Question

Lettie, a 65 year-old diabetic woman, had been experiencing increasing fatigue, dyspnea on exertion, orthopnea and paroxysmal nocturnal dyspnea (PND). In addition, her ankles remained swollen and she complained to her physician that her appetite was decreased. Physical examination revealed an obese woman with bilateral pitting edema of the ankles, hepatosplenomegally, shortness of breath on mild exertion, crackles on auscultation and hypertension. Based on echocardiography results, a diagnosis of chronic heart failure was made.

Please respond to each of the following

1. Name the symptoms associated with left-sided (systolic) heart failure and those associated with right-sided heart failure. Which does Lettie show symptoms of?
2. What relationship does Lettie's long-term hypertension and obesity have to her diagnosis of heart failure?
3. In Lettie, which do you think came first, the left-sided or right-sided failure? What led you to that conclusion?
4. What medical therapies will probably be used to treat Lettie's chronic left heart failure?

Answer 1

Chronic Heart failure: The chronic inability of heart to pump a sufficient amount of blood throughout the body, leading to a pooling of blood and shortness of breath.

1. Symptoms associated with Left sided heart failure: Inability of left ventricle to pump a sufficient amount of blood throughout the body , it may be result in build up of blood in Pulmonary veins , that carries blood away from heart. This condition may lead to the symptoms such as:

* Exertional dyspnoea

* fatigue, restlessness, confusion

* Paroxysmal nocturnal dyspnoea

* Pulmonary congestion leads to crackles, cough, wheezing, tachypnoea and blood tinged sputum

* Orthopnea

* Cyanosis

Symptoms associated with Right sided heart failure: Inability of Right ventricle of the heart to pump a sufficient amount of blood to the lungs. This leads to the venous stasis ( collection of venous blood) in the tissue and organs. This condition may lead to the symptoms such as

* Fatigue

* Increased peripheral venous pressure

* Enlarged liver and spleen ( hepatomegaly and spleenomegally

* Distended jugular vein

* weght gain

* Anorexia, GI distress

2.    Lettie show Symptoms of both Right side and left side heart failure. She has the symptomsof fatigue, exertional dyspnoea, oryhopnea and Paroxysmal nocturnal dyspnoea ( Left side heart failure)

She also has swelling of ankles, reduced appetite, hepatospleenomegally, crackles on Auscultation, shortness of breath ( zright side failure)

3. Relationships between  Long term Hypertension ,Obesity on Heart failure:

Hypertension means abnormally high Blood pressure. Obesity refers to a state of being obese due to an excess of body fat. Obesity may leads to various problems such as Diabetes, hypertension, Atherosclerosis and Coronary artery disease etc. During Chronic hypertension , pressure in the bloo vessels are too high, this cause the heart to pump more harder to keep blood circulating. Gradually this process leads to the enlargement and weakening of heart muscles, leads to heart failure.

4. The left side heart failure comes first then leads to right side heart failure. Usually Right side heart failure occurs as a result of left side heart failure. During left ventricular failure, the left ventricle fail to pump enough blood to the different parts of the body and blood build up in the pulmonary veins . Increased fluid pressure damages the right side of the heart and thus causes Right side heart failure.  

5. Medical therapies for left heart failure:

a. Beta blockers: metoprolol, bisoprolol to slow heart rate xnd reduce blood pressure.

b. ACE inhibitors ( Angiotensin Converting Enzyme Inhibitors): Enalapril, Captopril to reduce the Blood pressure.

c. Diuretics: Lasix , to decrease fluid collection in the lungs ( reduces symptoms associated with pulmonary congestion) and to reduce swelling.

Potassium sparing diuretics: Aldactone

d. Ionotropes: Intravenous medications to improve the pumping of heart.

e. Digitalis/ Digoxin: to strengthen heart muscles and to slow heart beat.

Surgeries such as Coronary bypass surgery, Heart valve replacement and also devices such as Implantable Cardioverter Defibrillators (ICD), Ventricular assist devices also can be used to treat heart failure.