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Cardiology: breathlessness

John Walker, a 63 year old gentleman, presents to his GP’s surgery and tells the receptionist he is having trouble breathing. Since the GP is unfamiliar with the patient, he takes a quick glance at Mr Walker’s file and notices a previous myocardial infarction and various atherosclerotic risk factors. As he walks into the clinic he is clearly out of breath.

The GP asks him what has been going on and Mr Walker describes being short of breath when walking long distances, especially uphill. He also feels tired and thinks this is because he keeps waking up in the middle of the night gasping for air. Afterwards he has trouble going back to sleep and usually ends up going to the bathroom (to urinate) before falling back asleep.

What symptoms has he described so far?

From the description of the symptoms, the GP suspects that Mr Walker has developed heart failure.

What type of heart failure is being described?

  • Muscle wasting
  • Cold peripheries
  • Hepatomegaly
  • S3 gallop rhythm
  • Elevated JVP
  • Peripheral basal crepitations
  • Ascites
  • Ankle/sacral oedema

  • Interstitial oedema
  • Diverted bloodflow
  • Pleural effusion
  • Alveolar oedema
  • Cardiomegaly
  • Kerley B lines
  • Bat’s wings
  • Costophrenic angle blunting
  • Cardiothoracic ratio >50%
  • Dilated upper lobe vessels

The GP also refers him for an echocardiogram and a cardiology appointment. Echocardiogram is a ultrasound scan of the heart showing the myocardium and valves in movement, and is therefore a very useful tool in heart failure and valve disease. The ejection fraction of each ventricle is used to determine the function of that ventricle. It is the proportion of blood pumped from a ventricle with each contraction. What ejection fraction measurement would you expect in Mr Walker?

Mr Walker returns from the hospital with the echocardiogram results and he has also several new medications with him: a Beta-blocker, an ACE inhibitor and spironolactone. He was already on aspirin and a statin. He says that he is feeling significantly better than before, however the GP becomes concerned over the medications he has been given and asks him to go for a blood test and stop one of the drugs. What is the GP most likely to be concerned of?

The GP also asks Mr Walker if he was told about any lifestyle changes that should be made for patients with heart failure. Which of the following topics should the GP discuss with Mr Walker (if he had enough time)?

Over the next ten years, Mr Walker’s heart failure worsens and whilst management is stepped up with the use of additional diurectics and digoxin. Ultimately the pharmacological agents cannot control the symptoms and surgical options are considered. Which approach would NOT be considered?

 
After the surgery, Mr Walker's ejection fraction improves by 15% and he feels significantly better with this new lease on life and plans to go to Cornwall for holiday.
 
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Diagram of heart failure

Some of the key symptoms of heart failure showing the underlying organ involvement. Copyright © 2012 NIH.






Left vs right heart failure.













HF CXR

Chest X-ray demonstrating the findings of heart failure.

HF CXR post

Chest X-ray of the same patient after medical treatment. Copyright 2012 © The Radiology Assistant.



Description of how ejection fraction can be measured.