Heart Failure: Celine's Clinical Case

• These notes pertain to a clinical case involving Celine, focusing on her symptoms, examination findings, and potential diagnoses.

Fatigue and Shortness of Breath

• These symptoms indicate left-sided heart failure.
• Fatigue arises from reduced cardiac output, leading to insufficient oxygen-rich blood reaching muscles and organs.
• Shortness of breath is common in left-sided failure due to blood backing up into pulmonary circulation, causing pulmonary congestion.
• An S3 gallop is a sign of ventricular dysfunction.
• Pulmonary wheezing and decreased breath sounds indicate fluid buildup in alveoli, which is known as pulmonary edema.
• Tachypnea (RR 22) is a compensatory mechanism for hypoxia.
• Chest X-ray confirms cardiomegaly and pulmonary congestion.

Chest Pain

• Celine's intermittent, dull chest pain suggests a cardiac origin, differentiating it from acute ischemia.
• The discomfort may stem from angina due to oxygen demand-supply mismatch, stretching of the heart muscle because of fluid overload, or pulmonary congestion pressing on chest structures.
• Elevated BP (155/95) increases workload on the heart.
• Left ventricular strain is observed with S3 gallop and cardiomegaly.

Edema

• Bilateral lower extremity edema indicates right-sided heart failure which often follows left-sided failure.
• Blood backs up into systemic veins which increases hydrostatic pressure, resulting in fluid leaking into tissues of legs and ankles.
• Reduced filtration is indicated by an eGFR of 45 and a creatinine level of 1.5.
• Kidneys retain more sodium and water, worsening the edema.
• Edema is not a sign of venous thrombosis because it's bilateral, not localized.

Frequent Infections

• Likely caused by a combination of immune suppression from chronic disease and stress, and poor oxygen delivery.
• Tissues can't mount strong immune responses.
• Chronic inflammation may impair normal immune cell signaling.
• Enlarged lymph nodes and skin pustules indicate an immune system under stress.
• Kidney dysfunction leads to uremia, weakening immune defense.
• Heart failure reduces perfusion to lymphoid tissues.

CBC (WBC = 10,500/µL)

• A slightly elevated WBC count suggests an ongoing low-grade infection or inflammation.
• This finding correlates with frequent respiratory infections and inflammatory stress from cardiac or renal issues.
• While abnormal, the elevation is not severe enough to indicate acute sepsis.

C-Reactive Protein (CRP = 20 mg/L)

• Such a high CRP level reflects chronic systemic inflammation.
• Heart failure-related inflammation, endothelial dysfunction, or frequent infections may be the cause.
• It also signals higher cardiovascular risk.

Arterial Blood Gases

• A PaO₂ of 70 mmHg indicates hypoxemia, which is below the normal range of 80–100 mmHg.
• A PaCO₂ of 32 mmHg is slightly low, possibly due to hyperventilation.
• The impaired gas exchange is from fluid in alveoli (pulmonary edema).

Diagnosis

• The most likely diagnosis is Congestive Heart Failure (CHF), with cardiorenal syndrome and secondary immune suppression.
• Cardiovascular evidence includes cardiomegaly, hypertension, S3 gallop, edema, and JVD.
• Respiratory evidence includes SOB, pulmonary congestion, wheezing, and low PaO₂.
• Renal evidence includes elevated creatinine and BUN, and reduced eGFR (45 mL/min).
• Immune evidence includes frequent infections, enlarged lymph nodes, high CRP, and minor skin infections.
• Likely etiology is Longstanding hypertension leading to diastolic dysfunction, possible undiagnosed cardiomyopathy, and Early right-sided failure from progressive left-sided failure.

Systemic Interactions

• Heart failure reduces kidney perfusion leading to renal dysfunction.
• Kidney dysfunction leads to fluid retention which increases preload, worsening CHF.
• Pulmonary congestion causes hypoxia which leads to fatigue and respiratory strain.
• Immune suppression from chronic inflammation and poor tissue perfusion increases infections which causes inflammatory stress, causing further damage to heart and kidneys.
• It's a vicious cycle where dysfunction in one system leads to failure in another.

Role of Chronic Inflammation

• A CRP of 20 mg/L is a strong marker of chronic inflammation.

• Ongoing inflammation can promote cardiac remodeling and fibrosis, damage the endothelial lining worsening hypertension and cardiac strain, impair glomerular filtration in kidneys, and exhaust the immune system over time.

• Inflammation also raises cardiovascular risk and accelerates progression to end-stage organ damage.

• Summary Diagnosis: Congestive Heart Failure with secondary kidney dysfunction and immune compromise.

• Likely driven by long-term hypertension, possible diastolic heart failure, and chronic inflammation.