Download - Four causes of CHF09
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Congestive Heart Failure:
Four CategoriesMay 27, 2009
M. LaCombe/MDFPRUNECOM
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A 64 y.o. housewife from Moldova presents to the ER with the following symptoms:
•Anxiety•Dyspnea at rest•Dyspnea on exertion•Orthopnea and paroxysmal nocturnal dyspnea•Cough productive of pink, frothy sputum•Edema•Weakness•Lightheadedness•Abdominal pain•Malaise•Wheezing•Nausea
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She speaks no English, and her daughter, whom she is
visiting, says that her mother gets little or no medical care
in Rudi Village, that the nearest good hospital with good doctors is in Bălţi to
the south.
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Here Rudi Village, in northern Moldova
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…and here is where Moldova is situated in
Eastern Europe:
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You ask the daughter where exactly this
place is and she gets out the maps:
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The patient is ethnic Ukrainian but also speaks a Moldovan
dialect of Romanian Her husband makes wine, for which Moldova is very
famous.
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(the world’s largest winecellar is said to
be in Moldova)
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There is not much else in the patient’s
history. She is on no medications, has had no surgeries, and no hospitalizations to speak of. All seven of her children were delivered at home.
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On physical exam, the patient is visibly short of breath with a respiratory rate of 32, a HR of 114, a BP of 105/50, an O2 sat of 89%, and no fever. Her
neck veins are distended to the angle of the jaw when
she is sitting upright, and she has râles easily heard over her chest. Her heart sounds are muffled by the
respiratory noise.
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She has 4+ pedal edema, and this is her
chest xray:
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...and her EKG
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Her laboratory studies show no abnormalities
save for a random blood sugar of 188.
What will you do next?
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Yes, emergently treat, then admit her and
continue the workup. This is pretty
straight-forward. The chest xray shows
severe CHF.
Initial drug treatment?
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Yes, a loop diuretic, preferably IV, but
what else?
You could use this mnemonic:
MOST DAMP
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MOST DAMP
• M orphine• O xygen• S it up• T ournequets• D igoxin• A minophylline (no longer used)• M ercurhydrin (an ancient diuretic replaced by lasix)
• P hlebotomy (rarely, when the kidneys are gone)
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Well, there, she feels better, smiles to show you her gold-capped tooth, and mumbles
something in Moldovan, which you take as “thank you
Doctor.”
The following morning her chest exam is largely normal, she has diuresed 2 liters, and now you clearly hear a third
heart sound, which your attending tells you is an S-3.
(http://www.wilkes.med.ucla.edu/Rubintro.htm)
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What will you do now?
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Yes, an echocardiogram. You don’t know why your
patient has congestive heart failure, which
is, after all a symptom, not a
disease.Here is her echo:
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In diastole In systole
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...so our patient has congestive heart failure due to
systolic dysfunction secondary to a dilated cardiomyopathy (DCM),
in this case, of unknown cause
(although the most common cause of DCM in the world is– Chagas
Disease)
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Case #2: A 56 y.o. woman from Changning, China with shortness
of breath
She is here visiting her daughter, and speaks no
English
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Her daughter however does supply some
history: the patient is a diabetic, is cared for by an
endocrinologist at the hospital there, and
receives quite excellent care.
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You are curious about where your patient is from, and the daughter gets out the maps....
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Changning is very near Shanghai
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The Shanghai Skyline
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The patient is on insulin twice daily, and takes two blood
pressure pills. One, her daughter believes, is a diuretic, and the
second is unknown.
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The patient has been short of breath for six months, increasingly so,
and more so since arriving in Maine two
months ago. Her daughter notices her mother has become
sedentary because of such marked shortness of breath on exertion. The
patient has had no anginal equivalent whatsoever. Her
cholesterol profile has been normal.
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The rest of the history is
unremarkable, save for some form of heart
disease in the patient’s mother and
grandmother.Her vital signs: BP
178/110, HR=78, RR=26, afebrile, O2 sat of
95%
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On exam, she has no JVD, does have râles, quite prominent in the chest, and has a gallop
rhythmn:
(http://www.wilkes.med.ucla.edu/Rubintro.htm
)
Your attending tells you it is an S-4 gallop.
There is 2+ pedal edema.
This is her chest xray:
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And this is her EKG:
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Now what?
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Yes, she has symptomatic CHF, and you will initially
treat with diuretics. Do you admit her?
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YES!You don’t yet know the cause of the symptom, i.e. the CHF and it is incumbent upon you to
find out before sending her home.
So... What next?
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Yes, an echo:
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This patient has diastolic dysfunction causing her CHF and secondary to non-
obstructive hypertrophic
cardiomyopathy (HCM)
Yes, there are reported familial
HCM’s in China at a rate of 80 cases per
100,000 adults
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In diastolic dysfunction, the
mainstay of therapy is beta blockers rather
than diuretics. Calcium channel
blockers with negative inotropicity (e.g. verapamil) are also
used.
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So, now we have seen two broad categories of CHF, systolic and diastolic
dysfunction. Within these two categories are a great
many disease entities causing them, eg. Chagas
Disease and familial hypertrophic
cardiomyopathy. More common in the U.S. are
inflammatory and hypertensive
cardiomyopathies, respectively.
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Case #3 is the reason why you do not send
home Case #2 prematurely.
A 55 y.o. Cree Indian from Winnipeg, Manitoba is visiting his son and comes to the ER short of
breath.
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We all know where Winnipeg is, right?
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The Winnipeg Skyline: a lot like downtown Augusta
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Manitoba was a center for the aboriginal people of Canada
Cree Camp Ojibwe Wigwam
Assiniboine People
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Major Segue:
Why bother with these geography lessons?
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Four New Interns Are Coming From:
Inna AndrewsChisinau, Moldova Lily Li
Changning, China
Suhas Pinnaka Laxminagar, India
Kernjeet Sandhu Winnipeg, Canada
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How nervous would you be if you were
starting an internship in central China right
now?
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Your patient’s symptoms came on rather abruptly, today, and he has not
experienced them before.He was at a coffee shop in
Hallowell when someone asked him where Manitoba
was. He became so upset at the man’s ignorance, so
agitated in fact, that his shortness of breath would
not abate and he was brought to the ER.
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His BP is 144/87, his pulse 94, his O2 sat on 2 liters is 99%, and he is afebrile. His RR presently is 18.His lung exam discloses a few râles, on cardiac exam you hear the S-4 you have
only just so recently learned about, and on chest
xray:
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And this is his EKG:
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He feels fine now, and back to normal, ready to go home. His
son agrees and prepares to take him home. His father,
the patient, who is a cheese-maker back home, wants to get
back to work.
What’s your next move, Doctor?
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Well, yes, you can get an echo, and you’re in
luck. The tech is still around.
The patient’s EF is mildly, globally depressed, and
estimated at 40%. There are no other echo-abnormalities.
What now?
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You MUST admit him, get serial enzymes, serial EKG’s because this patient’s CHF as a symptom may well be an anginal equivalent.
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His enzymes prove normal, his EKG
completely normalizes, and his stress mibi
shows:
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...so this patient has CHF secondary to stunned
myocardium secondary to ischemic heart disease.
There are two lessons here:
First: patients who quickly recover from CHF in the ER with minimal treatment may
be dangerously ill.
And second:
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...even people of the First Nations can have
coronary artery disease.
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Which leads us to Case #4 the 66 year man
from Laxminagar, India with shortness of
breath.Fortunately, he speaks excellent English. How
is your Hindi?
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You ask where Laxminagar is.
Out comes the map:
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And the pictures:
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Your patient describes a heart murmur present for several years. He has had an echo back home, but cannot tell you the diagnosis.
His chest xray shows CHF, his EKG shows LVH, and when you
listen to his heart you hear:
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A grade III/VI systolic murmur
http://www.wilkes.med.ucla.edu/Systolic.htm
His echo done here shows critical aortic stenosis, a probable
bicuspid aortic valve, and LVH
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And so our man from India illustrates the fourth of the four
most common causes of CHF, that of valvular
heart disease.
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To review then, systolic dysfunction, diastolic dysfunction,
ischemic heart disease, and valvular heart disease. We need a mnemonic
device, don’t we.
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IMG’s might work
• I ischemic heart disease• M itral (i.e. valvular heart disease)
• G reat, i.e. LVH, i.e. diastolic dysfunction
• S ystolic dysfunction