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Chief Complaint Chief Complaint: Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, bilateral lower extremity edema Onset: 1 week before admission The patient reports worsening shortness of breath over the past week, preventing her from walking more than a few steps without needing to stop and catch her breath. She also endorses orthopnea and paroxysmal nocturnal dyspnea, requiring her to sleep sitting up using multiple pillows. Additionally, significant bilateral pitting edema is noted up to her legs History of Present Illness Additional history: The patient was diagnosed with systolic heart failure one year ago after an MI. Since then, her heart failure has been managed as an outpatient on guidelinedirected medical therapy. Over the past week, she reports worsening dyspnea on exertion, orthopnea, and edema suggestive of an acute exacerbation of her chronic systolic heart failure. Of note, the patient recently missed several doses of her heart failure medications due to the inability to refill them on time. Past Medical History Past medical history: Chronic systolic heart failure (LVEF 30%), hypertension, diabetes mellitus type 2, chronic kidney disease stage 3. Past surgical history: None Medications and Social History Medications: o Furosemide 40 mg PO daily o Metoprolol succinate 50 mg PO daily o Lisinopril 10 mg PO daily o Aspirin 81 mg PO daily Social history: Retired teacher, smoking history (quit 10 years ago), consumes 1-2 alcoholic beverages per week. Widowed, lives alone with home health assistance due to difficulties with ADLs from heart failure symptoms. Vital Signs and Physical Exam Findings Vital signs: T: 37 C P: 112 bpm irregularly BP: 172/92 mmHg RR: 21 bpm SpO2:97% on room air Physical exam: Pleasant female, speaking in full sentences. Lung exam with bilateral rales mid to lower zones, 2+ bilateral pitting edema. Diagnostic Results Initial diagnostics: o BNP: 1230 pg/mL o Troponin: 0.05 ng/mL CXR: Pulmonary vascular congestion, small bilateral pleural effusions EKG: Atrial fibrillation, left bundle branch block, ST depressions suggestive of left ventricular hypertrophy Assessment and Plan Assessment: o Acute on chronic systolic heart failure exacerbation o Differential diagnosis: MI, COPD exacerbation, pneumonia Treatment recommendations: o IV diuresis with furosemide drip, consider ultrafiltration o Rate control medications o Reinitiate GDMT titration o Consider AICD/CRT given LBBB Epidemiology Over 6 million adults in the US have CHF, with incidence approaching 10 per 1000 in those over 65 years old. Annual mortality rates approach 50% in those with severe symptoms. The total cost of CHF care is estimated at over $30 billion annually. Pathophysiology In chronic systolic heart failure, reduced LVEF leads to decreased cardiac output. Complex syndrome that results from any functional impairment of ventricular filling or ejection of blood. Exacerbating factors like medication/ dietary noncompliance can acutely worsen hemodynamic status. Evidence-Based Treatment GDMT medications, including ACEi/ARBs, beta-blockers, and Aldosterone receptor antagonists, have grade recommendations for reducing mortality and rehospitalization (Abe et al., 2020). Ultrafiltration has recommendation for acute fluid removal compared to IV diuresis alone in ADHF. References Abe, T., Jujo, K., Kametani, M., Minami, Y., Fukushima, N., Saito, K., & Hagiwara, N. (2020). Prognostic impact of additional mineralocorticoid receptor antagonists in octogenarian heart failure patients. ESC heart failure, 7(5), 2711– 2724. https://doi.org/10.1002/ehf2.12862 Borovac, J. A., D’Amario, D., Bozic, J., & Glavas, D. (2020). Sympathetic nervous system activation and heart failure: Current state of evidence and the pathophysiology in the light of novel biomarkers. World journal of cardiology, 12(8), 373–408. https://doi.org/10.4330/wjc.v12.i8.373 LeWine, H. E. (2023, July 7). 5 early heart failure warning signs. Harvard Health. https://www.health.harvard.edu/heart-health/5-warning-signs-of-early-heart-failure Vaidya, S. R., & Aeddula, N. R. (2023). Chronic kidney disease. StatPearls. StatPearls Publishing, Treasure Island (FL). https://www.ncbi.nlm.nih.gov/books/ NBK535404/
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