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%.
MY DISCUSSION BOARD POST WAS::::::
Case Study: Heart Failure
Differentiation Between Systolic and Diastolic Heart Failure
Failure of the left ventricle can be divided into systolic and diastolic heart failure. Systolic heart failure occurs when the left ventricles cannot contract completely with each heartbeat in the presence of marked cardiomegaly, implying that the heart cannot pump efficiently and forcefully throughout the body. During a contraction, the heart is supposed to pump out blood forcefully, and the failure results in a low ejection fraction (EF) and enlarged left ventricular (LV) chamber, hence systolic heart failure (Wahiba, 2023). Systolic heart failure is assessed through the estimation of global ejection function and regional wall motion.
Diastolic Heart Failure, on the other hand, occurs during relaxation when the LV cannot relax between heartbeats. It is characterized by increased resistance to filling with an increased heartbeat due to stiff tissues. The condition is accompanied by pulmonary congestion with a normal or slightly enlarged LV (Wahiba, 2023). Diastolic heart failure can be diagnosed indirectly either by normal or almost normal ejection fraction. However, since both systolic and diastolic heart failure have similar symptoms, a physician requires a left ventricular catheterization.
Diagnosis of the Patient’s Condition
The patient has systolic heart failure. The patient has a medical history of hypertension and type-2 diabetes, which increases the chances of contracting heart disease. The patient’s symptoms include shortness of breath leading to disengagement in physical activities, leg swelling (edema), fatigue, inability to sleep comfortably characterized by sleeping on multiple pillows and the recliner chair, presence of 3rd heart sound, jugular venous distention and bilateral pretibial which are all symptoms of systolic heart failure (Wahiba, 2023). The patient also has decreased wall motion of the anterior wall of the heart, indicating valve dysfunction, which is a symptom of a congestive heart condition.
Pathophysiology of: Dyspnea Pitting Edema, Jugular Vein Distention, and Orthopnea
The pathophysiology of Dyspnea lies in the interactions between the respiratory system, cardiovascular systems, neural response, and oxygen carriers. It can be caused by both systolic and diastolic heart failure. It is, however, commonly associated with systolic heart conditions characterized by sudden shortness or difficulty of breathing due to reduced cardiac output resulting in high pulmonary venous pressure (Jang et al., 2019). In this case, the symptom could have resulted due to the patient’s act of sleeping on pillows. Pitting edema results from the accumulation of excess fluids in the body, causing swelling. When pressure is exerted on a specific area, a pit or indentation occurs. It occurs during heart failure when blood is not forcefully pumped resulting in accumulation of blood in the tissues. Failure of the left ventricle also causes jugular vein distention (JVD), characterized by the increase of blood in the lungs, resulting in weakening of the right ventricle, hence slowing blood flow in the heart. The veins tend to bulge. Orthopnea occurs when heart failure limits the ability of the heart to pump out blood due to pulmonary congestion, resulting in shortness of breath (Jang et al., 2019).
Significance of the Presence of A 3rd Heart Sound and Ejection Fraction of 25%
A 3rd Heart Sound is an initial indicator of left ventricular heart failure. It is usually associated with low ejection fraction and the presence of severe mitral regurgitation (Shono et al., 2019). Past the age of 40, a third heart sound that is lower than the normal ejection fraction of 55% is an indication of abnormalities. Hence, an ejection fraction of 25% indicates poor functionality of the heart. A common cause of low ejection fraction is hypertension, which is present in the patient’s medical history.
References
Jang, S. K., Prasad, M., & Brewer, L. C. (2019). 50-Year-Old Man With Dyspnea on Exertion, Orthopnea, and Weight Gain. Mayo Clinic Proceedings, 94(8), e95–e100. https://doi.org/10.1016/j.mayocp.2018.12.038
Shono, A., Mori, S., Yatomi, A., Kamio, T., Sakai, J., Soga, F., Tanaka, H., & Hirata, K. I. (2019). Ultimate Third Heart Sound. Internal medicine (Tokyo, Japan), 58(17), 2535–2538. https://doi.org/10.2169/internalmedicine.2731-19Links to an external site.
Wahiba S., (2023). Systolic vs Diastolic Heart Failure: Paradigms to Heart Health, Revival Research Institute. https://revivalresearch.org/blogs/systolic-vs-diastolic-heart-failure/Links to an external site.
+++++ i need for you to reply to another peers post.
the peers post :::::::::
Alicia Johnson
TuesdayMay 14 at 5:46pm
Hello class and professor,
Differentiate between systolic and diastolic heart failure.
Heart failure is a pathophysiological condition where the heart cannot produce an adequate cardiac output (McCance & Huether, 2019). Heart failure can be divided into either systolic or diastolic heart failure. Systolic heart failure happens when the left ventricle loses its ability to contract normally. When the left ventricle doesn’t contract normally, the heart is unable to pump with enough force to push enough blood into circulation, causing a reduced ejection fraction or HFrEF. Systolic heart failure has an ejection fraction of less than 40% (American Heart Association, 2023). Common symptoms of systolic heart failure include shortness of breath, jugular vein distension, fluid retention, and inability to exercise.
Diastolic heart failure is when the left ventricle loses its ability to relax normally, usually due to muscles becoming stiff. Since the left ventricle loses its ability to relax normally, the heart cannot appropriately fill with blood during the resting period between each beat. In diastolic heart failure, the heart pumps greater than or equal to 50% EF. Diastolic heart failure often thickens the left ventricle (American Heart Association, 2023). Symptoms of diastolic heart failure range from mild to severe and include difficulty concentrating, fluid retention, coughing or wheezing, and shortness of breath (American Heart Association, 2023).
State whether the patient is in systolic or diastolic heart failure.
The 72-year-old male in this case study is experiencing systolic heart failure. The critical giveaway that the patient is in systolic heart failure and not diastolic heart failure is that his ejection fraction (EF) is 25%. Systolic heart failure is when the ejection fraction is less than 40% (McCance & Huether, 2019). The patient’s shortness of breath, leg edema, inability to exercise due to shortness of breath, fatigue, propping up on three pillows to sleep, bilateral lung bases with crackles, third heart sound, and JVD are all signs and symptoms that point to the patient experiencing systolic heart failure (McCance & Huether, 2019).
Explain the pathophysiology associated with each of the following symptoms: dyspnea on exertion, pitting edema, jugular vein distention, and orthopnea.
Dyspnea on exertion is when a person experiences shortness of breath with activity/exercise. Dyspnea in systolic heart failure is brought on by decreased cardiac output and pulmonary congestion. Since heart failure affects the heart’s ability to pump blood effectively, less oxygen-rich blood is sent to the body and vital organs such as the lungs. As a result of the less oxygen-rich blood due to low cardiac output, when a person is exercising, their body’s increased need for oxygen is not met, resulting in dyspnea (Schwinger, 2021). Also, since the heart is not pumping effectively in heart failure, it activates the neurohormonal system, which leads to fluid retention, which can cause pulmonary congestion, contributing to dyspnea (Abassi et al., 2022). Pulmonary congestion is when fluid builds up in the lungs (McCance & Huether, 2019). Due to that fluid buildup in the lungs when a person exerts themselves, they may feel like they are unable to breathe correctly. The fluid buildup impairs the exchange of oxygen and carbon dioxide in the lungs (McCance & Huether, 2019).
Pitting edema also occurs because of the heart’s inability to pump blood effectively. The reduced blood flow activates the neurohormonal systems, which leads to fluid retention, causing peripheral edema. Neurohormonal factors include the renin-angiotensin-aldosterone system, sympathetic nervous system, endothelin-1, and antidiuretic hormone (Abassi et al., 2022). The persistent activation of these systems results in sodium and water retention and extracellular fluid expansion. Due to the increased sodium and water retention and extracellular fluid expansion, venous capillary pressure increases, and oncotic plasma pressure decreases, causing pitting edema in the lower extremities (Abassi et al., 2022).
Jugular vein distention (JVD) occurs in heart failure because of elevated vein pressure due to the inability of the heart to pump blood effectively. JVD is a symptom of increased blood volume in the systemic veins and vena cava, causing the veins in the neck to bulge. JVD is frequently accompanied by right-sided heart failure. Right-sided heart failure occurs when the right ventricle cannot pump blood to the lungs for oxygenation. Due to this phenomenon, the venous stem is clogged with blood, which raises venous pressure. The increased blood in the venous system increases pressure in the jugular veins, which remove deoxygenated blood from the head and neck, become enlarged, and are very noticeably swollen on physical exam (McCance & Huether, 2019).
Orthopnea can be described as difficulties breathing when lying flat, requiring persons who suffer from it to lie elevated on pillows to be able to sleep. Orthopnea results due to pulmonary congestion. Pulmonary congestion is when fluid builds up in the lungs (McCance & Huether, 2019). Due to this fluid buildup, when a person lays flat to rest, the fluid in the lungs redistributes, limiting their ability to exchange oxygen and carbon dioxide, making breathing more difficult (McCance & Huether, 2019). Sitting up can lessen these symptoms.
Explain the significance of the presence of a third heart sound and ejection fraction of 25%.
The presence of a third heart sound (S3) can be a clue to providers that suggest severe heart problems, including left-sided heart failure. A third heart sound reflects rapid left ventricular distention and increased atrioventricular flow. The third heart sound can be heard at the end of the right or left ventricle’s rapid diastolic filling cycle in early diastole (Shono et al., 2019). A third heart sound is associated with severe mitral regurgitation, a low ejection fraction, restrictive diastolic filling, functionally severe heart failure, and cardiovascular mortality (Shono et al., 2019). The patient in this case study suffers from left-sided heart failure. In left-side heart failure, the left ventricle cannot pump blood effectively, causing it to dilate. Systolic heart failure increases the heart’s elasticity, causing atrial pressure to rise, which results from blood backing up (McCance & Huether, 2019). As a result of this phenomenon, the ventricles dilate, and an S3 sound develops. The ejection fraction measures how much blood the left ventricle pumps out with each contraction (McCance & Huether, 2019). A 25% ejection fraction is considered low, which means that only 25% of the blood is being pushed out of the left ventricle with each contraction. This low EF results in less oxygen-rich blood reaching the body, resulting in many problems (McCance & Huether, 2019).
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. https://doi.org/10.3389/fcvm.2022.933215
American Heart Association. (2023, May 16). Types of heart failure. www.heart.org. https://www.heart.org/en/health-topics/heart-failure/what-is-heart-failure/types-of-heart-failureLinks to an external site.
McCance, K. L., & Huether, S. E. (2019). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). Elsevier.
Schwinger, R. H. G. (2021). Pathophysiology of heart failure. Cardiovascular Diagnosis and Therapy, 11(1), 263–276. https://doi.org/10.21037/cdt-20-302
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
so again- you are only reflecting on this peers post- 1 page in length
