Evaluation of Dyspnea and Edema in a 72-Year-Old Male – A Case Study

Evaluation of Dyspnea and Edema in a 72-Year-Old Male – A Case Study

Differentiation between Systolic and Diastolic Heart Failure

Heart failure is defined as a complex syndrome with the heart’s inability to pump blood adequately enough to satisfy the body’s metabolic requirements. Systolic heart failure occurs in cases of reduced cardiac contractile function of the heart, which, in turn, causes a decreased ejection fraction (EF), which is usually derived from EF values equal to or less than 40%. This implies that the heart cannot properly pump blood during the systole period, which results in decreased stroke volume and cardiac output (Hajouli & Ludhwani, 2022). Another type, diastolic heart failure, is mainly attributed to the abnormality of ventricle relaxation during diastole, which results in impairment in the ventricles filling phase, also known as the diastole phase. Patients with diastolic heart failure suffer symptoms of heart failure even though the ejection fraction (EF often higher than 50%) is preserved; the daily activities are limited because the ventricles have ventricular filling impairments (Malik et al., 2023).

Determining the Patient’s Heart Failure Type

From the echo examination results of the diminished movement of the anterior wall and the EF of 25%, it is clear that the patient has systolic heart failure (Carroll, 2018). Low Ejection Fraction shows poor contractile function and the inability of the heart to effectively pump blood out during systole. This congruence illustrates the meaning and qualities of systolic heart failure.

Pathophysiology of Symptoms

Dyspnea on Exertion

Dyspnea during exertion is a classic sign of heart failure. It is caused by insufficient blood flow to the lungs and other tissues due to decreased cardiac output. The heart’s diminished capacity to pump blood results in inadequate oxygen delivery to tissues during physical exertion, which causes dyspnea.

Pitting Edema

Low cardiac output resulting from cardiac failure gives rise to defensive mechanisms like activation of the renin-angiotensin-aldosterone system and increased secretion of antidiuretic hormone (ADH) (Ames et al., 2019). These mechanisms make the body hold sodium and water, which causes fluid accumulation in the interstitial space, leading to swelling in the legs and ankles, referred to as pitting edema.

Jugular Vein Distention

Elevated jugular venous pressure, a sign of augmented central venous pressure, is commonly seen in right-sided heart failure. It may also be a manifestation of pulmonary hypertension and left-sided heart failure. Ultimately, these lead to increased pulmonary pressure, the direct result of which is increased pressure in the right heart chambers, and a consequence of this is right jugular vein distention.

Orthopnea

Orthopnea is a type of dyspnea that is exacerbated when a patient tries to lie in a flat position. In the case of heart failure, the lying flat position redirects the fluid from the legs towards the central circulation, thereby increasing the venous return to the heart. This makes pulmonary congestion and bronchospasm even worse. Patients can find relief by sleeping in a semi-upright position to reduce venous return and pulmonary congestion.

Significance of Findings

Presence of a 3rd Heart Sound (S3)

The inception of an S3 gallop is a characteristic finding in systolic heart failure. It is generated by the rapid filling of the ventricle in early diastole, which is usually a result of excessive volume. It is attributed to raised ventricular filling pressures and compromised ventricular function, and it is a clinical marker of the heart failure grade (Pfeffer et al., 2019).

Ejection Fraction of 25%

Ejection fraction is significant in assessing left ventricular systolic function, and values below 40% indicate systolic dysfunction. A reduced ejection fraction of 25% demonstrates significant difficulty in the heart’s response to contractility and pumping blood output, hence confirming the diagnosis of systolic heart failure and indicating the severity of ventricular dysfunction.

References

Ames, M. K., Atkins, C. E., & Pitt, B. (2019). The renin‐angiotensin‐aldosterone system and its suppression. Journal of Veterinary Internal Medicine, 33(2), 363–382. https://doi.org/10.1111/jvim.15454

Carroll, M. (2018, May 7). Ejection Fraction: Normal Range, Low, and Treatment. Healthline. https://www.healthline.com/health/ejection-fraction

Hajouli, S., & Ludhwani, D. (2022, December 23). Heart failure and ejection fraction. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK553115/

Malik, A., Brito, D., Vaqar, S., & Chhabra, L. (2023). Congestive Heart Failure. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430873/

Pfeffer, M. A., Shah, A. M., & Borlaug, B. A. (2019). Heart Failure With Preserved Ejection Fraction In Perspective. Circulation Research, 124(11), 1598–1617. https://doi.org/10.1161/

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Read the case study below.
In your initial discussion post, answer the questions related to the case scenario and support your response with at least one evidence-based reference by Wed., 11:59 pm MT.
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Evaluation of Dyspnea and Edema in a 72-Year-Old Male – A Case Study

Case Scenario

A 72-year-old male presents to the primary care office with shortness of breath, leg swelling, and fatigue. He reports that he stopped engaging in his daily walk with friends three weeks ago because of shortness of breath that became worse with activity. He decided to come to the office today because he is now propping up on at least 3 pillows at night to sleep. He tells the NP that he sometimes sleeps better in his recliner chair. PMH includes hypertension, hyperlipidemia, and Type 2 diabetes.

Physical Exam:

BP 106/74 mmHg, Heart rate 110 beats per minute (bpm)

HEENT: Unremarkable

Lungs: Fine inspiratory crackles bilateral bases

Cardiac: S1 and S2 regular, rate and rhythm; presence of 3rd heart sound; jugular venous distention. Bilateral pretibial and ankle 2+pitting edema noted

ECG: Sinus rhythm at 110 bpm

Echocardiogram: decreased wall motion of the anterior wall of the heart and an ejection fraction of 25%

Diagnosis: Heart failure, secondary to silent MI

Discussion Questions

Differentiate between systolic and diastolic heart failure.
State whether the patient is in systolic or diastolic heart failure.
Explain the pathophysiology associated with each of the following symptoms: dyspnea on exertion, pitting edema, jugular vein distention, and orthopnea.
Explain the significance of the presence of a 3rd heart sound and ejection fraction of 25%.