Posted: June 10th, 2023

Congestive Heart Failure Case Study

Congestive Heart Failure Case Analysis
Abstract: This paper analyzes the case of a 69-year-old female patient presenting with signs and symptoms suggestive of congestive heart failure (CHF). Key findings from the patient history, physical examination, and diagnostic tests are examined to determine the likely type and cause of CHF. Treatment considerations are also discussed.
Introduction
Congestive heart failure is a serious condition in which the heart fails to pump blood effectively, leading to fluid buildup in the lungs and peripheral tissues (Inamdar and Inamdar, 2016). This case study evaluates a patient with multiple risk factors and evidence of decompensated CHF.
Patient Presentation and Diagnosis
The 69-year-old female patient presented to the emergency department with dyspnea, peripheral edema, and other classic signs of CHF including jugular venous distention and bibasilar pulmonary rales (Di Palo and Barone, 2020). Her history of myocardial infarction, coronary artery bypass grafting, hypercholesterolemia, and smoking increased her risk of developing heart failure (Chaudhry and Stewart, 2017).
Based on the patient’s history, physical findings, chest x-ray showing pulmonary edema and cardiomegaly, and reduced ejection fraction of 39% on imaging, she meets diagnostic criteria for CHF with reduced ejection fraction (Lala and Mentz, 2018). The right-sided congestive signs, including JVD, hepatomegaly and peripheral edema extending to the calves, indicate severe right ventricular failure (Saito et al., 2020). Altogether, the evidence suggests advanced biventricular CHF, likely as a late complication of her previous myocardial infarction and coronary artery disease.
The patient also had mild hyponatremia and renal insufficiency, which are common complications of heart failure (Weir, 2022). Her elevated blood glucose may represent stress hyperglycemia in the setting of acute illness or previously undiagnosed diabetes. Mild transaminase elevation is likely related to hepatic congestion.
Treatment Considerations
In the acute setting, this patient would likely benefit from intravenous diuretics to offload fluid, vasodilators such as nitroglycerin, and noninvasive ventilation if needed for respiratory distress (Ezekowitz et al., 2017). Long-term management should involve guideline-directed medical therapy with drugs proven to reduce morbidity and mortality in heart failure with reduced ejection fraction, including beta blockers, ACE inhibitors or ARBs, mineralocorticoid receptor antagonists, and SGLT2 inhibitors (McDonagh et al., 2021).
Conclusion
This case illustrates a patient with advanced CHF related to ischemic heart disease. Careful attention to the history, exam, and diagnostic findings allows for determination of the underlying cause and severity of heart failure. Prompt initiation of evidence-based therapies is essential to improve symptoms, quality of life, and prognosis for patients with this condition.
References:
Chaudhry, S. and Stewart, G., 2017. Advanced Heart Failure: Prevalence, Natural History, and Prognosis. Heart Failure Clinics, 13(3), pp.491-504.
Di Palo, K. and Barone, N., 2020. Hypertension and Heart Failure. Heart Failure Clinics, 16(1), pp.99-106.
Ezekowitz, J., O’Meara, E., McDonald, M., Abrams, H., Chan, M., Ducharme, A., Giannetti, N., Grzeslo, A., Hamilton, P., Heckman, G., Howlett, J., Koshman, S., Lepage, S., McKelvie, R., Moe, G., Rajda, M., Swiggum, E., Virani, S., Zieroth, S., Al-Hesayen, A., Cohen-Solal, A., D’Astous, M., De, S., Estrella-Holder, E., Fremes, S., Green, L., Haddad, H., Harkness, K., Hernandez, A., Kouz, S., LeBlanc, M., Masoudi, F., Ross, H., Roussin, A. and Sussex, B., 2017. 2017 Comprehensive Update of the Canadian Cardiovascular Society Guidelines for the Management of Heart Failure. Canadian Journal of Cardiology, 33(11), pp.1342-1433.
Inamdar, A. and Inamdar, A., 2016. Heart Failure: Diagnosis, Management and Utilization. Journal of Clinical Medicine, 5(7), p.62.
Lala, A. and Mentz, R., 2018. The Evolution of Heart Failure with Reduced Ejection Fraction Heart Failure: A Disorder of the Left Ventricle or a Systemic Syndrome?. Current Heart Failure Reports, 15(6), pp.359-366.
McDonagh, T., Metra, M., Adamo, M., Gardner, R., Baumbach, A., Böhm, M., Burri, H., Butler, J., Čelutkienė, J., Chioncel, O., Cleland, J., Coats, A., Crespo-Leiro, M., Farmakis, D., Gilard, M., Heymans, S., Hoes, A., Jaarsma, T., Jankowska, E., Lainscak, M., Lam, C., Lyon, A., McMurray, J., Mebazaa, A., Mindham, R., Muneretto, C., Francesco Piepoli, M., Price, S., Rosano, G., Ruschitzka, F., Kathrine Skibelund, A. and Filippatos, G., 2021. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal, 42(36), pp.3599-3726.
Saito, S., Alkhouli, M., Nanayakkara, S. and Burkhoff, D., 2020. Right Heart Failure in Left Heart Failure. Current Heart Failure Reports, 17(4), pp.170-184.
Weir, M., 2022. Hyponatremia in Heart Failure. Frontiers in Cardiovascular Medicine, 9.

Congestive Heart Failure
PATIENT CASE
History of Present Illness
H.J. presented to the ER late one evening complaining of a “racing heartbeat.” She is an overweight, 69-year-old white female, who has been experiencing increasing shortness of breath during the past two months and marked swelling of the ankles and feet during the past three weeks. She feels very weak and tired most of the time and has recently been waking up in the middle of the night with severe breathing problems. She has been sleeping with several pillows to keep herself propped up. Five years ago, she suffered a transmural (i.e., through
the entire thickness of the ventricular wall), anterior wall (i.e., left ventricle) myocardial infarction. She received two-vessel coronary artery bypass surgery 41 ⁄2 years ago for obstructions in the left anterior descending and left circumflex coronary arteries. Her family history
is positive for atherosclerosis as her father died from a heart attack and her mother had several CVAs. She had been a three pack per day smoker for 30 years but quit smoking after her heart attack. She uses alcohol infrequently. She has a nine-year history of hypercholesterolemia. She is allergic to nuts, shellfish, strawberries, and hydralazine. Her medical history also includes diagnoses of osteoarthritis and gout. Her current medications include celecoxib, allopurinol, atorvastatin, and daily aspirin and clopidogrel. The patient is admitted to the hospital for a thorough examination. Patient Case Question 1. Based on the limited amount of information given above, do you suspect that this patient has developed left-sided CHF, right-sided CHF, or total CHF?
Patient Case Question 2. How did you arrive at your answer to Question 1?
Patient Case Question 3. What is a likely cause for this patient’s heart failure?
Patient Case Question 4. From the information given above, identify three risk factors
that probably contributed to the patient’s heart attack five years ago.
Patient Case Question 5. Why is this patient taking allopurinol?
Patient Case Question 6. Why is this patient taking atorvastatin?
Patient Case Question 7. Why is this patient taking celecoxib?
Patient Case Question 8. Why is this patient taking aspirin and clopidogrel?
CASE STUDY
CONGESTIVE HEART 3 FAILURE
For the Disease Summary for this case study,
see the CD-ROM.

CASE STUDY 3 ■ CONGESTIVE HEART FAILURE 11
Physical Examination and Laboratory Tests
Vital Signs
BP
125/80 (left arm, sitting); P
125 and regular; RR
28 and labored; T
98.5°F oral;
Weight
215 lb; Height
58; patient is appropriately anxious
Head, Eyes, Ears, Nose, and Throat
• Funduscopic examination normal
• Pharynx and nares clear
• Tympanic membranes intact
Skin
• Pale with cool extremities
• Slightly diaphoretic
Neck
• Neck supple with no bruits over carotid arteries
• No thyromegaly or adenopathy
• Positive JVD
• Positive HJR
Patient Case Question 9. What can you say about this patient’s blood pressure?
Patient Case Question 10. Why might this patient be tachycardic?
Patient Case Question 11. Why might this patient be tachypneic?
Patient Case Question 12. Is this patient technically underweight, overweight, obese, or is
her weight healthy?
Patient Case Question 13. Explain the pathophysiology of the abnormal skin
manifestations.
Patient Case Question 14. Do abnormal findings in the neck (JVD and HJR) suggest left
heart failure, right heart failure, or total CHF?
Lungs
• Bibasilar rales with auscultation
• Percussion was resonant throughout
Heart
• PMI displaced laterally
• Normal S1 and S2 with distinct S3 at apex
• No friction rubs or murmurs
Abdomen
• Soft to palpation with no bruits or masses
• Significant hepatomegaly and tenderness observed with deep palpation
Br
12 PART 1 ■ CARDIOVASCULAR DISORDERS
Extremities
• 2 pitting edema in feet and ankles extending bilaterally to mid-calf region
• Cool, sweaty skin
• Radial, dorsal pedis and posterior tibial pulses present and moderate in intensity
Neurological
• Alert and oriented  3 (to place, person, and time)
• Cranial and sensory nerves intact
• DTRs 2 and symmetric
• Strength is 3/5 throughout
Chest X-Ray
• Prominent cardiomegaly
• Perihilar shadows consistent with pulmonary edema
ECG
• Sinus tachycardia with waveform abnormalities consistent with LVH
• Pronounced Q waves consistent with previous myocardial infarction
ECHO
Cardiomegaly with poor left ventricular wall movement
Radionuclide Imaging
EF
39%
Patient Case Question 15. Which abnormal cardiac exam and chest x-ray findings closely
complement one another?
Patient Case Question 16. Which abnormal cardiac exam and ECG findings closely
complement one another?
Laboratory Blood Test Results
See Patient Case Table 3.1
Patient Case Table 3.1 Laboratory Blood Test Results
Na 153 meq/L PaCO2 53 mm Hg
K 3.2 meq/L PaO2 65 mm Hg (room air)
BUN 50 mg/dL WBC 5,100/mm3
Cr 2.3 mg/dL Hct 41%
Glu, fasting 131 mg/dL Hb 13.7 g/dL
Ca2 9.3 mg/dL Plt 220,000/mm3
Mg2 1.9 mg/dL Alb 3.5 g/dL
Alk phos 81 IU/L TSH 1.9 µU/mL
AST 45 IU/L T4 9.1 µg/dL
pH 7.35

CASE STUDY 3 ■ CONGESTIVE HEART FAILURE 13
Patient Case Question 17. What might the abnormal serum Na and K levels suggest?
Patient Case Question 18. Explain the abnormal BUN and serum Cr concentrations.
Patient Case Question 19. What might be causing the elevated serum glucose concentration?
Patient Case Question 20. Explain the abnormal serum AST level.
Patient Case Question 21. Explain the abnormal arterial blood gas findings.
Patient Case Question 22. Which of the hematologic findings, if any, are abnormal?
Patient Case Question 23. What do the TSH and T4 data suggest?
Patient Case Question 24. Identify four drugs that might be immediately helpful to this
patient.
Patient Case Question 25. Ejection fraction is an important cardiac function parameter
that is used to determine the contractile status of the heart and is measured with specialized testing procedures. If a patient has an SV
100 and an EDV
200, is EF abnormally
high, low, or normal?

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