Congestive Cardiac Failure - Questions & Answers For Long Case

Sample case: 
The patient Mrs …, 38-year-old, housewife, normotensive, nondiabetic, nonsmoker, presented with
progressively increasing difficulty in breathing for … months. Initially she felt breathless on moderate to severe exertion, but now it is more marked even during normal activities like going to toilet or dressing. She also complains of cough, with expectoration of mucoid sputum, but with no hemoptysis or wheeze. The cough is not aggravated by exposure to cold, dust, fume, etc. Occasionally, she experiences nocturnal breathlessness, at late hours of night, for which she has to get up from sleep and walk to take deep breath, which makes her comfortable. There is no history of breathlessness on lying flat (orthopnea).
The patient also experiences occasional palpitation, aggravated on mild exertion and relieved by taking rest. She also noticed pain in the right upper abdomen, which aggravates on lying on right
lateral position. The pain is dull aching in nature, but no radiation to any site. She also complains of
gradual swelling of both legs, which is more marked during prolonged sitting or standing. The swelling used to disappear while she gets up from sleep early in the morning. She also complains of weakness, loss of appetite and loss of about one third of her body weight within the last … months. There is no history of rheumatic fever or any cardiac disease. She does not give any history suggestive of COPD. There is no history of hypertension, diabetes mellitus. There is no family history of such illness. She used to take tablet frusemide and inhaler salbutamol as prescribed by local physicians.

On Examination Patient is ill looking and dyspneic, moderately anemic and has Pitting dependant edema. JVP is raised.
Vitals:
Pulse: 104/min, low volume and regular in rhythm
Blood pressure: 100/70 mm Hg
Temperature: 97.6ºF
Respiratory rate: 30/min.

Cardiovascular examination reveals a Left parasternal heave and epigastric pulsation. and an audible murmur.

On abdominal examination liver is enlarged.

What is the provision diagnosis? 
Congestive Cardiac Failure With a Valvular Lesion

What are your differential diagnoses?
As follows:

• Chronic cor pulmonale
• Nephrotic syndrome
• Cirrhosis of liver.

What investigations do you suggest in this case?

As follows:

• X-ray chest (cardiomegaly, plethoric lung fields)
• ECG
• Echocardiogram
• Others: CBC, ESR, urea, creatinine, electrolytes, serum total protein and AG ratio, lung function test (if COPD)
• Atrial natriuretic peptide.

What is heart failure?

It is defined as failure of the heart to maintain adequate cardiac output to meet the demand of the tissue or can do so only at the expense of an elevated filling pressure.

 

What are the cardinal signs of congestive cardiac failure?

Cardinal signs of CCF are:

• Engorged and pulsatile neck veins
• Enlarged and tender liver
• Dependent pitting edema.

What are the causes of CCF?

As follows:

• Secondary to left sided heart failure (common cause)
• Mitral stenosis with pulmonary hypertension
• Chronic cor pulmonale due to any cause
• Pulmonary hypertension
• Pulmonary valve disease (stenosis or regurgitation)
• Tricuspid regurgitation
• Shunt anomaly (ASD, VSD), when there is reversal of shunt (Eisenmenger’s syndrome)
• Cardiomyopathy
• Right ventricular myocardial infarction.

What is the functional classification of cardiovascular disease status?

 A close relationship of symptoms and exercise is the hallmark of heart disease. New York Heart

Association (NYHA) functional classification of cardiovascular status is as follows:

• Grade I: No limitation during ordinary activity (asymptomatic).
• Grade II: Slight limitation during ordinary activity (symptomatic with mild activity).
• Grade III: Marked limitation of normal activities without symptoms at rest (symptomatic with moderate activity).
• Grade IV: Unable to undertake physical activity without symptoms. Symptoms may be present at rest (symptomatic at rest).

How to treat CCF?

As follows:

• Complete rest.
• Restriction of fluid and salt.
• Diuretic (frusemide or bumetanide).
• Aldosterone receptor antagonist (e.g. spironolactone, eplerenone).
• Vasodilator (ACE inhibitor or ARB).
• b-blocker (especially bisoprolol 1.25 mg daily and gradually increased over 12 weeks up to 10 mg daily) may be used. It reduces the risk of arrhythmia and sudden death. b-blocker should not be initiated at a high dose since it may precipitate acute on chronic heart failure. But when given in a small incremental dose (as above), it can increase ejection fraction, improve symptoms, reduce frequency of hospitalization and reduce mortality in patient with chronic heart failure.
• Digoxin (helpful in CCF with atrial fibrillation).
• Treatment of arrhythmia (amiodarone is the drug of choice).
• Treatment of the underlying cause.
• Heart transplantation—if all above measures fail.

What are the complications of digoxin? How to treat if toxicity of digoxin develops?

As follows:

1. Extracardiac:

 - Gastrointestinal: anorexia, nausea, vomiting, diarrhea

 - Altered color vision (xanthopsia)

 - Others: weight loss, confusion, headache, gynecomastia.

2. Cardiac:

 - Bradycardia

 - Multiple ventricular ectopics

 - Ventricular bigeminy

 -Atrial tachycardia with variable block

 -Ventricular tachycardia (bidirectional VT is mainly due to digitalis)

 -Ventricular fibrillation.

Treatment of digoxin toxicity:

• Digoxin should be stopped
• Serum electrolytes, creatinine and digoxin level should be checked.
• Correction of electrolytes, if any
• If bradycardia: IV atropine, sometimes pacing may be needed
• Correction of arrhythmia.

What are the causes of peripheral edema?

As follows:

1. Pitting edema occurs in:

• CCF
• Hypoalbuminemia (nephrotic syndrome, protein loosing enteropathy or less protein intake, CLD)
• Chronic venous insufficiency (varicose vein0
• Drugs (calcium channel blockers, e.g. nifedipine, amlodipine
• Idiopathic (also called ‘Fluid retention syndrome’, common in women).

2. Non-pitting edema occurs in:

• Myxedema.
• Chronic lymphatic obstruction or lymphedema (e.g. filariasis, Milroy’s disease).

What is high output cardiac failure and low output cardiac failure? What are the causes?

1. High output cardiac failure means “the heart fails to maintain sufficient circulation despite an

increased cardiac output”. Presentations are same as in low output cardiac failure except tachycardia, gallop rhythm, warm extremities with distended superficial veins. 

Causes are:

• Severe anemia
• Thyrotoxicosis
• Arteriovenous fistula
• Beriberi
• Gram-negative septicemia
• Paget’s disease of the bone.

2. Low output cardiac failure means “the heart fails to maintain sufficient circulation with low cardiac

output”. 

Common causes are:

• Ischemic heart disease
• Multiple valvular lesion
• Hypertension
• Cardiomyopathy
• Pericardial disease.

What is cardiac cachexia?

Marked loss of weight or body mass that may occur in some cases of long standing moderate to severe cardiac failure is called cardiac cachexia.

It occurs commonly in patient more than 40 years with heart failure for more than 5 years. It is

associated with high morbidity and mortality. 

Probable mechanisms are as follows:

• Malabsorption, anorexia and nausea due to intestinal venous congestion or edema, congestive hepatomegaly or toxicity of drugs (digoxin).
• Increased metabolic activity.
• TNF-a is increased, which is an important contributing factor for cachexia.
• Natriuretic peptide C is also increased.
• Poor tissue perfusion due to low cardiac output.