Systolic Heart Failure

A 58-year-old man is evaluated in the office for a 3-month history of shortness of breath with exertion. He has a 10-year history of hypertension and type 2 diabetes mellitus but no history of coronary artery disease. His medications are extended-release metoprolol, aspirin, metformin, and atorvastatin.

On physical examination, blood pressure is 165/92 mm Hg and heart rate is 88/min. Jugular venous pressure is 10 cm H2O. Bibasilar crackles are present, cardiac rhythm is regular, and an S3 is present. Electrocardiogram shows normal sinus rhythm and left ventricular hypertrophy. Laboratory test results include potassium of 4.2 meq/L and creatinine of 1.0 mg/dL. An echocardiogram is ordered, and furosemide is prescribed.

The patient returns the following week with resolution of his symptoms. His blood pressure at this visit is 130/78 mm Hg, his heart rate is 65/min, jugular venous pressure is 4 cm H2O, lungs are clear, and the S3 is absent. The echocardiogram shows left ventricular hypertrophy, reduced systolic function, and inferior wall hypokinesis.

Which of the following is the most appropriate medication change at this time?
A Change metoprolol to carvedilol
B Start digoxin
C Start lisinopril
D Start spironolactone

Key Point
Angiotensin-converting enzyme inhibitors are indicated for all patients with systolic heart failure, regardless of ejection fraction or functional status, barring contraindications.

Answer and Critique (Correct Answer = C)

Angiotensin-converting enzyme inhibitors are indicated for all patients with systolic heart failure, regardless of the level of the ejection fraction or functional status unless there are contraindications (including hyperkalemia, acute renal failure, or a history of angioedema).

Sustained-release metoprolol and carvedilol are both approved for heart failure treatment in the United States. Currently, there is no definitive evidence indicating whether one is better than the other for the treatment of heart failure. Digoxin improves symptoms and reduces hospitalizations for patients with heart failure but is not indicated for patients with asymptomatic heart failure in the absence of other indications (such as rate control for atrial fibrillation). Spironolactone is indicated for patients with heart failure who have severe symptoms (New York Heart Association class III or IV).
Bibliography

1. Dagenais GR, Pogue J, Fox K, Simoons ML, Yusuf S. Angiotensin-converting-enzyme inhibitors in stable vascular disease without left ventricular systolic dysfunction or heart failure: a combined analysis of three trials. Lancet. 2006;368:581-8. [PMID: 16905022]

Heart Failure

A 68-year-old woman is hospitalized with palpitations and shortness of breath. She has a history of hypertension and chronic atrial fibrillation, and her medications are furosemide, candesartan, and warfarin. On physical examination, the heart rate is 120/min with an irregularly irregular rhythm, and blood pressure is 130/80 mm Hg with no evidence of pulsus paradoxus. She has an elevated jugular venous pressure with normal x and y descent, crackles in both lungs, and marked lower extremity edema. Echocardiography shows left ventricular hypertrophy, an ejection fraction of 70%, and no significant valvular disease.

After intravenous diuretics are begun, the patient's symptoms improve, and the crackles and peripheral edema resolve. Her heart rate is now 99/min, and her blood pressure is 120/75 mm Hg.

Which of the following is the most likely primary mechanism of her heart failure?
A Constrictive pericarditis
B Diastolic dysfunction
C Systolic dysfunction
D Valvular disease

Key Point
The diagnosis of diastolic heart failure is generally made when signs and symptoms of systolic heart failure are present but the echocardiogram shows a normal left ventricular ejection fraction and an absence of significant valvular abnormalities.

Answer and Critique (Correct Answer = B)

This patient has a history and echocardiographic findings consistent with diastolic dysfunction. She has hypertension, which predisposes to the development of left ventricular hypertrophy and associated impaired ventricular relaxation.

Although she presented with evidence of heart failure, the echocardiogram demonstrated normal systolic function and no significant valvular abnormalities that could account for the heart failure. Therefore, systolic dysfunction and valvular disease are unlikely. Constrictive pericarditis is also unlikely in the absence of pulsus paradoxus, normal x and y descent, and no echocardiographic evidence of constrictive pericarditis, such as pericardial thickening or abrupt posterior motion of the ventricular septum in early diastole with inspiration.

The primary treatment goals in patients with diastolic heart failure are to treat the underlying cause (if possible), manage any potentially exacerbating factors, and optimize diastolic filling by slowing the heart rate with β-blockers. To date, there have been no medications shown to reduce morbidity and mortality in patients with diastolic dysfunction.
Bibliography

1. Chinnaiyan KM, Alexander D, Maddens M, McCullough PA. Curriculum in cardiology: integrated diagnosis and management of diastolic heart failure. Am Heart J. 2007;153:189-200. [PMID: 17239676]