Case 31 - 66 yo with SOB

Question 1

Risk factors for CAD

Answer 1

diabetes, hypertension, sedentary lifestyle, obesity, smoking, hyperlipidemia, older age, male gender, fam hx, low HDL

Question 2

Prevalence of CAD

Answer 2

leading cause of death in the united states

Question 3

CHF pathophys

Answer 3

• diastolic heart failure: signs and symptoms of CHF present but left ventricular function is preserved
• left ventricle becomes stiffer and non-compliant leading to increased pulmonary vessel pressure, and congestion
• all pts with systolic dysfxn have diastolic dysfxn

Question 4

Heart failure physical exam

Answer 4

• rales in lung bases
• dullness to percussion
• JVD
• PMI laterally displace
• S3
• hepatojugular reflex
• abd distention or shifting dullness
• lower extremity edema

Question 5

Differential diagnosis for fatigue, SOB, pedal edema

Answer 5

1. Acute MI - overwhelms cardiac reserve, usually assoc with chest pain but can be painless so work up on EKG
2. Arrhythmia - can cause heart failure by impeding forward flow of blood through the heart
3. Chronic CAD/ischemic cardiomyopathy - often assoc with chest pain
4. Uncontrolled hypertension/diastolic dysfunction
5. Non-ischemic cardiomyopathy - less common than ischemic, esp in context of risk factors
6. Valvular disease - unlikely w/o murmur
   Less likely: anemia, PE, hypothyroidism

Question 6

Studies for SOB, fatigue, pedal edema

Answer 6

1. Chest x-ray - r/o pulm disease, look for cardiomegaly, central vasc congestion, pleural effusions, Kerley B lines (interstitial fluid in lung fields)
2. EKG: signs of ischemia include t-wave inversion and st elevation
3. Echo/Doppler - establishes diagnosis by measuring size of heart and ejection fraction (EF >45% + HF sx = diastolic heart failure)
4. Stress test - exercise tolerance test recommended in intermediate risk pts for initial work up of CAD, nuclear stress test has superior sensitivity and specificity
5. BNP

Question 7

CAD interventions

Answer 7

• blood pressure - ACE inhibitors recommended, can be given in conjunction with HCTZ
• diabetes - recommend reduction <100
• aspirin - reduces risk of MI
• weight loss - beneficial for heart disease

Question 8

Heart failure treatment

Answer 8

• new onset CHF - send pt directly to ED, need urgent stabilization with IV furosemide, if cardiac enzymes up, needs CCU
• Systolic HF management: give ACEI (or arbs), digoxin (reduces sx), loop diurectics, beta-blockers (reduce mortality), spironolactone for pts with Class III and IV HF
• avoid calcium channel blockers as can increase edema
• diastolic HF management: either beta-blocker or CCB (like diltiazem) to slow heart rate and increase ventricular filling time
• psychosocial - social work, minful medical practice