HEART FAULURE

A 35 YEAR OLD MALE WITH SHORTNESS OF BREATH AND PEDAL EDEMA

Presented by Alekhya,8th semester.

I have been given this case to understand the topic of patient clinical data analysis 
You can find the entire patient's clinical case in the link 
https://madhur116.blogspot.com/2020/05/on-1452020.html?m=1

So after going through the above given case
The chief compliants of the patient are:

1.Shortness of breath since 2 weeks
2. Bilateral pedal edema since 2 weeks.

Following is my analysis

1.SHORTNESS OF BREATH
Onset : acute 
Duration : since 2 weeks
Initially NYHA class 3 but after treatment NYHA class 2

The differential diagnosis could be:
1.Pulmonary cause
2.Cardiac cause
3.Anemia
4.Renal failure
5.abdominal wall hernia
6.mental disorder like anxiety and emotional states.

  • The patient doesn't have cold,cough, chocking,wheeze so it could not be a pulmonary cause
  • His hemoglobin is within normal range so anaemia can be ruled out
  • He has no facial puffiness and decreased urine output so renal cause can be ruled out
  • He has no gastric reflux,heartburn,abdominal pain so abdominal hernia can be ruled out
  • The patient has complains of paroxysmal nocturnal dyspnea,inspiratory crepts,peripheral edema ,distension of neck veins strongly support the cardiac cause.
2.BILATERAL PEDAL EDEMA
onset:since 2 weeks, 
pitting type,gradually progressive ,upto to the level of knees.

Different diagnosis :
1.heart failure
2.liver diseases
3.renal failure
4.malnutrion 
5.chronic venous insufficiency
  • The patient has no oliguria,facial puffiness so renal cause is ruled out
  • The patient has no jaundice,or any elevated liver ezymes so hepatic causes can be ruled out.
  • The patient doesn't have weight loss,loss of fat ,muscle mass,so malnutrition acn be ruled out
  • No skin changes so venous insufficiency can be ruled out.
  • The possible cause could be cardiac.
The patient has history of fever associated with chills one month back
  • It can be due to infectious cause like bacterial ,viral,parasitic(most probable in this case)
  • Noninfectious cause like drugs,neoplasia (rare).
Hence based on above given data,Cardiac cause (heart failure) is to be suspected.

ON EXAMINATION 
The positive findings are:
  • Elevated Jvp
  • Pedal edema grade 2
  • Generalised weakness
  • Inspiratory crepts + 
  • USG: right moderate pleural effusion,mild ascitis.
  • 2D ECHO: EF :27%,IVC dilated,mild TR+,severe MR+,,trivial AR+,All chambers dilated ,global hypokinesia,LV dysfunction,mild pulmonary hypertension.
The above features indicate HEART FAILURE
✓Elevated Jvp, pedal edema, ascitis are features of right heart failure.
✓pulmonary edema and hypertension, paroxysmal noturnal dyspnea ,decreasedejection fraction ,generalised weakness indicate left heart failure.




Heart failure with reduced ejection fraction,indicating that it is systolic heart failure. 
The above feature are characteristic of congestive heart failure

The left ventricular systolic dysfunction has incresed left atrial pressures causing increase in pulmonary capillary wedge pressure,leading to pulmonary hypertension,which ultimately causes right ventricular hypertrophy and incresed right atrial pressures .Simply left heart failure leading to right heart failure.

But why did left sided systolic dysfunction develop??
It could be due to :
  • Ischemic heart disease
  • Long standing hypertension
  • Valvular stenosis
  • Dilated cardiomyopathy
✓As the patient doesn't have chest pain or angina ischemic cause can be ruled out
✓the patient is not a known case of hypertension .
✓The patient doesn't have valvular stenosis as he has no complaints of syncope ,also his 2D ECHO shows no evidence for aortic stenosis
✓ The probable cause could be DILATED CARDIOMYOPATHY

But how did he develop all of these??

ANATOMICAL LOCATION
As he had history of fever,it could be possibly due to viral infection.
This viral infection caused inflammation of myocardium of heart-MYOCARDITIS

"Myocarditis in 50% of cases is idiopathic. However in identified causes,the most common etiology is viral, and a viral prodrome usually 1 to 2 weeks before the onset of heart failure symptoms."
https://www.ncbi.nlm.nih.gov/books/NBK441847/

PATHOLOGY RESPONSIBLE FOR MYOCARDITIS.
"It is an immune mediated,where there is molecular mimicry plays a role
After the virus gains entry and binds to receptors in heart causing cell lysis and death, this results in molecular mimicry and further enhances the cardiac damage.
*If the damage is severe and prolonged it results in dilated cardiomyopathy
Biopsy reveals lymphocytic myocarditis"

As there is dilatation of all chambers of the heart in dilated cardiomyopathy ,the walls become thin resulting in weak contraction, decreased left  and right ventricular outflow, causing biventicular congestive heart failure.

As there is dilatation of heart chambers,there is stretching of the Atrioventricular valves causing valvular insufficiency
*As in our patient having mitral,tricuspid and aortic regurgitation.

https://www.ncbi.nlm.nih.gov/books/NBK441847/

The diagnosis is dialted cardiomyopathy due to viral myocarditis.

INVESTIGATIONS
  • BNP and NT pro BNP (heart failure markers)
  • Troponin and CK-MB
  • Endomyocardial biopsy and PCR to find out the organism
TREATMENT
  • Fluid and salt restriction
  • Lasixs
  • Diuretics
  • ACE inhibitors,
  • ARNI ( VALSARTAN + SACUBITRIL)
  • Hydralazine
  • Nitrates.
REFERENCES

https://madhur116.blogspot.com/2020/05/on-1452020.html?m=1

https://www.ncbi.nlm.nih.gov/books/NBK441847/

















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