Case Conference #1

1. Case Conference #1 Mark Randolph

2. Setting the stage Sheila Jones is a 66 year old retired nurse, chief complaint is cough for about 6 weeks. Cough is none productive. No chest or back discomfort, palpitations, lightheadedness, or syncope. Her cough was treated with azithromycin without benefit by family doctor.

3. Past Medical History • Myocardial infarction 3 years ago. After an angiogram, "They told me that I had a blocked vessel, and that surgery was not necessary." • No history of hypertension. • No history of serious infectious disease. • No history of heart murmur. • No known allergies. • Random blood glucose intermittently elevated for 5 years

4. Medications: • ASA 325 mg QD/ Metoprolol 25 mg bid. Both were started after Her MI. • She has never used nitroglycerin products

5. Family History • Father died of a myocardial infarction at age 72. • Mother died of colon cancer at age 70.

6. Personal and Social History • Sedentary since she retired from her job as a nurse at age 60. • Avoids red meat whenever possible and observes no other dietary restrictions. • No drug abuse. Occasional alcohol intake. • No history of exposure to cardiotoxins. Thirty-five pack-year smoking history (stopped at the time of her MI).

7. Conversation with the patient • Doctor: What's bothering you? • Mrs. J .: I've had a bad cough for about 6 weeks. And I've been waking up at night coughing. • Doctor: Are you bringing up any phlegm? • Mrs. J.: No, doctor. It's a dry cough. • Doctor: When you awake at night, are you short of breath? • Mrs. S.: Sometimes. I am usually nervous, too. But after I sit on the side of the bed for a few minutes, I begin to feel better. • Daughter:she's tired all the time. She watches soap operas all day long and hardly ever gets up. And when we do go for a walk, I notice her gasping for air. • Mrs. J: I get short of breath easily. I also have to go to the bathroom to pass water a lot at night. My last doctor thought I had a bladder problem

8. Review of Systems • Appetite ok, but she eats very little, but the patient notes that she has been gaining weight. • Occasional ankle swelling, particularly after standing or sitting for prolonged periods “Shoes too tight, usually”.

9. Lung exam Patient- Sheila Jones Neuro Extremities Neck exam Precordial Exam Abdominal exam Vital Signs

10. Vital Signs • 135/85. • Pulse 90, regular. • Afebrile. • Respiratory rate 18/minute

11. Neurological Exam • Alert and oriented. • Speech fluent and appropriate. • No focal deficits

12. Inspection Cardiac apex displaced laterally. Auscultation Precordial Exam Inspection

13. Neck Exam • Normal carotid pulsations. • No carotid bruits. • JVD estimated at 10 cm H2O (nl: <9 cm H2O).

14. Extremities • Distal pulses are 2+ throughout

15. Lung Exam • Resonant to percussion bilaterally. • End-inspiratory rales audible at the lower 1/3 of both lung fields

16. Abdominal Exam • Active bowel sounds. • Liver palpable at the right costal margin;the liver edge is smooth, non-tender, without nodularity. • The aorta is not palpable

17. BUN and Creatinine Electrolytes and Glucose Liver Function Tests Thyroid Function Tests Urinalysis Complete Blood Count CPK (Creatinine phosphokinase) Blood Cultures Immunoelectrophoresis Ferritin Labs- Which ones?

18. BUN and Creatinine • BUN: 10 mg/dl    Creatinine: 1.3 mg/dl    Within the normal range • Why? • Necessary for several reasons. Severe renal insufficiency can lead to volume overload. Diuretics and ACE inhibitors, common therapies for CHF, may adversely affect renal function. In addition, if renal insufficiency is advanced, medication dosing adjustments may be necessary.

19. Electrolytes; Glucose • (Na,K,Cl,HCO3):137/4.2/100/25     • Glucose: 140 mg/dl    Within the normal range, except glucose • Why? • An essential test. Diuretics can cause hypokalemia which may predispose to ventricular arrhythmias. For this reason, the serum potassium should be maintained at a level greater than 4.0. In chronic congestive heart failure, hyponatremia has grave implications.1 This glucose is high. Given this patient's reported history, it might be prudent to check the Hbg A

20. Liver Function Tests • Alkaline phosphatase is mildly elevated. Otherwise within the normal range. • Why? • A reasonable choice. Liver function can be adversely affected by congestive heart failure. In addition, peripheral edema secondary to hypoalbuminemia should be ruled out.

21. Thyroid Function Tests • Within the normal range • Why? • This test is a reasonable choice. Hypothyroidism may present without its usual signs and symptoms and may manifest as CHF, especially in the elderly. Hyperthyroidism can cause CHF, and can provoke CHF in patients with intrinsic heart disease. The Agency for Health Care Policy and Research (AHCPR) Guidelines2 suggest that thyroid function tests be routinely checked in patients over 65 years of age, those with atrial fibrillation, and those with symptoms of thyroid disease.

22. Urinalysis • Specific Gravity: 1.020    Blood: Neg.    Protein: Neg • Why? • This test is also recommended by the AHCPR guidelines2, as a screen for nephrotic syndrome or glomerulonephritis, both of which may coexist with CHF.

23. Complete Blood Count • Hematocrit: 43%     • WBCs: 8,000/mm3    •  Platelets: 304,000/mm3    • Within the normal range • Why? • This test is useful, as anemia may aggravate congestive heart failure.

24. Lipid Profile • Total cholesterol: 190 mg/dlLDL Cholesterol: 120 mg/dlHDL Cholesterol: 30 mg/dlTriglycerides: 110 mg/dl • Why? • A reasonable choice in a patient with a history of ischemic heart dis

25. CPK (Creatine phosphokinase) • Not necessary! The history and physical do not suggest active ischemia.

26. Blood Cultures • This test is not necessary. It is true that endocarditis with valvular damage can cause heart failure, and that any infection can precipitate heart failure in a predisposed individual. However, this patient's history, vital signs, physical exam.

27. Immunoelectrophoresis • Not indicated. While amyloidosis can cause heart failure, immunoelectorphoresis should not be used as a screening test.

28. Ferritin • Not indicated. This is a valuable test when hemochromatosis is suspected, but that is not thecase in this instance.

29. Other Tests • A recent 12 lead ECG is a necessary component of the evaluation. • X-ray

30. Rhythm: Sinus. Normal intervals and axes. Nonspecific ST-T wave changes. Q waves are present in leads V1-V5 and are consistent with an anterior infarct.

31. The issue of arrhythmias This patient has a heightened likelihood of developing atrial fibrillation and ventricular arrhythmias. Symptomatic arrhythmias merit investigation. Symptomatic, non-sustained ventricular tachycardia in patients with prior infarction and EF 0.35 should lead to consideration for an electrophysiological evaluation The electrocardiogram shows normal sinus rhythm and Q waves in V1 to V5 indicative of an extensive anterior myocardial infarction of indeterminate age. In addition, the broad P wave in lead II and terminal negative P wave forces in lead V1 indicate interatrial conduction abnormality.

32. The issue of arrhythmias: continued • The finding of abnormal P waves in this patient's electrocardiogram would most likely indicate? Significant left ventricular dysfunction is indicated

33. Why- is significant left ventricular dysfunction indicated • In patients with coronary artery disease, the finding of interatrial conduction abnormality is a good indicator of significant left ventricular dysfunction. Only 20% of patients with coronary disease and this abnormality have normal left ventricular function.4 The patient's presenting symptoms and physical exam along with the ECG findings of an anteroseptal myocardial infarction and interatrial conduction abnormality certainly would indicate significant left ventricular dysfunction. • Although LA abnormality is seen in LVH, the ECG and past history (no known hypertension) don't support a diagnois of left ventricular hypertrophy. Also, as there is no diastolic murmur, mitral stenosis is not a likely diagnosis. Finally, idiopathic dilated cardiomyopathy is incorrect because the history of MI and ECG is consistent with prior MI, as is the history of CAD at catheterization.

34. X-ray Information Cardiomegaly and pulmonary vascular congestion are noted

35. Information • The chest X-ray plays an essential role in the evaluation of suspected heart failure. It is useful in distinguishing pulmonary from cardiac causes of dyspnea. Left atrial size and ventricular enlargement, as well as valvular calcification, can often be discerned on routine chest X-rays. The lateral view can provide additional information on chamber size and valvular calcification. In patients with ischemic cardiomyopathy, cardiomegaly is usually associated with an EF 35%. 5 • Based on the history, physical exam, preliminary labs, ECG, and CXR, this diagnosis is possible. Further evaluation is required to determine the degree to which valvular dysfunction, on-going ischemia, or the consequences of ventricular remodeling following an infarction are each contributing to the patient's heart failure. Continuing evaluation is clearly indicated; however, treatment should be initiated at this juncture. • At this point the patient has been found to have a history and physical exam suggestive of congestive heart failure. His CXR supports this diagnosis. The ECG shows evidence of previous infarct.

36. What should we do with the Mrs. Jones? • Admit • Treat out patient

37. You are wrong Go back and find out why!!

38. Treat out patient According to the AHCPR guidelineson CHF, indications for admission include: • Clinical or ECG evidence of acute ischemia • Pulmonary edema or severe respiratory distress • O2 saturation less than 90% • Severe complicating medical illness • Anasarca • Symptomatic hypotension or syncope • Heart failure refractory to outpatient therapy • Inadequate social support for safe outpatient therapy

39. Which outpatient treatment would you first recommend? • ACE inhibitor • Digoxin • ß blocker • Loop diuretic

40. Correct • A loop diuretic should be administered • Loop diuretics are indicated for the signs and symptoms of volume overload. Their potency is preferred to relieve symptoms. Milder fluid overload can be treated with thiazides. • The starting dose should be 10-40 mg of furosemide (or the equivalent dose of another loop diuretic). Since loop diuretics interfere with renal handling of Mg++ and K+, hypokalemia and hypomagnesemia are potential problems. Such electrolyte disturbances can predispose to serious arrhythmias..

41. Correct- Continued • Supplementation of K+ and sometimes Mg++ is often required, but, as a general rule, treatment should not be delayed while labs are pending. Given normal renal function and K+ in the low end of the normal range, K+ supplement would be started. • ACE inhibition full dose ß blockade and digoxin may be indicated, but not yet. ACEI and ß blocking drugs have proven to be of most certain benefit in cases where the EF is depressed (as determined by echocardiogram, radionuclide scan, or contrast ventriculogram).6-8 Digoxin may be indicated, but only if he remains symptomatic after diuretics, ACEI, and ß blocking agents. 9

42. Thank you for your time.