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Heart don't fail me now...

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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