Internal Medicine · Year 3 · from Internal Medicine
Case 1: Acute Decompensated Heart Failure (HFrEF)
Patient Presentation
A 68-year-old man with a history of ischemic cardiomyopathy (EF 30%) presents with worsening dyspnea over the past week. He now becomes short of breath walking from his bed to the bathroom and requires 4 pillows to sleep. He reports weight gain of 12 pounds over 2 weeks and leg swelling. He admits to dietary indiscretion over the holidays, eating ham and other salty foods.
Vital Signs
- Blood Pressure: 142/88 mmHg
- Heart Rate: 96 bpm
- Respiratory Rate: 24/min
- Oxygen Saturation: 91% on room air
- Temperature: 36.7°C
Physical Examination
- General: Moderate respiratory distress, speaking in short sentences
- HEENT: JVD to the angle of the jaw at 45°
- Cardiovascular: S3 gallop, laterally displaced PMI, 2/6 holosystolic murmur at apex
- Pulmonary: Crackles two-thirds up lung fields bilaterally
- Abdomen: Hepatomegaly, positive hepatojugular reflux
- Extremities: 3+ pitting edema to mid-thigh bilaterally
Initial Workup
- BNP: 2,450 pg/mL (normal <100)
- Troponin: 0.03 ng/mL (normal)
- Creatinine: 1.6 mg/dL (baseline 1.3)
- Sodium: 132 mEq/L
- Chest X-ray: Cardiomegaly, pulmonary vascular congestion, Kerley B lines, bilateral pleural effusions
- ECG: Sinus tachycardia, Q waves in V1-V4, low voltage
Clinical Image
Figure 1: Chest X-ray demonstrating cardiomegaly with pulmonary vascular congestion, Kerley B lines (arrow), and bilateral pleural effusions consistent with acute decompensated heart failure.
Image Source: Educational illustration for teaching purposes.
Questions
- What is this patient's NYHA functional class?
- A) Class I
- B) Class II
- C) Class III
- D) Class IV
- What is the most appropriate initial treatment for this patient?
- A) Oral diuretics and observation
- B) IV loop diuretics and supplemental oxygen
- C) Dobutamine infusion
- D) Emergent cardiac catheterization
- What clinical findings indicate right-sided heart failure?
- A) Pulmonary crackles and orthopnea
- B) JVD, hepatomegaly, peripheral edema, hepatojugular reflux
- C) S3 gallop
- D) Displaced PMI
- What does the low sodium level indicate in heart failure?
- List the four pillars of guideline-directed medical therapy (GDMT) for HFrEF.
Answers
- D) Class IV - NYHA Class IV describes symptoms at rest or with minimal exertion. This patient is dyspneic walking to the bathroom and requires multiple pillows to sleep.
- B) IV loop diuretics and supplemental oxygen - Acute decompensated heart failure with volume overload requires IV diuretics (typically furosemide 40-80 mg IV or 1-2x home oral dose). Supplemental oxygen addresses hypoxemia.
- B) JVD, hepatomegaly, peripheral edema, hepatojugular reflux - These reflect elevated right-sided filling pressures and systemic venous congestion. Pulmonary crackles and orthopnea reflect left-sided failure and pulmonary congestion.
- Significance of hyponatremia in heart failure:
- Dilutional hyponatremia from neurohormonal activation (ADH, RAAS)
- Indicates severe heart failure with poor prognosis
- Associated with increased mortality and morbidity
- Fluid restriction recommended if sodium <130 mEq/L
- May limit diuretic effectiveness (diuretic resistance)
- Four pillars of GDMT for HFrEF:
- Beta-blocker: Carvedilol, metoprolol succinate, or bisoprolol
- RAAS inhibitor: ACEi/ARB or preferably ARNI (sacubitril-valsartan)
- Mineralocorticoid receptor antagonist: Spironolactone or eplerenone
- SGLT2 inhibitor: Dapagliflozin or empagliflozin All four classes have mortality benefit in HFrEF and should be initiated and titrated to target doses.