Heart Failure- 2
CASE OF A 35 YEARS OLD MALE WITH HEART FAILURE
But since he has no productive cough which is characteristic of Pneumonia, I rule out pneumonia.
https://www.cedars-sinai.org/health-library/diseases-and-conditions/r/right-bundle-branch-block.html
Submitted by: Simran Dash
MBBS-IV | Roll number- 153
I have been given this case data here to solve in an attempt to understand Heart Failure
My analysis for the above patient is as follows-
Age: 35 years
Sex: Male
Chief Complaints:
- Shortness of Breath since 2 weeks
- Bilateral Pedal edema
- Dyspnea
- Onset- sudden
- Duration- 2 weeks
- Progression- Gradually progressive (NYHA class 3)
- Relieving factors- Medication (It was not completely relieved but decreased from class 3 to class 2)
- Associated complaints-
a) Paroxysmal Nocturnal Dyspnea- since 2 weeks
b) Generalised weakness since 2 weeks
He might have anemia which could be responsible for these complaints (there is no pallor).
It could also be a respiratory cause but since he has no other associated complaints like hemoptysis, wheezing, it might not be any respiratory pathology.
2. Bilateral Pedal edema
- Onset- sudden
- Duration- 2 weeks
- Site- Bilateral Pedal edema extending upto both the knees
- Type- Pitting
- Progression- Progressive
- Associated complaints- Abdominal Distension
So the possible etiology could be in the
- Heart
- Kidneys
- Liver
But since he has no periorbital edema which is the classical feature of renal failure. So I rule out Renal failure.
He could have Ascites which may be responsible for his abdominal distension and also has a history of drinking occasionally.This could suggest that there is a pathology in the liver.
And he could also have heart failure which is responsible for all her symptoms.
Past History: Had a history of fever with chills 1 month back for which he took anti-malarial medication and it got relieved.
So from the history I think the main pathology could be in the heart or liver.
On Examination, the positive findings found are:
- General examination- Bilateral pitting edema upto knees (grade 2= Edema disappears within 15 seconds).
- Respiratory System- Early inspiratory fine Crepts/crackles. This could be-
- Pneumonia
- Heart failure
- Interstitial Lung Diseases (No data suggestive of that)
- CVS-
A) Peripheral Examination:
i) JVP: Around 20 cm elevated (Definitive of Right sided Heart Failure)
Investigations:
- CBP- High Post Prandial Blood sugar
- ECG-
- Ventricular Premature Complexes
- Right Axis Deviation
- Right Bundle Branch Block (because of 2 R waves in V1)
- Heart disease due to high BP in the lungs (Pulmonary Hypertension)
- COPD (Because he is a smoker, but there is no cough)
- Pulmonary embolism
- Right heart failure (Cor pulmonale)
- Cardiomyopathy
- Myocarditis
3. USG abdomen-
- Grade 1 Fatty liver
- Mild ascites
- Moderate Right sided pleural effusion
4. 2D ECHO-
- Reduced ejection fraction i.e. 27% (<40%)
- IVC dilated (2-3 cm), not collapsing
- Mild TR
- Severe MR
- Trivial AR
- All the chambers are dilated
- Global hypokinesia
- Severe LV dysfunction
- Mild PAHT (could be responsible for the Right Heart Failure)
- No MS/AS
- No PE/LV clot
The ECHO findings are suggestive of Dilated Cardiomyopathy. In this case, it could be caused by-
- Diabetes (high Post prandial Blood sugar)
- Alcohol abuse
- Infections- viral, bacterial,parasitic,fungal (past history suggestive of fever)
"Contractile dysfunction and impaired left ventricular ejection fraction are hallmarks of dilated cardiomyopathy."
So from the above investigations I came to a conclusion that this is a case of Dilated cardiomyopathy causing Right sided Heart Failure. The possible causes for which in this case could be Myocarditis or Diabetes (But in this case since he does not have a history of Diabetes Mellitus until recently where he has an elevated blood sugar, so we rule out Diabetes as the cause.)
Reason for Myocarditis in this patient could be -
- Viral infection (most common cause)
- Alcohol can directly injure the myocardium
- Could be from the anti-malarial medication (assuming it is Chloroquine/Hydroxychloroquine)
"They comprise conduction disturbances (bundle-branch block, atrioventricular block) and cardiomyopathy – often with hypertrophy, restrictive physiology and congestive heart failure."
So in order to confirm the cause, Additional investigations required are:
- Endomyocardial Biopsy
"EMB is a safe diagnostic tool and up to date the gold standard for the diagnosis of (viral) myocarditis, as via histology,immunohistochemistry and viral diagnostics, it allows the quantification and identification of immune cell infiltrates, the proof of viral RNA and DNA presence, quantification of viral loads and confirmation of virus subtypes via sequencing."
"B19V and HHV6 are detected in about 70% and 14–18% of EMB of patients with persisting symptoms of unexplained heart failure, respectively."
2. PCR - To know the causative virus (most commonly -Coxsackievirus group B, Parvovirus B19, HHV-6)
3. Chest X ray- To see the size oh heart, pleural effusion
4. MRI - This shows the size, shape and structure of the heart. Can also show signs of inflammation of the heart muscle.
5. Blood tests- Can detect antibodies against viruses.
6. Cardiac catheterization
More data is needed on the auscultatory findings which could tell us about any added heart sounds or murmurs which could accentuate our echo findings of Mitral regurgitation, Tricuspid regurgitation.
Anatomical location of the root cause is in the myocardium.
Pathophysiology which could explain the case:
Possible etiologies responsible for myocarditis in this patient are:
- Viral infection
- Alcohol consumption
Various Risk Factors present in this case-
- Past history of viral fever
- Alcohol consumption
- Diabetes Mellitus
Complications of myocarditis in this case-
- Dilated Cardiomyopathy
- Pulmonary artery hypertension
- Right Heart Failure
- Cirrhosis of liver
Treatment Modalities-
a) Pharmacological-
- Medical treatment- Already received by the patient. Additional treatment modalities required are:
- Beta blockers such as metoprolol (Lopressor)
3. Omecativ mecarbil
4. Tolvaptan(Oral vasopressin type 2 receptor antagonist) - Advantage over loop diuretics is it causes diuresis without any electrolyte imbalance.
5. Certain rare types of myocarditis such as giant cell and lymphocytic myocarditis respond to corticosteroids.
- Surgical treatment-
- Ventricular Assist Devices- mechanical pumps that help pump blood from the ventricles) to the rest of the body.
2. Intra aortic balloon pumping-A thin tube (catheter) is inserted in a blood vessel in the leg and is guided to the heart using X-ray imaging. A balloon is attached to the end of the catheter in the main artery leading out to the body from the heart (aorta). As the balloon inflates and deflates, it helps to increase blood flow and decrease the workload on the heart.
3. Extra corporeal membrane oxygenation- With severe heart failure, this device can provide oxygen to the body. When blood is removed from the body, it passes through a special membrane in the ECMO machine that removes carbon dioxide and adds oxygen to the blood. The newly oxygenated blood is then returned to the body.
4. Heart transplantation
b) Non pharmacological-
- In mild cases, competetive sports should be avoided.
- Adequate Rest and exercise is required.
- Reducing the amount of fluid intake.
- Reducing the salt intake to <2gm/day.
- Avoid smoking.
- Drinking should be reduced to a minimum.
Things which I did not understand in this case are:
- Why was Anti-malarial drug prescribed for him if it was a simple viral fever? Why not Paracetamol/ Ibuprofen?
- What were his auscultatory findings?
- What is his occupation?
References:
- Harrison's principles of internal medicine
- Davidson's principles and practice of medicine
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