HEART FAILURE

I have been given this case to solve in an attempt to understand the topic of "Patient Clinical Data Analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and diagnosis with a treatment plan.

You can find the entire real patient clinical problem in the following link:
https://madhur116.blogspot.com/2020/05/on-1452020.html?m=1

Following is my analysis of the patient's problem. The problems in the order of priority I found are:

• Shortness of breath since 2 weeks
• Fatigue since 2 weeks
• Pedal edema since 2 weeks

SHORTNESS OF BREATH (DYSPNEA)

Patient presented with shortness of breath which is acute in onset, NYHA class 3 initially and class 2 after treatment.

Some of the structures (differential) related to dyspnea are:

• Cardiac
• Respiratory
• Anemia
• Renal
• Metabolic
• Neuromuscular
• Drugs

Based on history and examination

• No history of cough ,cold and wheeze. This excludes respiratory cause of dyspnea
• No history of facial puffiness and oliguria.So there is no renal involvement.
• No history of chronic use of drugs such as NSAIDs, steroids.
• No history of muscle pain,muscle loss, tingling and numbness.This excludes neuromuscular involvement.
• Not a known case of diabetes mellitus
• History of fatigue and PND are present.

From the above details I think there might be anemia or cardiac pathology

PEDAL EDEMA

Patient presented with progressive bilateral pitting type of pedal edema extending up to the knees.

Differential diagnosis for pitting type of pedal edema are:

• Heart failure 
• Kidney failure 
• Liver failure

Based on history and examination

• No history of periorbital edema and oliguria, so there is no renal involvement.
• Ascites is present but not prominent as pedal edema.so there might not be hepatic pathology.

From the above details I think there is cardiac pathology.

CARDIAC PATHOLOGY

After analyzing the above complaints I am of the opinion that there is some cardiac pathology.What could be the pathology???

In this case patient has fatigue, dyspnea, pedal edema which are cardinal features of HEART FAILURE. Next question that arises is, Is it Right heart failure or Left heart failure?? 

• Symptoms of left heart failure are fatigue and dyspnea.
• Symptoms of right heart failure are pedal edema, ascites.

Patient has features of both,so it must be CONGESTIVE CARDIAC FAILURE.Possible explanation is, left ventricular failure has lead to increase in pressures in left atrium which lead to increase in pressures in pulmonary veins and arteries leading to right heart failure.

Next question that arises is whether it is systolic failure or diastolic failure?To know this 2D echo is performed.

Findings of 2D ECHO is:

• Ejection fraction -27% - which suggests it is systolic failure(heart failure due to reduced ejection fraction).

HEART FAILURE DUE REDUCED EJECTION FRACTION

As we now know it is HFrEF , we should find the cause for this.Some of the important causes are:

• Myocardial infraction
• valvular heart disease
• non ischemic dilated cardiomyopathy

Based on the history and examination

• There is no history of chest pain
• There is no history of syncope
• There is no history of palpitations

From this history we can eliminate MI (as there is no chest pain ),MS and AS( as there is no chest pain,syncope,palpitation which are cardinal features).My differential diagnosis is left with NON-ISCHEMIC DILATED CARDIOMYOPATHY and  MITRAL REGURGITATION.

To know the exact cause, investigations that are performed is:

2D ECHO

• EF -27%
• global hypokinesia
• all chambers are dilated
• severe LV dysfunction
• severe MR
• trivial AR
• mild TR
• no MS/AS
• no pulmonary emboli and LV clots
• mild pulmonary artery hypertension
• IVC dilates not collapsing

As all the chambers are dilated MR and TR are also present.Based on the above findings,my diagnosis is NON-ISCHEMIC DILATED CARDIOMYOPATHY.

What might be the etiology related to it???It could be inflammatory cardiomyopathy or alcohol induced dilated cardiomyopathy.

Patient also has a history of fever with chills 1 month back. So I think there might be some infective cause of myocarditis. To know the exactly which organism is involved, following investigations can be done.

• ECG 
• 2D ECHO
• Serum levels of troponin
• Creatinine phosphokinase fractions
• MRI
• Immunohistochemistry
• PCR

Since most common cause of myocarditis is due to viral etiology , I am of the opinion it might be viral myocarditis.

TREATMENT

Pharmacological treatment

• Captopril
• Candesarten
• Valcyclovir
• Gancyclovir
• Interferon beta
• treatment that is given :Tab.lasix 80mg...40mg...40mg
                                  Tab.isosorbide mononitrate10mg bd
                                         Tab.hydralazine 25mg
                                         Tab. Telma20mg

Non pharmacological treatment 

• reduce physical activity
• reduce salt intake
• fluid restriction

https://www.intechopen.com/books/cardiomyopathies-types-and-treatments/infective-cardiomyopathy