not been pregnant recently. There is no family history of cardiac problems. She was not taking any medications. For the last 2 nights, the patient has been unable to sleep due to respiratory distress whenever she lay flat. The patient has also been nauseous and anorexic for 24 hours. There have been no palpitations or episodes of presyncope or syncope.

Q.2

What other examination findings are important?

The patient was not peripherally or centrally cyanotic. The peripheries were cool to touch. There was no fever. Abdominal examination was unremarkable other than mild hepatic tenderness. There was no clinical evidence of anaemia. The peripheral pulses were palpable and mildly reduced in intensity.

Q.3

What investigations would you initially order to help assess this patient?

The full blood count is normal. U&Es show a Na+ of 131, K+ of 3.8, creatinine of 97 and urea of 5. Liver function tests reveal a total protein = 55, albumin = 23, ALP = 235, GGT = 187, ALT = 23, bilirubin = 12. INR = 1.3. BNP = 2187. Cardiac enzymes are normal.

A 12-lead ECG showed a sinus tachycardia, normal axis, normal intervals and no ST-T wave changes.

The chest X-ray showed an increased cardiothoracic ratio, a small left pleural effusion and interstitial and alveolar oedema.

Q.4

What is the likely diagnosis?

Q.5

What is the next investigation that should be ordered?

A transthoracic echocardiogram was performed at the bedside in the emergency department, which showed a dilated and severely globally impaired left ventricle with a left ventricular ejection fraction (LVEF) of 20%. The right ventricle was also dilated and severely impaired. There was moderate mitral regurgitation, moderate tricuspid regurgitation and no pulmonary hypertension.

Q.6

What is the initial management of this patient in the emergency department?

This patient had acute cardiogenic pulmonary oedema due to a recent onset of a viral dilated cardiomyopathy. As the patient was hypoxic, she should be given oxygen and be sitting upright. A bolus dose of 40 mg of intravenous furosemide was given, followed by an infusion of glyceryl trinitrate (GTN).

Q.7

What further treatment should be commenced when the patient is more stable on the ward?

The patient’s breathlessness improved and she was transferred to the coronary care unit on telemetry. She was commenced on an ACE inhibitor (tritace 2.5 mg bd), regular oral furosemide (40 mg daily) and a heart failure beta blocker (carvedilol, initially starting at 3.125 mg bd). Over the next 5 days, the patient’s condition stabilized. Contact was made with the hospital multidisciplinary heart failure team (consisting of a heart failure cardiologist, heart failure nurse, pharmacist and physiotherapist) and they coordinated the patient’s ongoing inpatient and outpatient care, in consultation with the patient’s usual general practitioner. The patient was discharged on day 7 on ramipril 5 mg bd, carvedilol 6.25 mg bd, and furosemide 40 mg daily.

Q.8

What sort of follow-up should be arranged after discharge?

The patient had close follow-up through the heart failure outpatient service, which included outpatient visits to the heart failure cardiologist and heart failure nurse, telephone contact and monitoring by her general practitioner. A follow-up CXR showed cardiomegaly, no pleural effusions and clear lung fields. A repeat transthoracic echocardiogram at 3 months showed a moderately dilated left ventricle, a LVEF of 25%, mildly impaired right ventricular function and mild tricuspid regurgitation and mild mitral regurgitation only.

Q.9

What options are available if the patient severely deteriorates?

The patient re-presented to the emergency department 6 months later with severe acute cardiogenic shock, with a heart rate of 130 and a blood pressure of 70/40 mmHg. This did not respond to conventional therapy and after extensive consultation with the cardiac transplant team, the intensive care unit and cardiothoracic surgery, a left ventricular assist device was inserted. This was used as a bridge to transplantation and the patient underwent a successful heart transplantation 4 months later. The patient was discharged 2 weeks after her transplant, with no episodes of rejection, and is now back at work.

Answers

A.1

• The history of a recent viral illness should alert to the possibility of a viral respiratory infection, a postviral pneumonia or even a virally induced cardiomyopathy.
• A history of recent pregnancy or childbirth is also important due to the possibility of this being a peripartum cardiomyopathy. It is important that family history is obtained as some cardiomyopathies are familial in aetiology.
• Conventional medical history-taking will also provide clues as to other possible causes (such as diabetes, haemochromatosis, hypertension, thyroid disorders, drugs or medications, alcohol or rheumatic heart disease).
• The history of being unable to lie flat due to breathlessness (orthopnoea) or waking up during the night breathless (paroxysmal nocturnal dyspnoea) is a very important feature as this is usually due to heart failure.
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