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HEART FAILURE

CASE OF HEART FAILURE

I have been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan. 

You can find the entire real patient clinical problem in this link here..

https://madhur116.blogspot.com/2020/05/on-1452020.html?m=1

Following is my analysis of the patient problem

The positive findings from the History, Clinical examination includes

HISTORY
-High grade fever with chills - 1 mon ago.
-Shortness of breath since 2 weeks
-Pedal edema since 2 weeks.
-Generalized weakness since 2 weeks.
-Paroxysmal nocturnal dyspnea.

CLINICAL EXAMINATION
-Pitting type of pedal edema
-Elevated jvp
-Early inspiratory crepts on right side.

INVESTIGATIONS
-USG : Moderate pleural effusion on  Rt side
           Grade 1 fatty liver
           Mild ascites
-2D ECHO: EF-27 %
                  IVC dilated non collapsing
                  Mild Tricuspid regurgitation
                  Severe Mitral regurgitation 
                  Aortic regurgitation
                  All chambers dilated 
                  Global hypokinesia
                  Severe LV dysfunction

From the above data we can exclude
-Respiratory causes as there is no any complaints of cough , cold, sore throat, wheeze .
- Renal causes as there is no decreased urine output, facial puffiness, burning micturition.
- Liver causes as there is no tenderness in RUQ , hepatomegaly, predominant ascites.
 So all the features like SOB , pedal edema in association with orthopnea and PND point the diagnosis towards cardiac pathology mostly towards HEART FAILURE WITH REDUCED EJECTION FRACTION as the EF is <40% .

ETIOLOGY OF HEART FAILURE WITH REDUCED EJECTION FRACTION
As the patient had history of fever we can infer that etiology may be Viral myocarditis that caused heart failure.

PATHOPHYSIOLOGY
Viral myocarditis progresses chronologically in three distinct pathological phases 
FIRST PHASE- Direct destruction of cardiomyocytes occurs in viral mediated lysis causing degradation of cell structures which in turn facilitates entry of virus into cells with consequential myocyte injury and cardiac dilatation. Initial phase passes unnoticed as it is prevented by innate immune response.
SECOND PHASE- It developed as a result of immune response dysregulatio n triggered by initial cardiomyocyte injury. The initial cellular and humoral immune responses Amy improve the outcome during phase 1 conversely they are responsible for the harmful effect during phase 2 . This is in part induced by molecular mimicry which is caused by mimicked epitopes shared between viral and cardiac antigens.
THIRD PHASE- Typically picture of dilated cardiomyopathy developed as a result of extensive myocardial injury.
 


Cardiotropic viruses that can cause myocarditis include Adenoviruses, Enterovirus, Parvovirus B19, CMV all of which are common cold viruses which individual may be attacked once in their life time but only a few developing cardiac problems shows role of GENETICS .
POSSIBLE TREATMENT OPTIONS 

NON PHARMACOLOGICAL OPTIONS
-Limitation of direct physical activity - as exercise during active viral infection may increase viral replication.

PHARMACOLOGICAL OPTIONS
It includes symptomatic and standard treatment for heart failure. Which includes
Diuretics 
Beta blockers
ACE inhibitors OR  ARB 
Careful monitoring for arrhythmias.

SPECIFIC THERAPY
Preventing direct viral damage using antiviral therapy is one possible option.
Immunomodulatory and or antiviral treatment along with the symptomatic treatment shown to be beneficial in some clinical trials.

REFRENCES
- Harrison principles of internal medicine 19 e 

- Davidson principles and practice of medicine

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2519249/

https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.113.001372

https://www.uwhealth.org/health/topic/special/heart-failure-with-reduced-ejection-fraction-systolic-heart-failure/tx4090abc.html

Doubts arises while analysing the case 

- Is there any shift in the apex beat ??
- Are there any murmurs as echo showed regulation in aortic and tricuspid valves ?
- How antimalarial drugs provided initial relief as it is viral etiology ??
- History regarding fever like diurnal variations , associated symptoms , any rashes etc to know exact etiology behind fever .
- Exactly which antimalarial drugs he was prescribed ??

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