# Clinical Cases: Heart Failure

## 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
![Pulmonary Edema CXR](image_01.png)
*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

1. **What is this patient's NYHA functional class?**
   - A) Class I
   - B) Class II
   - C) Class III
   - D) Class IV

2. **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

3. **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

4. **What does the low sodium level indicate in heart failure?**

5. **List the four pillars of guideline-directed medical therapy (GDMT) for HFrEF.**

### Answers

1. **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.

2. **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.

3. **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.

4. **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)

5. **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.

---

## Case 2: Heart Failure with Preserved Ejection Fraction (HFpEF)

### Patient Presentation
A 72-year-old woman with hypertension, type 2 diabetes, and atrial fibrillation presents with gradually worsening exertional dyspnea over 6 months. She becomes short of breath climbing one flight of stairs and has difficulty doing housework. She has gained 8 pounds and notes swollen ankles. She denies chest pain or palpitations.

### Vital Signs
- Blood Pressure: 158/92 mmHg
- Heart Rate: 82 bpm (irregularly irregular)
- Respiratory Rate: 18/min
- Oxygen Saturation: 96% on room air
- BMI: 34 kg/m²

### Physical Examination
- General: Obese, mild dyspnea with talking
- HEENT: JVD to mid-neck at 45°
- Cardiovascular: Irregularly irregular rhythm, S4 gallop, no murmurs
- Pulmonary: Bibasilar crackles
- Extremities: 2+ pitting edema to knees bilaterally

### Laboratory and Imaging
- **BNP**: 380 pg/mL
- **Creatinine**: 1.2 mg/dL
- **HbA1c**: 7.8%
- **Echocardiogram**:
  - EF 62%
  - Concentric LVH
  - Grade II diastolic dysfunction (E/e' ratio 15)
  - Left atrial enlargement
  - Moderate tricuspid regurgitation

### Clinical Image
![Diastolic Dysfunction Echo](image_02.png)
*Figure 2: Doppler echocardiography demonstrating elevated E/e' ratio consistent with elevated left ventricular filling pressures and diastolic dysfunction.*

**Image Source**: Educational illustration for teaching purposes.

### Questions

1. **What criteria support the diagnosis of HFpEF in this patient?**
   - A) Preserved EF alone
   - B) Signs/symptoms of HF, preserved EF (≥50%), elevated BNP, structural heart disease, diastolic dysfunction
   - C) Elevated BNP only
   - D) Atrial fibrillation with dyspnea

2. **What is the H2FPEF score used for?**
   - A) Determining prognosis in HFpEF
   - B) Calculating probability of HFpEF diagnosis
   - C) Guiding medication selection
   - D) Staging heart failure severity

3. **Which medication class has proven mortality benefit in HFpEF?**
   - A) ACE inhibitors
   - B) Beta-blockers
   - C) SGLT2 inhibitors
   - D) Digoxin

4. **What are the key differences between HFrEF and HFpEF management?**

5. **What comorbidities commonly contribute to HFpEF and should be addressed?**

### Answers

1. **B) Signs/symptoms of HF, preserved EF (≥50%), elevated BNP, structural heart disease, diastolic dysfunction** - Diagnosis requires symptoms/signs of HF plus preserved EF (≥50%) plus objective evidence of cardiac structural and/or functional abnormalities or elevated natriuretic peptides.

2. **B) Calculating probability of HFpEF diagnosis** - The H2FPEF score uses clinical and echocardiographic variables (Heavy/BMI >30, Hypertensive, atrial Fibrillation, Pulmonary HTN, Elder >60, Filling pressures) to estimate probability of HFpEF.

3. **C) SGLT2 inhibitors** - The EMPEROR-Preserved and DELIVER trials demonstrated that SGLT2 inhibitors reduce heart failure hospitalizations and cardiovascular death in HFpEF. This is the only class with robust mortality/morbidity benefit in HFpEF.

4. **Key differences in HFrEF vs HFpEF management**:
   - HFrEF: All four GDMT pillars (BB, ARNI/ACEi/ARB, MRA, SGLT2i) have mortality benefit
   - HFpEF: Only SGLT2 inhibitors have proven benefit; diuretics for congestion
   - Both: Treat underlying conditions, sodium/fluid restriction, cardiac rehab
   - HFpEF: Focus on comorbidity management (HTN, AF, obesity, diabetes)
   - Rate control is important if AF present in both

5. **Comorbidities contributing to HFpEF**:
   - Hypertension (causes LVH and diastolic dysfunction)
   - Obesity (increases cardiac workload, inflammation)
   - Diabetes mellitus
   - Atrial fibrillation
   - Coronary artery disease
   - Chronic kidney disease
   - Sleep apnea (obstructive)
   - Pulmonary hypertension
   Aggressive management of these conditions is central to HFpEF treatment.

---

## Case 3: Cardiogenic Shock

### Patient Presentation
A 62-year-old man with no significant past medical history presents with sudden onset of severe chest pain followed by shortness of breath and near-syncope. EMS found him diaphoretic and hypotensive. In the ED, he appears ashen and confused.

### Vital Signs
- Blood Pressure: 78/52 mmHg
- Heart Rate: 115 bpm
- Respiratory Rate: 28/min
- Oxygen Saturation: 85% on room air
- Temperature: 36.5°C

### Physical Examination
- General: Critically ill, diaphoretic, cool and mottled extremities
- HEENT: JVD present
- Cardiovascular: Tachycardic, S3 gallop, new 3/6 holosystolic murmur at apex
- Pulmonary: Diffuse crackles
- Extremities: Cold, mottled, weak pulses

### Initial Workup
- **ECG**: ST elevation in leads II, III, aVF with reciprocal changes
- **Troponin I**: 18.4 ng/mL
- **Lactate**: 6.2 mmol/L
- **Creatinine**: 2.4 mg/dL
- **Chest X-ray**: Pulmonary edema

### Clinical Image
![Inferior STEMI ECG](image_03.png)
*Figure 3: 12-lead ECG demonstrating ST-segment elevation in inferior leads (II, III, aVF) with reciprocal ST depression in lateral leads, consistent with acute inferior STEMI.*

**Image Source**: Educational illustration for teaching purposes.

### Questions

1. **What defines cardiogenic shock?**
   - A) Hypotension requiring vasopressors
   - B) Sustained hypotension (SBP <90 for >30 min) with evidence of tissue hypoperfusion despite adequate filling pressures
   - C) Heart failure with EF <20%
   - D) Any patient requiring inotropic support

2. **What is the most likely cause of the new murmur in this patient?**
   - A) Aortic stenosis
   - B) Ventricular septal rupture or acute mitral regurgitation (papillary muscle rupture)
   - C) Tricuspid regurgitation
   - D) Aortic regurgitation

3. **What is the most important intervention for this patient?**
   - A) IV diuretics
   - B) Emergent coronary revascularization
   - C) Intra-aortic balloon pump first
   - D) Medical management with inotropes

4. **What hemodynamic parameters characterize cardiogenic shock?**

5. **What is the role of mechanical circulatory support in cardiogenic shock?**

### Answers

1. **B) Sustained hypotension (SBP <90 for >30 min) with evidence of tissue hypoperfusion despite adequate filling pressures** - Cardiogenic shock requires hypotension (SBP <90 for 30 min or requiring support) PLUS evidence of end-organ hypoperfusion (altered mental status, cold extremities, elevated lactate, oliguria) with adequate or elevated filling pressures.

2. **B) Ventricular septal rupture or acute mitral regurgitation (papillary muscle rupture)** - Mechanical complications of MI include VSR and papillary muscle rupture causing acute severe MR. Both present with new holosystolic murmur and cardiogenic shock. Inferior MI involves the posteromedial papillary muscle.

3. **B) Emergent coronary revascularization** - The SHOCK trial demonstrated that early revascularization improves survival in cardiogenic shock complicating acute MI. PCI is preferred; CABG may be needed for mechanical complications.

4. **Hemodynamic parameters in cardiogenic shock**:
   - Cardiac index <2.2 L/min/m²
   - Pulmonary capillary wedge pressure >15-18 mmHg (elevated filling pressures)
   - Systemic vascular resistance typically elevated (compensatory vasoconstriction)
   - Mixed venous oxygen saturation <65%
   - Right heart catheterization helps confirm diagnosis and guide therapy

5. **Mechanical circulatory support (MCS) in cardiogenic shock**:
   - Intra-aortic balloon pump (IABP): Improves coronary perfusion and reduces afterload; limited mortality benefit
   - Impella: Axial flow pump providing greater hemodynamic support than IABP
   - ECMO (VA-ECMO): For refractory shock; provides biventricular and respiratory support
   - TandemHeart: Percutaneous left atrial-to-femoral artery bypass
   - MCS serves as bridge to recovery, decision, or transplant/durable LVAD

---

## Learning Points

1. **Heart failure classification** includes HFrEF (EF ≤40%), HFmrEF (EF 41-49%), and HFpEF (EF ≥50%), each with different management approaches.

2. **GDMT for HFrEF** includes four pillars: beta-blocker, ARNI (or ACEi/ARB), MRA, and SGLT2 inhibitor - all with mortality benefit.

3. **HFpEF management** focuses on SGLT2 inhibitors, diuretics for congestion, and aggressive treatment of comorbidities.

4. **Cardiogenic shock** is a medical emergency requiring early revascularization for MI-related shock and consideration of mechanical circulatory support.

5. **Volume assessment** using JVD, orthopnea, edema, and BNP guides diuretic therapy in heart failure.