Case Study

CASE VIGNETTE
Mr. Cee, a 75-year-old male widower, born in Bulan, Sorsogon and residing Sorsogon City was
admitted to the hospital in October 2022 due to Congestive heart failure. The patient was referred 1 year
before to SPH with a history of progressive dyspnea triggered by less than ordinary activities, and lower-
extremity edema. The patient was a previous smoker and had stopped smoking at the age of 37 years. He
was also an alcoholic and reported drinking alcohol for the last time 1 year before. He was referred to
ISPH for treatment of heart failure. The patient reported daily use of furosemide 20 mg, and digoxin
0.125 mg.
On October 2022, his physical examination showed a weight of 55 kg, height of 1.75 m, body mass index
(BMI) of 18 kg/m2, heart rate of 60 bpm, blood pressure of 90 X 50 mm Hg, and the presence of a
hepatojugular reflux.
INTRODUCTION
Congestive heart failure, according to Mayo Clinic occurs when the heart muscle doesn't pump
blood as well as it should. When this happens, blood often backs up and fluid can build up in the lungs,
causing shortness of breath. Furthermore, Certain heart conditions, such as narrowed arteries in the heart
(coronary artery disease) or high blood pressure, gradually leave the heart too weak or stiff to fill and
pump blood properly. Heart failure often develops after other conditions have damaged or weakened the
heart. However, heart failure can also occur if the heart becomes too stiff.
Signs and Symptoms
Signs and symptoms of congestive heart failure may include breathlessness during activity (most
commonly), at rest, or while sleeping, which may come on suddenly and wake you up, fatigue and
weakness, swelling in the legs, ankles and feet, rapid or irregular heartbeat , reduced ability to exercise
persistent cough or wheezing with white or pink blood-tinged mucus, swelling of the belly area
(abdomen), very rapid weight gain from fluid buildup, nausea and lack of appetite, difficulty
concentrating or decreased alertness, chest pain if heart failure is caused by a heart attack.
Causes
Heart failure can start suddenly after a medical condition or injury damages your heart muscle.
But in most cases, heart failure develops slowly from long-term medical conditions.
Conditions that can cause heart failure include:
 Arrhythmia (a problem with the rate or rhythm of your heartbeat)

 Cardiomyopathy
 Congenital heart defects or other types of heart diseases that you are born with
 Coronary artery disease
 Endocarditis
 Heart attack
 Heart valve diseases
 High blood pressure
 A blood clot in your lung
 Diabetes
 Certain severe lung diseases, such as COPD (chronic obstructive pulmonary disease)
 Obesity
Risk factors
Risk factors for heart failure include:
 Coronary artery disease. Narrowed arteries may limit your heart's supply of oxygen-rich blood,
resulting in weakened heart muscle.
 Heart attack. A heart attack is a form of coronary artery disease that occurs suddenly. Damage
to your heart muscle from a heart attack may mean your heart can no longer pump as well as it
should.
 Heart valve disease. Having a heart valve that doesn't work properly raises the risk of heart
failure.
 High blood pressure. Your heart works harder than it has to if your blood pressure is high.
 Irregular heartbeats. These abnormal rhythms, especially if they are very frequent and fast, can
weaken the heart muscle and cause heart failure.
 Congenital heart disease. Some people who develop heart failure were born with problems that
affect the structure or function of their heart.
 Diabetes. Having diabetes increases your risk of high blood pressure and coronary artery disease.
Don't stop taking any medications on your own. Ask your doctor whether you should make
changes.
 Some diabetes medications. The diabetes drugs rosiglitazone (Avandia) and pioglitazone
(Actos) have been found to increase the risk of heart failure in some people. Don't stop taking
these medications on your own, though. If you're taking them, ask your doctor if you need to
make any changes.
 Certain other medications. Some medications may lead to heart failure or heart problems. They
include nonsteroidal anti-inflammatory drugs (NSAIDs); certain anesthesia medications; and
certain medications used to treat high blood pressure, cancer, blood conditions, irregular or
abnormal heartbeats, nervous system diseases, mental health conditions, lung and urinary
problems, inflammatory diseases, and infections.
 Alcohol use. Drinking too much alcohol can weaken the heart muscle and lead to heart failure.
 Sleep apnea. The inability to breathe properly while you sleep results in low blood-oxygen levels
and an increased risk of irregular heartbeats. Both of these problems can weaken the heart.
 Smoking or using tobacco. If you smoke, quit. Using tobacco increases your risk of heart
disease and heart failure.
 Obesity. People who have obesity have a higher risk of developing heart failure.
 Viruses. Certain viral infections can cause damage to the heart muscle.
ANATOMY
Heart failure often develops after other conditions have damaged or weakened the heart.
However, heart failure can also occur if the heart becomes too stiff. In heart failure, the main pumping
chambers of the heart (the ventricles) may become stiff and not fill properly between beats. In some
people, the heart muscle may become damaged and weakened. The ventricles may stretch to the point that
the heart can't pump enough blood through the body. Over time, the heart can no longer keep up with the
typical demands placed on it to pump blood to the rest of the body. Ejection fraction is used to help
classify heart failure and guide treatment. In a healthy heart, the ejection fraction is 50% or higher —
meaning that more than half of the blood that fills the ventricle is pumped out with each beat.
But heart failure can occur even with a normal ejection fraction. This happens if the heart muscle
becomes stiff from conditions such as high blood pressure.
Heart failure can involve the left side (left ventricle), right side (right ventricle) or both sides of your
heart. Generally, heart failure begins with the left side, specifically the left ventricle — your heart's main
pumping chamber.
Type of heart failure Description
Left-sided heart failure Fluid may back up in the lungs, causing

shortness of breath.
Right-sided heart failure Fluid may back up into the abdomen, legs and
feet, causing swelling.
Systolic heart failure (also called heart failure The left ventricle can't contract vigorously,
with reduced ejection fraction) indicating a pumping problem.
Heart failure with preserved ejection fraction The left ventricle can't relax or fill fully,
indicating a filling problem.
PATHOPHYSIOLOGY
Congestive heart failure is a syndrome that can be caused by a variety of abnormalities, including
pressure and volume overload, loss of muscle, primary muscle disease or excessive peripheral demands
such as high output failure. In the usual form of heart failure, the heart muscle has reduced contractility.
This produces a reduction in cardiac output, which then becomes inadequate to meet the peripheral
demands of the body. The 4 primary determinants of left ventricular (LV) performance are generally
altered as follows: (1) There is an intrinsic decrease in muscle contractility. (2) Preload or left atrial filling
pressure is increased, resulting in pulmonary congestion and dyspnea. (3) Although systemic blood
pressure is often reduced, there is an increase in systemic vascular resistance (afterload), which can
further reduce cardiac output. (4) Heart rate is generally increased as part of a compensatory mechanism
associated with an increase in sympathetic tone and circulating catecholamines. In patients with coronary
disease, there is often an imbalance between myocardial oxygen supply and demand. An increase in heart
size may be particularly deleterious by increasing wall tension because of the Laplace relation and
increasing myocardial oxygen consumption.

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CASE VIGNETTE

 Arrhythmia (a problem with the rate or rhythm of your heartbeat)

Type of heart failure Description

Left-sided heart failure Fluid may back up in the lungs, causing

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