Internal Medicine · Year 3 · from Internal Medicine
Case 1: Acute Decompensated Heart Failure
Patient Presentation
A 72-year-old woman with a history of heart failure with reduced ejection fraction (HFrEF, EF 30%), coronary artery disease status post CABG, type 2 diabetes mellitus, and chronic kidney disease stage 3 presents to the emergency department with worsening shortness of breath over the past 3 days. She reports orthopnea requiring 4 pillows to sleep (increased from her baseline of 2 pillows) and paroxysmal nocturnal dyspnea. She also noticed progressive bilateral lower extremity swelling and a 5-pound weight gain over the past week. She admits to dietary indiscretion at a family gathering and ran out of her furosemide last week.
Vital Signs
- Blood Pressure: 165/95 mmHg
- Heart Rate: 98 bpm
- Respiratory Rate: 26/min
- Oxygen Saturation: 88% on room air
- Temperature: 36.8°C
Physical Examination
- General: Sitting upright, moderate respiratory distress
- HEENT: JVP elevated to 14 cm H2O
- Cardiovascular: Tachycardic, irregular rhythm, S3 gallop present, 2/6 holosystolic murmur at apex
- Pulmonary: Bibasilar crackles extending to mid-lung fields
- Abdomen: Hepatomegaly, positive hepatojugular reflux
- Extremities: 3+ pitting edema to knees bilaterally
Initial Workup
- BNP: 1,850 pg/mL (baseline 450 pg/mL)
- Troponin I: 0.06 ng/mL (mildly elevated)
- Creatinine: 1.8 mg/dL (baseline 1.4 mg/dL)
- Sodium: 132 mEq/L
- Chest X-ray: Cardiomegaly, bilateral pleural effusions, Kerley B lines, cephalization of pulmonary vessels
Clinical Image
Figure 1: Chest radiograph demonstrating cardiomegaly, bilateral pleural effusions, pulmonary vascular congestion with cephalization, and Kerley B lines consistent with acute decompensated heart failure.
Image Source: Educational illustration for teaching purposes.
Questions
- What is the most likely diagnosis?
- A) Community-acquired pneumonia
- B) Acute decompensated heart failure (ADHF)
- C) Pulmonary embolism
- D) COPD exacerbation
- What is the most appropriate initial management?
- A) Broad-spectrum antibiotics
- B) IV loop diuretics and oxygen
- C) Anticoagulation with heparin
- D) Bronchodilators and steroids
- Which finding is most specific for elevated left-sided filling pressures?
- A) Peripheral edema
- B) S3 gallop
- C) Hepatomegaly
- D) Elevated JVP
- How would you classify this patient's heart failure presentation?
- What is the target for diuresis in this patient, and how would you monitor response?
Answers
- B) Acute decompensated heart failure (ADHF) - The patient has classic signs and symptoms of ADHF including orthopnea, PND, weight gain, elevated JVP, S3 gallop, pulmonary crackles, peripheral edema, and elevated BNP with chest X-ray findings of pulmonary edema.
- B) IV loop diuretics and oxygen - Initial management of ADHF includes IV loop diuretics (furosemide) to relieve congestion and supplemental oxygen to maintain SpO2 >90%. The typical starting dose is 1-2.5 times the patient's home oral dose given IV.
- B) S3 gallop - While all findings can be present in heart failure, an S3 gallop is most specific for elevated left ventricular filling pressures and indicates a non-compliant, volume-overloaded left ventricle. It correlates with elevated PCWP.
- Heart failure classification:
- NYHA Class IV: Symptoms at rest
- ACC/AHA Stage C: Structural heart disease with prior or current HF symptoms
- Hemodynamic profile: "Wet and warm" - congested (wet) with adequate perfusion (warm) as evidenced by normal blood pressure and lack of cool extremities
- Precipitating factors: Dietary indiscretion, medication non-adherence
- Diuresis targets and monitoring:
- Target: Net negative 1-2 liters per day (or 0.5-1 kg weight loss/day)
- Monitoring:
- Daily weights (most important)
- Strict intake/output
- Electrolytes (K+, Mg2+, Na+) every 12-24 hours
- Creatinine monitoring (mild rise acceptable)
- Symptom improvement (dyspnea, orthopnea)
- Physical exam (JVP, edema, lung sounds)
- Endpoint: Return to "dry weight" with resolution of congestion