Andrew Rose presents a case of
Middle aged gentleman presents with fatigue, shortness of breath and cough, diagnosed with acute heart failure exacerbation.
Teaching points:
1. Shortness of breath has a wide differential. It is important to think of it in 2 ways...
---> Can't MISS diagnoses:
Pulmonary: Pneumothorax, PE
CV: Aortic dissection (more-so pain), MI (can be painless in a diabetic pt or pt with other risk factors), pericardial effusion and tamponade
---> More likely diagnoses:
Pulmonary: pneumonia, COPD exacerbation, Bronchitis, pleural effusions
CV: Heart failure, stable angina,
Endo: hypothyroidism, adrenal insufficiency
Heme: anemia
Neuro: ALS, panic attack
Iatrogenic: opioid overdose
2. How do we define heart failure? A clinical syndrome of decreased cardiac output that can result from systolic or diastolic dysfunction. Increase in pressures causes signs and symptoms of heart failure - dyspnea, paroxysmal nocturnal dyspnea, orthopnea, peripheral edema, crackles on pulmonary auscultation, elevated JVP and an S3.
HFrEF: Heart failure with reduced EF
CAD
Myocarditis
Valve disease
Infiltrative process
HTN
HFpEF: Heart failure with preserved EF
Hypertension
Aging
Obesity
DM
CAD
Compensatory mechanisms
--Remember the frank starling curve??
--Upregulation of the renin-angiotensin-aldosterone system:
Angiotensin II causes vasoconstriction to improve blood pressure and stimulate thirst
Aldosterone increases fluid retention by increasing sodium resorption
--Adrenergic nervous system: increased release of epinephrine, norepinephrine, and vasopressin
3. What can tip over a patient in heart failure?
-Diet (eating a lot of salt!)
-Missing medications
-ACS
-Infection
-Hypertensive emergency/urgency
4. When to get an ECHO?
-Initial diagnosis
-Follow up after 3-6 months of goal-directed medical therapy
-After 12-24 months to analyze response to therapy
-If there is a change in status to identify disease progression
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