Congestive Heart Failure: Causes, Symptoms, and Treatment

Question 1. Based on the information given above, do you suspect that this patient has developed left-sided H.F., right-sided H.F., or total (both left and right H.F.)?

I suspect that the patient above developed a right-sided Congestive Heart Failure.

Question 2. How did you arrive at your answer to question 1?

Physical examination reveals Jugular Vein Distention (JVD), where the superior Vena Cava swells and bulges outwards as it fills with too much blood, indicating flawed pumping of blood into the lungs. Hence there has to be a failure in the right ventricle. Secondly, the X-ray image revealed prominent cardiomegaly with persistent pulmonary oedema. The oedema is due to deoxygenated blood not being fully pumped out towards the lungs. In addition to that, the patient presented with 2+ pitting feet oedema, cool sweaty skin and significant hepatomegaly that was tender to deep palpation. These signs indicate blood retention in the lower extremities, which are consistent with a right-sided H.F. Even though there is a low erectile fraction, left-sided H.F. is ruled out by the absence of aortic oedema.

Question 3. What is the most likely cause of H.J.'s heart failure? (Identify only one)

The most probable cause of the patient's heart failure is Coronary Artery Disease. She has had issues with her coronary arteries, requiring Coronary Artery Bypass Surgery after suffering a Myocardial Infarction in 2016.

Question 4. Identify three risk factors that likely contributed to the patient's heart attack (MI) in 2014.

The patient's congestive heart failure could have been contributed to by some of his lifestyle habits. First, she is an infrequent alcoholic. Secondly, she used to be a chain smoker in the past, and the effects of that could be still haunting her today. She is obese and, elderly and less likely to indulge in any exercise, hence weakening her heart and subjecting it to straining over typical tasks. Lastly, she had a Coronary Artery Bypass Surgery four years ago; therefore, she has past scars. The four factors could contribute to this occurrence.

Question 5. Why is the patient taking Aspirin?

She takes Aspirin because she has had a heart attack before, the risk of its reoccurrence is still there. If there was a blood clot in her arteries, it could easily block the coronary artery, causing her another heart attack. The Aspirin prevents the probability of platelet agglutination to occur, possibly preventing another heart attack (Ge et al., 2019). It does not heal anything, but it prevents a looming danger.

Question 6. Why is this patient tachycardic? Explain the pathophysiology.

Tachycardia occurs due to the inefficiency in blood supply as a result of heart failure. The body is not getting enough oxygen as characterized by a relatively low SpO2 level and elevated respiratory rate (Ge et al., 2019). The heart pumps faster to supply more blood to where it is needed more. Unfortunately, during tachycardia, the heart does not pump powerfully, and neither does it fill up with blood well, thereby resulting in even poorer oxygenation and circulation.

Question 7. Why is this patient tachypneic? Explain the pathophysiology.

Tachypnea occurs when one has so much carbon dioxide concentration in his or her body, thereby causing him to have shallow yet frequent breaths. In this case, due to the right-sided HF, blood cannot be sufficiently pumped into the lungs, which lowers its level and rate of oxygenation far much. The blood becomes slightly acidic, and the brain responds by signaling the lungs to pick up the pace to restore the normalcy.

Question 8. Explain the pathophysiology of abnormal skin manifestations in this patient's compensated H.F.

Physical examination of the patient revealed that she had pale, cool and sweaty extremities, and was slightly diaphoretic. Her extremities were pale because they lacked a sufficient supply of oxygenated blood around the limbs. Her extremities were cool and clammy due to sweating that occurs systematically to cool the body down as the heart is being overworked to pump more blood, thereby producing a lot of heat.

Question 9. Are jugular vein distension (JVD) and hepatomegaly signs of left-sided H.F. or right-sided H.F.? Explain the rationale.

Jugular Vein Distention and Hepatomegaly are signs of right-sided heart failure. JVD refers to bulging of the superior vernacular, which brings blood back into the heart from other parts of the body. If the blood is not being pumped into the longs properly, it accumulates in the vein, which makes it distended. As such, a distended jugular vein means that there is a failure on the right side of the heart (Francis, & Tang, 2019). Hepatomegaly indicates the same, as it results from impaired drainage of blood from the liver, thereby making it enlarge. If the right ventricle was functioning properly, the blood would move from the liver through the heart to the lungs, leaving the liver in its normal size.

Question 10. Which abnormal cardiac exam and chest x-ray findings closely complement one another?

The lateral displacement of PMI (Point of Maximal Impulse) indicates cardiomegaly, where the heart becomes enlarged and spreads far beyond its normal position. Auscultation with a stethoscope revealed. The observation was further confirmed by the X-ray image, which showed an enlarged heart. Therefore, the two observations complement each other.

Question 11. Explain the pathophysiology of the abnormal serum Na+ and K+ levels in this patient's compensated H.F.

Laboratory tests indicate that L.M. was hypernatremic and hypokalemic. Hypernatremia occurs as a step to preserve blood pressure, where after the pumping action of the heart is insufficient to sustain the pressure, reabsorption of so much more water in the kidney tubules with the release of much more sodium can keep the pressure up (Dokainish et al., 2017). In the early stages of the CHF when the renal function is still reserved, but water has been reabsorbed, the blood is diluted of Potassium ions at first, and is then replaced with hyperkalemia. As such, the patient presented with hypokalemia and hypernatremia.

Question 12. Explain the pathophysiology of the abnormal serum BUN and creatinine levels.

BUN and Creatinine became elevated after Congestive heart failure because the heart was unable to sufficiently circulate the blood through the kidneys where the urea and the Creatinine is cleared from the blood. The poor cardiac output means that more blood is laying around the body instead of being pushed to the kidneys for purification. With restored circulation and functional kidneys, the two would normalize.

References

Dokainish, H., Teo, K., Zhu, J., Roy, A., AlHabib, K. F., ElSayed, A., ... & Orlandini, A. (2017). Global mortality variations in patients with heart failure: results from the International Congestive Heart Failure (INTER-CHF) prospective cohort study. The Lancet Global Health, 5(7), e665-e672.

Francis, G. S., & Tang, W. W. (2019). Pathophysiology of congestive heart failure. Reviews in cardiovascular medicine, 4(S2), 14-20.

Ge, Z., Li, A., McNamara, J., Dos Remedios, C., & Lal, S. (2019). Pathogenesis and pathophysiology of heart failure with reduced ejection fraction: translation to human studies. Heart failure reviews, 24(5), 743-758.