NR 507 Week 2 Case Study Assignment

Heart Failure Case Study

Differentiate Between Systolic and Diastolic Heart Failure

Systolic heart failure, also referred to as heart failure with reduced ejection fraction (HFrEF), is a consequence of the inability of the heart to effectively pump blood to meet the body’s metabolic demands (Hajouli & Ludhwani, 2020). It causes a decrease in the left ventricular ejection fraction (LVEF) to below 40%, although it may be as low as 5-10% in other patients. HFrEF results from different mechanisms caused by different disorders, which include impaired contraction secondary to myocardial infarction, increased afterload due to hypertension, cardiomyopathies, and mechanical abnormalities caused by valvular heart disorders (Hajouli & Ludhwani, 2020).

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The left ventricle (LV) loses the capacity to generate enough pressure to pump blood through the aorta, and with time, it dilates and hypertrophies. Consequently, adequate stroke volume (SV) cannot be generated, and the cardiac output (CO) is impaired. With time, the end-diastolic volume and LV pressure increase due to the weakened pumping mechanism of the LV, causing blood to back up into the left atrium (LA) and fluid accumulation in the lungs (Arena & Ozemek, 2019). Because of high pulmonary hydrostatic pressure, fluid leaks from the pulmonary capillary bed to the interstitium and later the alveoli causing pulmonary congestion and edema.

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Diastolic heart failure, also referred to as heart failure with preserved ejection fraction (HFpEF), is due to the inability of the ventricles to relax and fill up with blood during diastole. It accounts for approximately 50% of patients with HF. According to Hajouli & Ludhwani (2020), the ejection fraction in diastolic heart failure is equal to or more than 50%. The LV becomes stiff and noncompliant, causing high filling pressures. With a decreased ventricular filling, the SV is decreased. The consequence of diastolic heart failure is similar to that of systolic heart failure, fluid congestion from reduced CO. The primary cause of diastolic heart failure is hypertension. It may be due to other causes such as advancing age, female sex, diabetes mellitus, and obesity.

State Whether the Patient is in Systolic or Diastolic Heart Failure.

The patient in the case has systolic heart failure (HFrEF). The presenting complains of shortness of breath, swelling of the legs bilaterally to the level of the tibia, fatigue, shortness of breath with exertion, and having to use a pillow to support himself to facilitate his sleep supports the HF type. These symptoms reported by the patient are due to fluid leakage from the pulmonary capillary bed into the interstitium and alveoli, which are causing pulmonary congestion and edema. The findings from the echocardiogram show that the patient has an ejection of 25%. This supports systolic heart failure, where the ejection fraction is depressed to below 40%. The normal ejection fraction of the left ventricle is between 55% and 65%. The LVEF refers to the total blood volume in the LV expressed as a percentage at the end of diastole that is pumped out of the left ventricle with the subsequent systole. The echocardiogram also depicts a decreased wall motion in the heart’s anterior wall.

Explain the Pathophysiology Associated with Each of the Following Symptoms: Dyspnea on Exertion, Pitting Edema, Jugular Vein Distension, and Orthopnea.

Dyspnea is a sensation of difficult or uncomfortable breathing. Dyspnea on exertion is a consequence of the failure of the left ventricular output to rise during exercise with an associated increase in the pulmonary venous pressure (Sandeep Sharma et al., 2019). During the early failure of the left ventricle’s pumping mechanism, CO fails to sufficiently increase in response to moderate exercise by patients with HF. This causes tissue and cerebral acidosis causing the experience of dyspnea on exertion (Sandeep Sharma et al., 2019).

Pitting edema is a result of fluid accumulation in the lower limbs. With the onset of heart failure, many compensatory circulatory and neurohormonal modifications happen that maintain normal blood pressure to facilitate the perfusion of vital organs (Abassi et al., 2022). With the progress of HF, the stimulation of the above systems become exaggerated, and there is marked systemic vasoconstriction and overloading of a failing heart. The effector arm of volume control becomes impaired, and with disproportionate activation of the vasoconstrictor-sodium retaining system, the renin-angiotensin-aldosterone system (RAAS), and failure of vasodilatory natriuretic factors, there is excessive salt and water retaining in the body (Abassi et al., 2022). This causes pooling of the fluid in the lower extremities manifested as pitting edema. Disruption of the sterling forces where the hydrostatic pressure increases and plasma oncotic pressure decreases promotes the extravasation of fluids and the development of edema (Abassi et al., 2022).

Jugular vein distension refers to the bulging of major veins in the neck of a patient with HF. It is due to increased pressure within the superior vena cava that results in the bulging of the external jugular vein (Bricker, 2021).

Orthopnea is a sensation of breathlessness when HF patients assume a recumbent position and becomes relieved upon sitting or standing (Meysman & Droogmans, 2018). It is due to pulmonary congestion during the recumbent position. With recumbency, blood volume from the lower extremities and splanchnic bed redistributes and settles in the lungs. The consequence is that the left ventricle cannot effectively pump out the additional blood volume because its efficiency has been impaired (Meysman & Droogmans, 2018). This leads to a significant decrease in vital capacity and pulmonary compliance leading to shortness of breath.

Explain the Significance of the Presence of a 3rd Heart Sound and Ejection Fraction of 25%.

The third heart sound results from rapid distension of the LV during early diastole, which goes in hand with the rapid filling of the ventricles and sudden deceleration of atrioventricular (AV) blood flow. It indicates fluid overload due to dysfunction of ventricles in HF. According to Shono et al. (2019), the third heart sound is the initial clue that suggests a patient has left-sided heart failure. An ejection fraction of 25% indicates that the total blood volume in the left ventricle at the end of diastole that is pumped at the subsequent systole is only 25% expressed as a percentage. This differs significantly from the normal value of between 55-65%. This, therefore, indicates left ventricular wall impairment, and the heart cannot perfuse vital organs effectively.

References

Abassi, Z., Khoury, E. E., Karram, T., & Aronson, D. (2022). Edema formation in congestive heart failure and the underlying mechanisms. Frontiers in Cardiovascular Medicine, 9, 933215. https://doi.org/10.3389/fcvm.2022.933215

Arena, R., & Ozemek, C. (2019). Intracardiac multimorbidity: assessing right ventricular function in left-sided heart failure through cardiopulmonary exercise testing. Expert Review of Cardiovascular Therapy, 17(5), 331–333. https://doi.org/10.1080/14779072.2019.1585808

Bricker, D. (2021). Does this patient have jugular venous distension? Vein finder‐enhanced assessment of jugular venous pressure. Clinical Case Reports, 9(3). https://doi.org/10.1002/ccr3.3747

Hajouli, S., & Ludhwani, D. (2020, January 18). Heart failure and ejection fraction. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK553115/

Meysman, M., & Droogmans, S. (2018). Orthopnea and pulmonary hypertension. Treat the underlying disease. Respiratory Medicine Case Reports, 24, 105–107. https://doi.org/10.1016/j.rmcr.2018.05.004

Sandeep Sharma, Hashmi, M. F., & Madhu Badireddy. (2019). Dyspnea on Exertion (DOE). Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499847/

Shono, A., Mori, S., Yatomi, A., Kamio, T., Sakai, J., Soga, F., Tanaka, H., & Hirata, K. (2019). Ultimate Third Heart Sound. Internal Medicine, 58(17), 2535–2538. https://doi.org/10.2169/internalmedicine.2731-19

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Preparing the Assignment

Requirements

Read the case study below.

In your initial discussion post, answer the questions related to the case scenario and support your response with at least one evidence-based reference by Wed., 11:59 pm MT.

Provides a minimum of two responses weekly on separate days; e.g., replies to a post from a peer; AND faculty member’s question; OR two peers if no faculty question using appropriate resources, before Sun., 11:59 pm MT.

Case Scenario

A 72-year-old male presents to the primary care office with shortness of breath, leg swelling, and fatigue. He reports that he stopped engaging in his daily walk with friends three weeks ago because of shortness of breath that became worse with activity. He decided to come to the office today because he is now propping up on at least 3 pillows at night to sleep. He tells the NP that he sometimes sleeps better in his recliner chair. PMH includes hypertension, hyperlipidemia and Type 2 diabetes.

Physical Exam:

BP 106/74 mmHg, Heart rate 110 beats per minute (bpm)

HEENT: Unremarkable

Lungs: Fine inspiratory crackles bilateral bases

Cardiac: S1 and S2 regular, rate and rhythm; presence of 3rd heart sound; jugular venous distention. Bilateral pretibial and ankle 2+pitting edema noted

ECG: Sinus rhythm at 110 bpm

Echocardiogram: decreased wall motion of the anterior wall of the heart and an ejection fraction of 25%

Diagnosis: Heart failure, secondary to silent MI

Discussion Questions

Differentiate between systolic and diastolic heart failure.

State whether the patient is in systolic or diastolic heart failure.

Explain the pathophysiology associated with each of the following symptoms: dyspnea on exertion, pitting edema, jugular vein distention, and orthopnea.

Explain the significance of the presence of a 3rd heart sound and ejection fraction of 25%.

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NR 507 Week 2 Case Study Assignment