Sometimes Heart Failure is just Heart Failure

Respirology Morning Report

The case featured a 77-year-old man with a history of rheumatic heart disease comprised of AS/MS, ‘heart failure,’ atrial fibrillation, and a possible diagnosis of interstitial lung disease worked up at another hospital.  He presented with dyspnea of around one month’s duration and had signs and symptoms consistent with right-sided heart failure (predominantly).  He was diuresed to ‘euvolemia’ and continued to have some breathlessness.  His CT imaging was inconsistent with idiopathic pulmonary fibrosis, and more consistent with pulmonary edema due to decompensated left-sided heart failure.  He has since responded to diuresis.

The imaging below is classical imaging of idiopathic pulmonary fibrosis featuring basilar and subpleural disease in contrast to our patient.

There were multiple valuable learning points from today’s morning report:

-The epidemiology of interstitial lung disease in people at the higher extremes of age is such that idiopathic pulmonary fibrosis is the usual culprit.

-We talked about an approach to suspected IPF.  This involves taking a history predominantly to rule out non-idiopathic contributors to interstitial lung disease such as: drugs, autoimmune conditions, exposures/pneumoconiosis/hypersensitivity pneumonitis among others.  Once ILD is suspected imaging is typically an important diagnostic step.  CT imaging patterns consistent with IPF include a subpleural/lower lobe-predominant pattern, reticular pattern, honeycombing, and sometimes ground glass appearances.

-It is challenging to diagnose an interstitial lung disease on physical examination.  Helpful findings include clubbing, findings associated with secondary causes (skin discoloration, hand findings in RA, etc), and characteristic “Velcro” sounding crackles in late inspiration suggestive of fibrotic lung.  These can be contrasted with the fine, early inspiratory crackles caused by alveoli full of fluid in pulmonary edema, and coarse, non-specific crackles caused by airway secretions.  Most of the time, a high-resolution CT of the chest is helpful as well as pulmonary function tests.  Plain X-rays are more helpful to rule out another process such as a pneumothorax or very obvious congestive heart failure findings.

Further Reading:

Sahni, P., & Shapera, S. Idiopathic Pulmonary Fibrosis: an update.