Congestive Heart Failure (Case 5)

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Chapter 10
Congestive Heart Failure (Case 5)

Sameer Bashey MD and Michael Kim MD

Case: The patient is a 68-year-old woman with a past medical history of hypertension and rheumatoid arthritis. Her hypertension has been well controlled over the past few years with hydrochlorothiazide. She now presents to your office stating she’s become progressively short of breath over the past few months, most notably with exertion. Initially she felt she was simply “out of shape,” as these symptoms began upon starting an exercise regimen now that she’s retired. However, over the past few months her symptoms have continued to worsen despite regular exercise. She reports having no other associated symptoms and denies chest pain, nausea, vomiting, or palpitations. When not exerting herself, she feels she is at her usual state of health and is enjoying the extra time she has to catch up on several of her interests.

On physical examination, you note a mildly diminished carotid upstroke, nondisplaced point of maximal impact, and a normal jugular venous pressure (JVP). You also note a grade 3/6 systolic murmur most notable at the apex and 1+ pitting edema in the lower extremities bilaterally.

Differential Diagnosis

Aortic stenosis

Dilated cardiomyopathy

Ischemic cardiomyopathy

Mitral regurgitation

Hypertrophic cardiomyopathy

Pulmonary hypertension

Diastolic dysfunction

Restrictive cardiomyopathy


Speaking Intelligently

When encountering a patient presenting with shortness of breath, first try to understand what the patient is actually experiencing, as the sensation of shortness of breath can encompass a range of symptoms including difficulty with air movement, dyspnea despite adequate air movement, and generalized fatigue. These and other associated symptoms may help narrow the differential diagnosis specifically to pulmonary, cardiac, musculoskeletal, or psychiatric causes. In patients with symptoms consistent with heart failure, the next step is to determine the presence of heart failure, the underlying etiology, and the severity for both medical management and prognosis. Finally, it important to bear in mind that effective treatment of chronic heart failure requires a multimodal approach encompassing patient education, coordination of care with nurses and other midlevel providers, and a stepwise implementation of medical and device therapies aimed at improving patient morbidity and mortality.


Clinical Thinking

• Given the broad range of possible etiologies leading to heart failure, a careful history is required to narrow the diagnosis.

• Particular attention must be paid to the chronicity of symptoms, risk factors for ischemic heart disease, and evidence of systemic diseases associated with heart failure.

• Keeping in mind the pathophysiology and subsequent differences in presentation between right-sided versus left-sided heart failure as well as systolic versus diastolic dysfunction is helpful in both establishing a diagnosis and understanding appropriate interventions.

• In patients with an established diagnosis of heart failure, the severity of disease by New York Heart Association (NYHA) classification, staging, or LV ejection fraction is important in determining appropriate therapeutic interventions.


• As 50% to 75% of systolic heart failure cases are secondary to ischemia, assessing CAD risk factors to form a pretest probability is an important first step in establishing a diagnosis. Ischemic cardiomyopathy is not only the most common cause of heart failure but is also somewhat reversible in a minority of patients with large proportions of “hibernating” myocardium secondary to chronic ischemia. Age is another important factor to help inform a differential diagnosis. Aortic stenosis, mitral regurgitation, and diastolic dysfunction increase with age and are oftentimes pathophysiologically related via increased pressure and thus workload, leading to various structural changes.

• Determining the chronicity of symptoms may provide a diagnostic clue. In younger patients and those with rapid onset of symptoms without prior limitation in exercise tolerance, the symptoms may be secondary to systemic diseases, most commonly an infectious myocarditis.

• A careful history including evaluating for evidence of rheumatologic, infectious, and hereditary causes of heart failure is important.

• Regardless of the etiology, patients with left-sided heart failure will predominantly present with symptoms of exercise intolerance secondary to shortness of breath, fatigue, orthopnea, or paroxysmal nocturnal dyspnea.

• In isolated right-sided heart failure, dependent edema and increased abdominal girth may predominate.

Physical Examination

• Classically, patients will present with elevated jugular vein distension, pulmonary crackles, lower extremity edema, and hypoxia.

• In more advanced disease, patients may have a laterally displaced point of maximal impact, a pulsatile liver, or extrasystolic heart sounds (S3 or S4).

• Additional heart sounds, murmurs, and special maneuvers to alter hemodynamic parameters may assist in diagnosing many etiologies including aortic stenosis, mitral regurgitation, hypertrophic cardiomyopathy, and pulmonary hypertension.

• Evidence of extracardiac manifestations of systemic disorders should also be evaluated.

Tests for Consideration

Serum troponin concentrations are elevated in conditions associated with cardiac ischemia, such that measurement of this parameter is frequently ordered in patients presenting with an acute exacerbation of congestive heart failure (CHF) to rule out an acute MI as the cause of the new decompensation.
However, interpretation can be difficult as patients with advanced heart failure frequently have ongoing myocardial cell death secondary to heart failure that is unrelated to coronary ischemia. Similarly, patients with chronic kidney disease will accumulate troponin as it is cleared by the kidneys.


Brain natriuretic peptide (BNP) is secreted by the ventricles in response to excessive stretching and is elevated in heart failure. It is frequently used to differentiate shortness of breath secondary to heart failure versus that caused by intrinsic pulmonary disease. While BNP levels less than 100 pg/mL and greater than 500 pg/mL are generally used as cutoffs to exclude or diagnose CHF, respectively, often the results fall somewhere in between with an indeterminate significance.


ECGs are useful in patients presenting with clinical signs and symptoms of heart failure to determine an etiology.
Evidence of prior ischemia may be noted in patients with ischemic cardiomyopathy. Left ventricular hypertrophy secondary to aortic stenosis, long-standing hypertension, or hypertrophic cardiomyopathy may similarly be noted.
Finally, low voltage in the precordial leads may be seen in restrictive cardiomyopathy.



→ Transthoracic echocardiography (TTE) is the single most helpful study in diagnosing heart failure and determining the etiology. By providing both qualitative and quantitative data regarding ventricular and atrial chambers, valvular function, wall thicknesses, and Doppler measurements, one is able to differentiate among most etiologies of heart failure. Additionally, wall motion abnormalities provide evidence of infarction in ischemic cardiomyopathy.


→ Stress echocardiography is a transthoracic echocardiograph done at rest followed by a dobutamine infusion to increase heart rate and contractility. It can be used to diagnose ischemic cardiomyopathy by looking for new wall motion abnormalities as well as hypertrophic cardiomyopathy by assessing the functional significance of an outflow obstruction.


→ Cardiac catheterization is divided into left and right heart catheterization. A left heart catheterization is the reference standard for diagnosing coronary disease and should be performed on patients with new-onset heart failure of unclear etiology to exclude coronary disease. A right heart catheterization can assess the severity of pulmonary hypertension and obtain myocardial tissue to diagnose the various restrictive and dilated cardiomyopathies.


→ Cardiac MRI is relatively new imaging modality. It is mainly used to diagnose various dilated and restrictive cardiomyopathies but also can define anatomic parameters similar to echocardiography with a higher degree of accuracy.


Clinical Entities Medical Knowledge

Aortic Stenosis (AS)

In industrialized countries, degenerative calcification of a congenital bicuspid valve and degenerative calcification of an anatomically normal trileaflet valve represent the two most common causes of AS. Worldwide, rheumatic disease is the most common etiology. Degenerative calcification is characterized by a process of lipid accumulation and inflammation, leading to calcification.


Patients most commonly present with decreased exercise tolerance and dyspnea on exertion. In more advanced disease, exertional chest pain, syncope, and symptoms of heart failure may be present and portend a poor outcome without intervention. Physical examination may be notable for a weak and delayed carotid upstroke (parvus et tardus

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