Case history
A 67-year-old man with diabetes mellitus, hypertension and renal impairment is referred to the cardiology outpatient department because of fatigue. He is overweight and relatively inactive, but still able to visit his country property and went hunting as recently as last year. He has experienced shortness of breath when climbing two flights of stairs at home and has difficulty in walking uphill to his house. He has no history of ischemic heart disease or other cardiac symptoms. His blood pressure is 164/96 mmHg and he has an irregular pulse of 102 beats per minute. He has no jugular venous distension or edema, and his chest is clear to auscultation; the apex beat is impalpable but there is a blowing pansystolic murmur at the apex. The chest X-ray shows cardiomegaly and the ECG shows atrial fibrillation with left bundle branch block.
This is a typical presentation of decompensating chronic heart failure (HF). The following questions need to be asked:
• Is this really HF?
• What was the functional status before this deterioration?
• What is the ejection fraction?
• What is the underlying etiology?
• What is the precipitant of this exacerbation?
• Is there coronary artery disease?
• What social support is in place that will support care at home?
• Are there features that may eventually require device therapy (implantable cardiac defibrillator [ICD] or cardiac resynchronization therapy [CRT])?
Table 5.1 provides an overview of the factors that contribute to acute presentations.
TABLE 5.1 Factors that contribute to acute presentation of heart failure |
• Poor adherence – medication – sodium/water restriction – obesity – alcohol • Pharmacotherapeutic issues – failure to use/inadequate dosing/too rapid introduction of beta-blockers and vasodilators – ineffective diuretic prescription – use of potentially harmful medications (antiarrhythmics, NSAIDs) • Inadequate syndrome recognition • Inadequate control of hypertension, diabetes mellitus • Failure to correct areas of reversible myocardial ischemia or surgery including valve repair/replacement or aneurysmectomy • Unrecognized hypo- or hyperthyroidism • Cardiovascular deconditioning • Failure to correct or control atrial fibrillation |
NSAID, non-steroidal anti-inflammatory drug. |
Symptoms and signs
The onset of HF symptoms (Table 5.2) may be acute (typically with pulmonary edema, even with cardiogenic shock) or subacute. Both right and left HF may occur in the context of low output (fatigue, syncope and hypotension), and both right- and left-sided HF usually occur together. Assessment of functional class (see Table 2.1), based on exercise capacity, is important in chronic HF because it is linked to outcome – the annualized mortality in NYHA class IV HF is about 50%, which is four to five times that of class II and twice that of class III.
TABLE 5.2 Symptoms of heart failure | |
Left-sided • Exertional dyspnea • Orthopnea • Paroxysmal nocturnal dyspnea | Right-sided • Edema • Abdominal distension (due to ascites) • Right upper quadrant discomfort (due to liver congestion) |
The signs of HF are often subtle. Jugular venous pressure is a sign of intravascular volume overload that is often overlooked (25–58% of cases) (Table 5.3).
TABLE 5.3 Jugular venous pressure |
• Changes with respiration (usually decreases with deep inspiration) • Multiphasic pulsation (the JVP ‘beats’ twice in a cardiac cycle [Figure 5.1], while the carotid artery only has one beat) • Location (but not height) changes with alteration of posture. Measurement is taken from the xiphisternum. The normal JVP will not be seen if the patient is lying flat (the vein is distended) or sitting up (the vein is empty). A 45° tilt is the best starting position, but if JVP is not apparent, sit the patient up further or lie them down further. The location of the pulse varies with the angle of the neck (Figure 5.2). You must see the upper limit of the JVP • Remove pulsation with venous compression (the JVP can be stopped by lightly pressing against the neck; it will fill from above) • Hepatojugular reflux (firm but gentle pressure over the right upper quadrant will move blood from the splanchnic to the central veins). Failure to distend the jugular veins indicates they may already be filled. Typically, distension is persistent in HF HF, heart failure; JVP, jugular venous pressure. |
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