1. HEART FAILURE Suggestions for Lecturer -1-hour lecture
-Use slides alone or to supplement your own teaching materials.
-Refer to the GNRS chapter on heart failure for additional material and for strength of evidence (SOE) levels.
-The GNRS Teaching Slides reflect care that can be provided to older adults in all settings. The words patient, resident, and older adult have been used interchangeably, as have the words provider, clinician, and primary care provider. Given the continually ongoing changes in health care today, some of the guidelines around reimbursement may have changed since publication.

2. The epidemiology, etiology, and pathophysiology of heart failure (HF)
OBJECTIVES
Know and understand:
The epidemiology, etiology, and pathophysiology of heart failure (HF)
The clinical signs and symptoms of HF as they manifest in older adults
Appropriate management strategies
How to provide end-of-life care with consideration of individual patient prognosis
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3. Etiology and Pathophysiology Clinical Features Diagnosis Management
TOPICS COVERED
Epidemiology
Etiology and Pathophysiology
Clinical Features
Diagnosis
Management
Recurrent Hospitalization
Prognosis
End-of-Life Care
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4. EPIDEMIOLOGY OF HEART FAILURE (HF)
Incidence and prevalence increase with age
Leading cause of hospitalization and rehospitalization in older adults
Median age of patients hospitalized with HF is 75 years, and approximately two thirds of deaths attributable to HF are in patients age 75 years or older
HF is a major cause of chronic disability and impaired quality of life in older adults
Heart failure affects more than 5 million Americans, and >650,000 new cases are diagnosed each year.
Although the incidence of HF is somewhat higher in men, women comprise slightly over half of prevalent HF cases.
The rising prevalence of HF with increasing age reflects the combination of age-related changes in cardiovascular structure and function that serve to diminish cardiovascular reserve, in conjunction with the rising prevalence of cardiovascular diseases with increasing age (especially hypertension and coronary artery disease) that predispose to HF.
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5. ETIOLOGY OF HF HF in older adults is often multifactorial in origin
Hypertension is the most common antecedent cardiovascular condition in both men and women
60%–70% of women, 30%–40% of men
In men, 30%–40% of HF cases are attributable to coronary artery disease (CAD)
Other common causes include valvular heart disease and nonischemic dilated cardiomyopathy
Less common causes of HF include hypertrophic cardiomyopathy, restrictive cardiomyopathy (eg, amyloid), and pericardial disease.
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6. HF with preserved ejection fraction (HFPEF) — HF with LVEF  50%
DEFINITIONS
Systolic HF — HF with reduced left ventricular ejection fraction (LVEF)
Up to 90% of HF patients < 65 years old have this form of the disease
HF with preserved ejection fraction (HFPEF) — HF with LVEF  50%
Affects 40% of men and two thirds of women > 65 years old with HF
The rising prevalence of HFPEF in older patients is due to age-associated alterations in LV diastolic function coupled with the increasing importance of hypertension as the etiologic mechanism for HF in older adults, particularly women.
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7. SYMPTOMS & SIGNS OF HF IN OLDER PATIENTS
Often atypical and nonspecific
Most common: exertional shortness of breath, fatigue, orthopnea, and leg edema
Exertional symptoms may be less prominent in older adults because of a more sedentary lifestyle
Prevalence of atypical symptoms increases with age
Decreased mental acuity, confusion, lethargy, irritability, anorexia, abdominal discomfort, or altered bowel function
Classical physical findings of HF in younger patients include tachycardia, narrowed pulse pressure, increased jugular venous pressure, hepatojugular reflux, an S3 gallop, moist pulmonary crackles, diminished breath sounds at the lung bases (due to pleural effusions), and pitting edema of the legs.
However, many or even all of these findings may be absent in older HF patients, especially those with HFPEF, in whom an S3 gallop and signs of right-heart failure are not usually present. In addition, pulmonary crackles in older patients may be due to comorbid chronic lung disease or atelectasis, and peripheral edema may be due to hepatic or renal disease, venous insufficiency, hypoalbuminemia, or medications (especially calcium channel blockers).
The diagnosis of HF can usually be established on clinical grounds in patients who present with a constellation of classical symptoms and signs. Often, however, the diagnosis is uncertain, and additional supporting evidence is required.
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8. DIAGNOSIS OF HF
Standard chest radiograph remains the most useful initial test for detecting pulmonary congestion and pleural effusions
Also excludes pneumonia as a cause of shortness of breath
B-type natriuretic peptide (BNP) and its precursor N-terminal pro-BNP (nt-proBNP) are valuable in establishing the presence of HF and, in particular, in distinguishing shortness of breath due to HF from that attributable to noncardiac causes
But specificity decreases with age
Chest radiograph may be difficult to interpret in older adults with chronic lung disease, kyphoscoliosis, or poor inspiratory effort, and absence of pulmonary congestion on chest radiograph does not preclude a diagnosis of HF.
The ECG may show LV hypertrophy, acute ischemia or prior myocardial infarction (MI), left atrial enlargement, or atrial fibrillation—all of which predispose to the development of HF—but the ECG is not usually helpful in establishing a diagnosis of either acute or chronic HF.
It is appropriate to obtain a CBC, routine chemistry panel, thyroid studies, a urinalysis, and, in selected cases, cardiac biomarker proteins (ie, troponin, creatine kinase) in patients with suspected HF, but in most cases these tests are insufficient for confirming the diagnosis.
BNP and nt-proBNP levels increase with age, especially in women, as well as with decreasing renal function. As a result, the specificity of increased levels of these peptides decreases with age, and the clinical significance of an isolated increased BNP or nt-proBNP level in an older adult may be difficult to interpret. Despite these caveats, a BNP level < pg/mL in an older adult with suspected acute HF makes the diagnosis very unlikely (likelihood ratio negative approximately 0.1), whereas a BNP level  500 pg/mL is consistent with active HF (likelihood ratio positive approximately 6).
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9. OVERVIEW OF HF MANAGEMENT
Goals are to decrease symptoms and improve quality of life, reduce acute exacerbations requiring hospitalization, and increase survival
Hypertension, hyperlipidemia, and diabetes should be treated in accordance with current guidelines
Smoking cessation should be strongly encouraged and supported if indicated, and alcohol intake should be limited to no more than 2 drinks/day in men and 1 drink/day in women
Once a diagnosis of HF has been established, it is important to determine the cause and to assess LV function, because these factors often affect management.
In most patients with recently diagnosed HF, an echocardiogram with Doppler is indicated for the assessment of LV and right ventricular (RV) size, systolic and diastolic function, atrial size, LV and RV wall thicknesses, valve function, and the pericardium.
In patients with suspected CAD who are suitable candidates for revascularization, a stress test should be performed, followed by coronary angiography if the stress test indicates severe CAD, especially in a multivessel distribution.
NSAIDs should be avoided because they promote water and sodium retention and antagonize the effects of diuretics and renin-angiotensin system inhibitors. CAD should be treated with anti-ischemic medications and, if indicated, percutaneous or surgical revascularization.
Valvular lesions should be managed in accordance with established practice guidelines.
Patients should be screened for anemia and thyroid dysfunction, and appropriate therapy should be initiated if indicated.
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10. NONPHARMACOLOGIC THERAPY
Restrict dietary sodium intake to ≤ 2 g/day
Most patients with HF should also engage in regular exercise such as walking, stationary cycling, swimming, or water aerobics
Exercise duration and intensity should be adjusted to the individual patient’s level of conditioning, severity of HF, and comorbidities
Patients should keep an ongoing record of their daily weight
Fluid restriction is not usually necessary except in patients with advanced HF, but patients should be advised to avoid excess fluid intake.
Exercise should be gradually increased over time, if possible, to achieve 30–60 minutes of aerobic exercise most days of the week. These activities should be complemented by stretching and strengthening exercises, as well as by gait and balance exercises if indicated.
Weights should be obtained in the morning without clothes after going to the bathroom but before eating. A “dry weight” should be established (based on the home scale, not the office scale), and the patient should be instructed to contact the provider if the weight varies by more than 2–3 pounds above or below the dry weight. Alternatively, selected patients may be provided with detailed instructions for self-adjustment of diuretic dosages based on daily weights.
Older patients with moderate or advanced HF, multiple comorbidities, or a recent HF exacerbation requiring hospitalization may benefit from participation in a structured HF disease management program. Such programs offer enhanced education and follow-up, usually by an HF nurse specialist or multidisciplinary team, in some cases supplemented by telemonitoring devices, and have been shown to reduce hospitalizations and inpatient costs, as well as to improve quality of life in older HF patients.
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11. PHARMACOTHERAPY OF SYSTOLIC HF
Optimal treatment usually requires 3 medications and, in some cases, up to 7
Almost all patients take 1 additional medications for coexisting illnesses
Problems: adherence, high potential for drug interactions and adverse events, cost
Therapy must be individualized: consider the multiple factors that influence QOL and other desirable clinical outcomes in older adults who have multiple chronic illnesses and limited life expectancy
Angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARBs), and β-blockers have been shown to improve outcomes and reduce mortality in multiple large prospective trials involving a broad range of HF patients with decreased LV systolic function. These agents are now considered the cornerstone of therapy for systolic HF. Although older patients, especially those with multiple comorbid conditions, have been markedly under-represented in these trials, the available evidence indicates that the beneficial effects of these agents likely extend to older patients.
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12. ACE INHIBITORS FOR SYSTOLIC HF
In general, start treatment at the lowest dosage and gradually titrate to the maintenance dosage as tolerated
Contraindications include known intolerance to these agents, hyperkalemia, and severe renal insufficiency in patients not currently undergoing dialysis
Common adverse events include cough in 5%–10% of patients during long-term treatment, mild worsening of renal function (often transient), hyperkalemia, hypotension, and GI distress
ARBs are an option for HF patients unable to tolerate ACE inhibitors because of cough, allergic reactions, or GI disturbances
For a list of ACE inhibitors approved for the treatment of HF, along with recommended initial and maintenance dosages, see GNRS Table 49.1.
Renal function and potassium concentrations should be monitored closely during initiation and titration of ACE inhibitor therapy.
Contraindications and adverse events associated with ARBs are similar to those of ACE inhibitors. In particular, the incidence of renal insufficiency, hyperkalemia, and hypotension are comparable with equivalent dosages of ACE inhibitors and ARBs.
Combination therapy with an ACE inhibitor and ARB is not currently recommended because of an increased incidence of adverse events in the absence of a clear clinical benefit.
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13. β-BLOCKERS FOR SYSTOLIC HF
As with ACE inhibitors and ARBs, treatment should be started at the lowest available dosage and gradually titrated to the maintenance dosage over several weeks
Contraindications include severe decompensated HF, active bronchospastic lung disease, marked bradycardia, relative hypotension, significant atrioventricular nodal block, and known intolerance to β-blockers
β-Blockers counteract the deleterious effects of chronic activation of the adrenergic nervous system in HF patients, and β-blockers have been shown to improve ventricular function and symptoms while reducing the risk of both sudden and nonsudden cardiac death.
See GNRS Table 49.1 for starting dosages.
Occasionally, HF symptoms will worsen on initiation or titration of a β- blocker (and patients should be warned about this possibility), but in most cases this is a transient phenomenon. The vast majority of HF patients (>80%) are able to tolerate long-term β-blocker therapy when judiciously initiated and titrated.
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14. DIURETICS FOR SYSTOLIC HF
An essential component of HF therapy in most patients
Most effective agents for relieving congestion, edema
In general, the diuretic dosage should be adjusted to maintain euvolemia
Manifested by the absence of pulmonary rales, an S3 gallop, increased jugular venous pressure, hepatojugular reflux, and peripheral edema
Some clinicians recommend obtaining serial BNPs as a means of assessing volume status, with a BNP level < 100–200 pg/mL indicative of optimal intravascular volume.
Some patients with mild HF respond satisfactorily to a thiazide diuretic, but most require maintenance therapy with a loop diuretic, such as furosemide, bumetanide, or torsemide. Patients with advanced HF and/or concomitant renal insufficiency may be resistant to conventional dosages of loop diuretics. In these patients, the addition of metolazone at 2.5–10 mg/day is often effective, but close monitoring of electrolytes is required. The principal adverse events associated with diuretic therapy are electrolyte disturbances, including hypokalemia, hyponatremia, and hypomagnesemia. Close monitoring of these electrolytes, as well as renal function, is therefore warranted.
Thiamine deficiency may occur during long-term treatment with loop diuretics and can contribute to apparent diuretic resistance. Although routine monitoring of thiamine levels is not currently recommended, supplemental thiamine in the form of a multivitamin is reasonable in older patients requiring long-term therapy with a loop diuretic. Older patients are also at increased risk of dehydration during diuretic treatment due to attenuation of the thirst response and diminished oral fluid intake, especially during periods of illness. Therefore, clinicians should remain vigilant for possible signs of dehydration, including excess weight loss during daily weight monitoring.
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15. MINERALOCORTICOID ANTAGONISTS FOR SYSTOLIC HF
The mineralocorticoid antagonist spironolactone has been shown to reduce mortality and hospitalizations in patients with NYHA class III–IV HF and LVEF ≤ 30%
The selective mineralocorticoid antagonist eplerenone has been associated with improved outcomes in patients with recent MI complicated by HF or LVEF < 40%, and in patients with NYHA class II HF and LVEF ≤ 30%
NYHA = New York Heart Association
Spironolactone or eplerenone at 12.5–25 mg/day is recommended in patients with severe LV dysfunction and persistent HF symptoms despite triple-drug therapy with an ACE inhibitor (or ARB), β-blocker, and diuretic. Benefits are similar in older and younger patients.
Older adults are at increased risk of worsening renal function and hyperkalemia during spironolactone therapy, and frequent monitoring of electrolytes and creatinine is necessary. Spironolactone and eplerenone are contraindicated in patients with serum creatinine 2.5 mg/dL or serum potassium 5 mEq/L.
Up to 10% of patients develop painful gynecomastia during long-term treatment with spironolactone; this adverse event is much less frequent with eplerenone.
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16. OTHER THERAPIES FOR SYSTOLIC HF
Digoxin improves symptoms and reduces HF hospitalizations in patients with chronic systolic HF but has no effect on mortality
Adverse events include nausea, visual disturbances, and cardiac arrhythmias
The combination of hydralazinenitrates is recommended for patients with contraindications to ACE inhibitors and ARBs and in black patients with advanced HF as an adjunct to ACE-inhibitor and β- blocker therapy
Digoxin remains a reasonable therapeutic option in patients with persistent limiting symptoms and/or recurrent hospitalizations who have not had a satisfactory response to the measures discussed above. Retrospective analyses based on a large randomized trial suggest that the optimal digoxin concentration for improving clinical outcomes is 0.5–0.9 ng/mL, which is substantially lower than the “therapeutic range” previously reported by most clinical laboratories. Therefore, digoxin should be dosed to maintain the digoxin concentration < 1 ng/mL, and a dosage of mg/day is likely to be sufficient in most older patients with relatively preserved renal function, while a lower dosage might be indicated in patients with moderate or severe renal insufficiency.
With appropriate monitoring of the serum digoxin concentration, serious digoxin toxicity is infrequent, and there is no convincing evidence that older patients are at increased risk of life-threatening digitalis intoxication. Amiodarone, quinidine, and verapamil, as well as several other medications, are associated with an up to a 2-fold increase in serum digoxin concentrations, and the dosage of digoxin should be reduced by 50% in patients receiving these medications.
Common adverse events associated with hydralazine include palpitations, nausea, and dizziness; rarely, a drug-lupus syndrome may occur during prolonged therapy at high dosage (300 mg/day). The most common adverse event from isosorbide dinitrate is headache; this usually resolves with continued use.
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17. PHARMACOTHERAPY FOR HF WITH PRESERVED EF
Optimal therapy remains undefined
Current recommendations:
Aggressively treat hypertension, other risk factors
Manage comorbid CAD
Maintain sinus rhythm or effective rate control in patients with AF
Judiciously use diuretics to maintain euvolemia while avoiding overdiuresis (many of these patients are “volume-sensitive”)
Trials have not demonstrated that any agent has a beneficial effect on mortality in patients with HFPEF.
The addition of an ACE inhibitor or ARB, and possibly a β-blocker (especially in patients with CAD), is appropriate to reduce the risk of hospitalization, recognizing that the impact of these agents on other clinically relevant outcomes is unproved.
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18. IMPLANTABLE CARDIAC DEFIBRILLATOR
Reduces mortality from sudden cardiac death in patients with systolic HF and LVEF  35%, regardless of ischemic or non-ischemic etiology
Prophylactic placement is advised for patients with NYHA class II or III HF, LVEF  35%, and life expectancy  1 year
Defer ICD implantation for 40 days after acute MI and 90 days after a new diagnosis of dilated cardiomyopathy, in the latter case because LV function often improves after initiation of β-blocker and ACE inhibitor therapy
Although few older patients were enrolled in the ICD randomized trials, subsequent observational studies indicate that the benefits of ICDs are similar in older and younger patients. Approximately 40%–45% of ICDs in the United States are implanted in patients ≥70 years old.
Implantable cardiac defibrillators have not been shown to improve survival in patients with NYHA class I or IV HF, and there is no survival benefit within the first 12–18 months after implantation. Quality of life is impaired in patients who receive one or more ICD shocks, and up to 20% of shocks are inappropriate (occur in the absence of a life-threatening tachyarrhythmia).
Recognizing that HF patients >75–80 years old have limited remaining life expectancy, especially if they have multiple comorbid illnesses or frailty, selection of older patients for ICD therapy must be individualized. Patients should be advised about the potential benefits and risks of ICD implantation, including the possibility of an adverse effect on quality of life. Although many older patients elect to forego ICD implantation after an informed discussion, those who choose to undergo the procedure should not be denied solely on the basis of age, assuming that appropriate indications for ICD therapy are present. In these patients, it is appropriate to discuss circumstances under which the patient would want to have the device disabled, especially at end of life because of progressive HF or other terminal illness.
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19. CARDIAC RESYNCRONIZATION
A biventricular pacemaker with one lead in the right ventricle and a second lead inserted retrograde into the coronary sinus to stimulate the left ventricle
Indicated in patients with dyssynchronous LV contraction, most commonly related to left bundle branch block, present in up to 30% of patients with systolic HF
Improves symptoms, exercise tolerance, quality of life, and survival in selected patients with advanced systolic HF and persistent severe symptoms (NYHA class III or IV) despite conventional medical therapy
The basis for cardiac resynchronization therapy (CRT), as the name implies, is to “resynchronize” LV contraction, thereby increasing myocardial efficiency, stroke work, ejection fraction, and cardiac output.
Patients with left bundle branch block and a QRS duration of at least msec appear to derive the greatest benefit from CRT.
Although few older patients have been enrolled in the CRT trials, observational studies indicate that appropriately selected older patients derive significant benefit from CRT.
Because the main objective of CRT is to improve symptoms and quality of life, and the only significant risk is modest and related to insertion of the device, it seems reasonable to offer CRT to older patients with severe LV dysfunction, advanced HF symptoms, and evidence of LV dyssynchrony.
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20. RECURRENT HOSPITALIZATION
Up to 50% of patients with HF are readmitted within 3–6 months after the initial hospitalization
Patients who experience recurrent HF hospitalization within 3–6 months after an index admission should be questioned carefully
Adherence to medication regimen; use of OTC medications
Recent changes in weight
Recent dietary choices
Daily fluid intake
The most common cause of readmission is nonadherence to the medication regimen and/or to dietary sodium and fluid recommendations. Other causes include inadequate follow-up, poor social support, and failure to seek medical attention promptly when symptoms worsen. Intercurrent cardiac events, such as an acute coronary syndrome or recurrent atrial fibrillation, are less common causes of repetitive hospitalizations.
In patients who acknowledge nonadherence to the medication regimen or sodium restriction, reasons for nonadherence should be explored. In the case of medications, these often include concerns about adverse events, cost, efficacy, and excess number of pills. Nonadherence to sodium restriction often involves lack of knowledge about the salt content of foods, inability to acquire low-sodium foods, frequent eating out, and poor sense of taste. If possible, strategies should be developed to overcome these barriers, and the importance of future adherence as a means to prevent subsequent admissions emphasized. A multidisciplinary team approach, including the physician, an HF nurse specialist (if available), dietitian, social worker, pharmacist (preferably with expertise in geriatric drug prescribing), and home-health representative is most likely to result in significant changes in health behavior.
When feasible, the patient’s family should be actively engaged in the evaluation and teaching process.
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21. PROGNOSIS Median survival rates of 2–3 years
25%–30% of patients die within 1 year after initial diagnosis
50% survive 1–5 years
20%–25% survive >5 years
Women and patients with HFPEF have somewhat better survival rates than men and patients with systolic HF
Other factors that adversely affect prognosis include older age, more severe symptoms (eg, higher NYHA functional class), lower systolic blood pressure, the presence of CAD (an important factor contributing to worse outcomes in men), diabetes (especially in women), peripheral arterial or cerebrovascular disease, cognitive impairment or dementia, renal insufficiency, anemia, and hyponatremia. Patients with higher BNP also have a worse prognosis, especially if the BNP remains substantially increased despite aggressive therapy.
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22. END-OF-LIFE CARE
Counsel regarding an advance directive, durable power of attorney for health care, and explicit instructions about what interventions they would or would not wish to undergo if death appeared imminent
Ask patients with ICDs to indicate under what conditions they would want the ICD turned off to avoid repetitive painful shocks at the end of life
In patients with particularly poor prognosis and remaining life expectancy < 6 months, undertake frank but empathetic discussions with the patient and family
In light of the poor prognosis of older HF patients, which is worse than for most forms of cancer, it is appropriate to initiate discussions about end-of-life care early in the course of treatment, and to readdress these issues as clinical circumstances evolve.
In patients with particularly poor prognosis and remaining life expectancy of less than 6 months, information about prognosis and likely disease trajectory should be conveyed, and transition to palliative care and hospice should be offered.
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23. SUMMARY
HF is the leading cause of hospitalization in older adults and a major source of chronic disability
Older patients with HF are more likely to be women and more likely to have preserved LV systolic function
ACE inhibitors, ARBs, β-blockers, and mineralocorticoid antagonists reduce morbidity and mortality from HF with reduced ejection fraction (systolic HF)
Optimal medical therapy for HF with preserved ejection fraction is undefined
Optimal management of HF in older patients often requires a multidisciplinary approach
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24. CASE 1 (1 of 4)
A 70-year-old man comes to the office for follow-up after hospitalization for exacerbation of HF.
History includes HF with preserved systolic function, hypertension, and atrial fibrillation.
Longstanding medications include extended-release metoprolol 100 mg/day, enalapril 10 mg q12h, and hydrochlorothiazide 25 mg/day. In addition, he was given both torsemide 40 mg q12h and digoxin mg every other day during hospitalization and at discharge.
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25. CASE 1 (2 of 4)
Today he reports new symptoms of fatigue and light-headedness when he initially stands. He has no chest pain, and there has been no change in SOB.
BP is 92/50 mmHg, pulse is 84 bpm, and O2 saturation is 97% on room air. Jugular venous pressure is 5 cm2 HO; neck veins are flat, even when he is supine. Chest is clear bilaterally. Heart sounds are irregularly irregular with no murmur. The abdomen is soft and nontender, with normal bowel sounds and no distension. Extremities are mildly cool; there is no edema, and dorsalis pedis pulses are 1+ bilaterally.
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26. Which of the following is the best next step?
CASE 1 (3 of 4)
Which of the following is the best next step?
Administer furosemide 80 mg by IV.
Discontinue enalapril and metoprolol.
Hold torsemide and hydrochlorothiazide and prescribe fluids.
Obtain serum digoxin levels and discontinue digoxin.
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27. Which of the following is the best next step?
CASE 1 (4 of 4)
Which of the following is the best next step?
Administer furosemide 80 mg by IV.
Discontinue enalapril and metoprolol.
Hold torsemide and hydrochlorothiazide and prescribe fluids.
Obtain serum digoxin levels and discontinue digoxin.
ANSWER: C
This patient was recently discharged from the hospital and has symptoms of hypotension. Patients who were recently hospitalized for heart failure can become dehydrated if they remain on an aggressive diuretic regimen. This patient is now taking torsemide, a loop diuretic that has double the potency of furosemide, as well as a thiazide diuretic, which augments the diuretic effect of torsemide.
The prevalence of heart failure with preserved systolic function increases with age; it is present in approximately half of older adults hospitalized with heart failure. It is often caused by longstanding hypertension. Frequent hospital admissions for exacerbation of heart failure and volume overload are common. Affected patients are reliant on adequate preload, which makes them particularly sensitive to dehydration. Control of blood pressure is essential, yet there are few therapeutic guidelines.
This patient’s current symptoms and the findings on physical examination are not consistent with exacerbation of heart failure. He is taking many antihypertensive agents, yet most are not new to him; the new agent, torsemide, is the most likely culprit. This patient does not have symptoms of digoxin toxicity.
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28. CASE 2 (1 of 4)
A 78-year-old woman is brought to the emergency department because she has had shortness of breath for 2 weeks; it has become more severe over the past 2 days.
She has difficulty sleeping and now requires 2 or 3 pillows to elevate her head at night.
History includes hypertension, osteoarthritis, and COPD secondary to 50 pack-years of smoking.
Medications include amlodipine, hydrochlorothiazide, and montelukast.
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29. CASE 2 (2 of 4)
Blood pressure is 160/90 mmHg, pulse is 84 bpm, and respirations are 18 breaths per minute.
There are jugular venous pulsations 5 cm above the sternal notch. Bibasilar crackles are heard, and cardiovascular examination reveals normal S1 and S2 without S3. The abdomen is soft and nontender. There is pitting pedal edema.
ECG is unchanged from a year ago; it shows normal sinus rhythm at 84 beats per minute and left ventricular hypertrophy with repolarization abnormalities.
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30. CASE 2 (3 of 4)
Which of the following tests would be most helpful in differentiating COPD from heart failure?
B-type natriuretic peptide level
Troponin level
Electrolyte panel
Coronary calcium score
Chest radiography
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31. CASE 2 (4 of 4)
Which of the following tests would be most helpful in differentiating COPD from heart failure?
B-type natriuretic peptide level
Troponin level
Electrolyte panel
Coronary calcium score
Chest radiography
ANSWER: A
Measurement of B-type natriuretic peptide (BNP) and N-terminal prohormone BNP (NT‑pBNP) is useful for risk stratification and for cases in which the clinical diagnosis of HF is uncertain in patients who need urgent care. The 2009 update to the American Heart Association Guidelines for the Diagnosis and Management of Heart Failure in Adults recommends measurement of BNP and NT‑pBNP for evaluating patients who present in the urgent care setting. The update notes that although BNP levels >500 pg/mL may help confirm suspected HF, the levels alone should not be used to confirm or exclude the diagnosis.
The consensus of cardiologists is that patients with left ventricular dysfunction and HF generally have one of the following: decreased exercise tolerance with fluid retention, no symptoms, or symptoms of another cardiac or noncardiac disorder. The patient in this case has predisposing characteristics of diastolic HF, namely her age, sex, and history of hypertension. In light of the 2-week history of increasing symptoms, without any mention of an increase in sputum or temperature, COPD is less likely than HF. In addition, the increase in jugular venous distention and the presence of bibasilar crackles and pedal edema are consistent with HF but do not differentiate between diastolic and systolic HF. The lack of an S3 heart sound is common in patients with diastolic HF.
Although chest radiographs, cardiac troponin testing, and serum electrolytes are key tests in the evaluation of patients with HF, they are not as helpful as measurement of BNP in differentiating HF from COPD.
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32. CASE 3 (1 of 3)
A 75-year-old man comes to the office to establish care because he has difficulty breathing. The breathing difficulty limits his ability to walk 2 blocks to the corner store, and he often has to sleep upright in his recliner.
He takes no medication except chewable calcium carbonate tablets for chronic indigestion.
BP is 154/88 mmHg, pulse is 80 bpm, and respirations are 16 breaths per minute. There are bibasilar fine crackles. Cardiac examination is notable for normal rhythm with ectopy and a II/VI holosystolic murmur at the apex. There is no peripheral edema. ECG, electrolyte panel, and CBC are ordered. The presumptive diagnosis is heart failure.
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33. Cardiac catheterization Echocardiography Radionuclide ventriculography
CASE 3 (2 of 3)
Which of the following tests should be ordered next to help establish diagnosis and treatment?
Cardiac catheterization
Echocardiography
Radionuclide ventriculography
MRI
Chest radiography
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34. Cardiac catheterization Echocardiography Radionuclide ventriculography
CASE 3 (3 of 3)
Which of the following tests should be ordered next to help establish diagnosis and treatment?
Cardiac catheterization
Echocardiography
Radionuclide ventriculography
MRI
Chest radiography
ANSWER: B
The single most useful diagnostic test in the evaluation of patients with heart failure is 2-dimensional echocardiography to determine the left ventricle ejection fraction as well as structural abnormalities of the left and right ventricles, valves, and pericardium, because it is common for patients to have >1 cardiac abnormality that contributes to the development of heart failure.
Although radionuclide ventriculography can provide highly accurate measurements of left ventricle function and right ventricle ejection fraction, it is unable to directly assess valvular abnormalities or cardiac hypertrophy. MRI or CT may be useful in evaluating chamber size and ventricular mass, detecting right ventricular dysplasia, or recognizing the presence of pericardial disease, but neither is the most appropriate next step for this patient. Because of their low sensitivity and specificity, neither chest radiography nor ECG should form the primary basis for determining the specific cardiac abnormality responsible for the development of heart failure.
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35. Copyright © 2014 American Geriatrics Society
GNRS4 Teaching Slides Editor: Barbara Resnick, PhD, CRNP, FAAN, FAANP, AGSF GNRS4 Teaching Slides modified from GRS8 Teaching Slides based on chapter by Michael W. Rich, MD, AGSF and questions by Mary Ann McLoughlin, MD Managing Editor: Andrea N. Sherman, MS
Copyright © 2014 American Geriatrics Society
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