Wednesday, April 11, 2012

Heart failure - Wednesday April 11, 2012

Thank you Dr. H. Rakowski for hosting a special cardiology morning report, and to team 5 for bringing the case.

Today, we discussed a man who had a history of hypertension, atrial fibrillation, and heart failure, who presented with a 1-week history of increasing shortness of breath on exertion (NYHA 3, worsened to 4), increased abdominal girth, and bilateral leg edema.

We discussed an approach to the chronic etiology of heart failure, as well as acute triggers for decompensation.  Common etiologies of heart failure include hypertension, diabetes, and coronary artery disease.  However, each part of the heart can give rise to heart failure.  These include cardiomyopathy, pericardial disease (constriction or effusion), ischemia, arrhythmia, and valvular lesions.  Also, the most common cause of right heart failure is left heart failure.  However, lung pathology (e.g. COPD, obstructive sleep apnea, pulmonary hypertension, PE) can also give rise to right heart failure.  The JVP is sometimes helpful in distinguishing right heart failure from cirrhosis.  Common acute triggers for decompensation include salt and fluid indiscretion, medication non-adherence, infection, and ischemia.

We discussed the basic investigations in someone presenting with apparent heart failure symptoms, including ECG and CXR.  We also looked at echo images for our patient.  Visiting the cardiologist reporting echocardiogram on the third floor can be very helpful.  Our patient had a large right pleural effusion that is not adequately explained by the lack of LV dysfunction shown in the echocardiogram.  A leg Doppler, CT chest and/or thoracentesis is likely the next step given his previous history of colon cancer.

Although we did not focus on management of heart failure in today’s morning report, you can find an article in Lancet about medical therapy of heart failure here, and the Canadian Cardiovascular Society heart failure guidelines can be found here.

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