Scenario Summary
A 72-year-old man presents with worsening shortness of breath, bilateral leg swelling, and fatigue. Over the past three weeks, his dyspnea has limited his daily walks, and he now needs three pillows to sleep or rests in a recliner. His medical history includes hypertension, hyperlipidemia, and type 2 diabetes.
Exam: BP 106/74 mmHg, HR 110 bpm, bilateral basal crackles, S3 heart sound, jugular venous distention, and 2+ bilateral pretibial and ankle edema. ECG shows sinus tachycardia. Echocardiogram reveals reduced anterior wall motion and an ejection fraction of 25%.
Diagnosis: Heart failure secondary to a silent myocardial infarction.
Systolic vs. Diastolic Heart Failure
A complicated clinical illness, heart failure (HF), occurs when the heart is unable to pump blood effectively enough to fulfill the body’s metabolic demands. Systolic and diastolic heart failure are two of its many manifestations. A reduced ejection fraction (EF), usually defined as less than 40%, indicates systolic heart failure, which occurs when the heart’s ability to contract and pump blood is diminished (McCance & Huether, 2019).
Diastolic heart failure, on the other hand, is characterized by increased stiffness and elevated filling pressures due to impaired relaxation and filling of the ventricles during diastole. This condition is also known as heart failure with preserved ejection fraction (HFpEF). Here, echocardiography shows systolic dysfunction with an ejection fraction of 25%. His symptoms will manifest as a reduction in cardiac output, which indicates his heart isn’t able to pump blood efficiently during systole.
Pathophysiology Associated with the Symptoms
The patient exhibits the hallmark symptoms of heart failure, which include orthopnea, jugular venous distention (JVD), swelling of the legs (pitting edema), and dyspnea with exercise. The reduction in cardiac output and the insufficient oxygen transport to tissues during exercise cause dyspnea on exertion. Shortness of breath occurs when the heart is unable to pump blood efficiently, causing blood to return to the pulmonary circulation (Short & Domagalski, 2013). This, in turn, increases the hydrostatic pressure in the lungs and causes pulmonary congestion.
Similar to how increasing hydrostatic pressure in the veins causes fluid to seep out into the interstitial spaces of the legs, pitting edema develops when this happens. Engorgement of the jugular veins, caused by an increase in the proper atrial pressure, is known as jugular venous distention. The research suggests elevated central venous pressure, a common finding in patients with heart failure (Yancy et al., 2017). Given that fluid redistributes from the legs into the central circulation in the supine position, increasing venous return to the heart and worsening pulmonary congestion, orthopnea, and a sense of breathlessness develop while lying flat. The patient’s predilection for sleeping in a reclining chair suggests they frequently experience relief from orthopnea when sleeping in a more upright posture.
Particularly relevant to the patient’s care are the third heart sound (S3) and the 25% ejection fraction. Immediately following S2 in early diastole is the third heart sound, a low-frequency ventricular gallop. It is a sign of increased ventricular compliance and fast ventricular filling, which are common in cases of volume overload such as heart failure – a considerably pressing issue in the US context (Birger et al., 2021).
This patient has systolic cardiac failure, which is compatible with the existence of an S3, since it indicates significant myocardial dysfunction and volume overload. Systolic heart failure is further supported by an ejection fraction of 25%, which shows that the left ventricle has considerably diminished contractile activity. This severely impaired ejection fraction highlights the gravity of the patient’s disease and the elevated danger of negative consequences, including death.
As a whole, the patient is suffering from systolic heart failure, which is marked by reduced ejection fraction and poor left ventricular contractile performance. It is crucial to promptly diagnose and treat heart failure in order to improve outcomes and quality of life since its symptoms, which include dyspnea on exercise, pitting edema, jugular venous distention, and orthopnea, are associated with its pathogenesis. Effectively reducing the course of systolic heart failure and improving patient outcomes requires early detection and management.
References
Birger, M., Kaldjian, A. S., Roth, G. A., Moran, A. E., Dieleman, J. L., & Bellows, B. K. (2021). Spending on cardiovascular disease and cardiovascular risk factors in the United States: 1996 to 2016. Circulation, 144(4), 271–282.
McCance, K.L. & Huether, S.E. (2019). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). Elsevier Health Sciences.
Short, M.W., & Domagalski, J.E. (2013). Iron deficiency anemia: Evaluation and managementLinks to an external site. American Family Physician, 87(2), 98-104.
Yancy, M., Jessup, M., Bozkurt, B., Butler, J., Casey Jr., D. E., Colvin, M. M., Drazner, M. H., Filippatos, G. S., Fonarow, G. C.,. Givertz, M. M., Hollenberg, S. M., Lindenfeld, J., Masoudi, F. A., McBride, P. E., Peterson, P. M., Stevenson, L. W., & Westlake, C. (2017). 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: A report of the American College of Cardiology/American Heart Assocation Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation, 136.