Congestive Heart Failure

Chapter 24 Congestive Heart Failure




Clinical Case Problem 1: A 78-Year-Old Woman with Shortness of Breath


A 78-year-old woman comes to the emergency department with a 6-month history of fatigue and shortness of breath, aggravated with performance of any exertional activity including activities of daily living. She has found that occasionally she has to get up at night to open the window to get air. There has been a weight gain of 15 pounds during the 6   months, and there has been gradual swelling of her ankles and legs. Her history reveals no previous myocardial infarction or heart disease, but it does reveal the presence of type 2 diabetes for 15   years, severe hypertension for 30   years, and obesity for 8   years. Although the shortness of breath has been a significant problem for only 6   months, she does mention having “some breathing problems” intermittently for at least 4   years, and she has been treated for intermittent atrial fibrillation and moderate chronic obstructive pulmonary disease. She is taking glyburide, hydrochlorothiazide, diltiazem, coumadin, ipratropium, and captopril. On physical examination, the patient’s blood pressure is 140/90   mm Hg. The respiratory rate is 28 breaths/minute, and the pulse is 98 beats/minute and regular; she is afebrile. Head, ears, eyes, nose, and throat are unremarkable; there is no elevated jugular venous distention (JVD). Both S1 and S2 are normal, but a fourth heart sound is present; there are no murmurs. Chest examination reveals bibasilar rales in both lung bases with dullness. Abdominal examination is benign; the hepatojugular reflux is negative. Extremities reveal bilateral 3 + pitting edema to both knees. Pulse oximetry shows an O2 saturation of 90% on room air. The electrocardiogram (ECG) reveals normal sinus rhythm, no acute changes, and left ventricular (LV) hypertrophy. You suspect a form of heart failure and order a chest radiograph.



Select the best answer to the following questions




1. Your working hypothesis, based on the history and physical examination, is that the patient has which of the following?


a. diastolic heart failure

b. systolic heart failure

c. biventricular heart failure

d. cor pulmonale

e. heart failure secondary to pulmonary fibrosis

2. Based on the type of failure this patient has, what is most likely to be found on the chest radiograph?


a. normal chest

b. congestion and cardiomegaly

c. pulmonary edema

d. congestion with or without cardiomegaly

e. cardiomegaly

3. The chest radiograph is consistent with the history and physical examination and your diagnosis of diastolic failure. The patient is admitted for therapy. You order echocardiography. Again, based on the type of failure this patient has, what is this likely to show?


a. normal LV cavity size

b. an ejection fraction of more than 40%

c. a dilated left ventricle

d. an ejection size of less than 40%

e. a and b

4. The targeted range of the diastolic blood pressure in this patient should be


a. < 90   mm Hg

b. < 80   mm Hg

c. between 80 and 90   mm Hg

d. it does not matter

e. > 90   mm Hg to maintain perfusion


Clinical Case Problem 2 A 62-Year-Old Man with Exertional Dyspnea, Orthopnea, and Wheezing


A 62-year-old man, with a long history of smoking two packs of cigarettes a day, presents to your office with a history of worsening shortness of breath with exertion for the past 3   weeks. He also relates recent onset of fatigue, two-pillow orthopnea, and scattered wheezes on climbing a flight of stairs. Five years ago, he had an anterior wall myocardial infarction but had been doing well until his recent symptoms. He has no other medical problems. He takes a baby aspirin and atenolol daily. On examination, his vital signs were as follows: pulse,100 beats/minute and regular; respiration, 24 breaths/minute; blood pressure, 129/89   mm Hg; afebrile. Weight has increased by 10 pounds since the last visit 6   months ago. There is JVD at 30 degrees of elevation, rales a third of the way up in both lung fields, moderate hepatic congestion, and a positive hepatojugular reflux. Heart examination reveals an S4 but no murmurs. There is also 1 + pitting edema in both legs to his midcalves. You obtain an ECG, which shows sinus rhythm and no acute changes but poor R-wave progression in the anterior leads. The chest radiograph reveals cardiomegaly and pulmonary vascular congestion.



5. Which of the following medications is (are) appropriate for acute management?


a. furosemide

b. captopril

c. diltiazem

d. labetalol

e. a, b, and c

6. The nonpharmacologic treatments(s) of choice for this condition may include which of the following?


a. salt restriction

b. fat restriction

c. water restriction

d. none of the above

e. a, b, and c

The patient described here is treated with the appropriate medication and improves. He returns in 2   weeks with dyspnea and fatigue, although it is not as severe as before. Vital signs are normal. At this time, the JVD has resolved and the hepatojugular reflux is absent. The cardiac examination is unchanged. There is trace pitting edema in his ankles bilaterally. He has lost 10 pounds. Results of echocardiography are pending.



7. At this time, which of the following is (are) appropriate medication(s) to consider instituting?


a. an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB)

b. a second beta blocker

c. a calcium channel blocker

d. digitalis

e. a and d

8. Which of the following pathophysiologic mechanisms may underlie heart failure in this patient and should be searched for as part of a comprehensive evaluation?


a. LV chamber remodeling

b. coronary artery disease

c. valvular heart disease

d. abnormal excitation-contraction coupling

e. all of the above

9. What is (are) the current indication(s) for the use of digitalis in this condition?


a. a dilated left ventricle

b. an S3 or S4 gallop

c. decreased ejection fraction

d. atrial fibrillation with a rapid ventricular rate

e. c and d

10. Which of the following is (are) correct about the effects of digitalis on patients with this condition?


a. digoxin reduces long-term mortality

b. digoxin decreases rates of worsening of heart failure in patients with reduced left ventricular ejection fraction (LVEF)

c. lower digoxin maintenance doses may be as effective as higher doses

d. digoxin use reduces hospitalizations

e. b, c, and d

11. In evaluating a patient for systolic dysfunction, the most important characteristic found on echocardiography is


a. myocardial hypertrophy

b. valvular heart disease

c. cor pulmonale

d. low ejection fraction

e. wall motion abnormalities

12. Which of the following correctly defines the American Heart Association (AHA) stages of heart failure?


a. stage A: asymptomatic patients at high risk but with no identifiable structural abnormalities

b. stage B: asymptomatic patients with identifiable structural abnormalities

c. stage C: symptomatic patients with structural abnormalities

d. stage D: end-stage patients refractory to standard therapy

e. all of the above

13. All of the following have been shown to reduce hospitalizations and mortality in selective patients with congestive heart failure except


a. beta blockers

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Oct 1, 2016 | Posted by in GENERAL SURGERY | Comments Off on Congestive Heart Failure

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