NR 507 Week 2 Discussion: Case Study

Discussion Questions

1. Differentiate between systolic and diastolic heart failure.

• Systolic heart failure is characterized by the heart’s inability to contract effectively during the systolic phase, leading to reduced ejection of blood from the ventricles. This condition is often referred to as heart failure with reduced ejection fraction (HFrEF) because the left ventricle loses its ability to generate enough force to pump a sufficient amount of blood into the systemic circulation. Common causes include ischemic heart disease, myocardial infarction, and dilated cardiomyopathy.
• Diastolic heart failure occurs when the heart can contract normally but is unable to relax and fill properly during the diastolic phase. This is often termed heart failure with preserved ejection fraction (HFpEF). In this condition, the left ventricle becomes stiff and less compliant, leading to inadequate filling and increased pressure in the heart chambers. Causes include hypertension, hypertrophic cardiomyopathy, and aging-related changes in myocardial tissue.

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

To accurately determine whether the patient is in systolic or diastolic heart failure, we would need more specific clinical information such as the patient’s ejection fraction, clinical history, and physical exam findings. However, based on the information given, such as an ejection fraction of 25% and the presence of a third heart sound, it is likely that the patient is in systolic heart failure. The significantly reduced ejection fraction strongly suggests HFrEF, which is typical of systolic heart failure.

3. Explain the pathophysiology associated with each of the following symptoms:

• Dyspnea on exertion: In heart failure, especially systolic heart failure, the heart’s reduced pumping capacity leads to inadequate oxygen delivery to tissues during physical activity. This causes a build-up of fluid in the lungs (pulmonary congestion), leading to shortness of breath or dyspnea, particularly on exertion when oxygen demand increases.
• Pitting edema: Pitting edema occurs due to the accumulation of fluid in the interstitial spaces, which is often a consequence of right-sided heart failure. In heart failure, reduced cardiac output leads to increased venous pressure, causing fluid to leak from capillaries into surrounding tissues, particularly in the lower extremities.
• Jugular vein distention (JVD): JVD is a visible sign of elevated central venous pressure, often associated with right-sided heart failure. When the right ventricle fails to pump blood effectively, it causes a backflow of blood into the right atrium and the venous system, leading to distended jugular veins.
• Third heart sound (S3): The presence of an S3, also known as a “ventricular gallop,” is indicative of systolic heart failure. It occurs when the left ventricle is overfilled during the early diastolic phase due to increased pressure in the ventricles, resulting in turbulent blood flow and the characteristic S3 sound. It is often associated with severe heart failure and indicates significant ventricular dysfunction.

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

• Third heart sound (S3): The presence of a third heart sound, also known as an S3 gallop, is significant in the context of heart failure. It is typically associated with increased filling pressures within the ventricles, which occurs when the ventricle is dilated and overfilled during the early part of diastole. The S3 sound is produced by the rapid deceleration of blood flow into the dilated ventricle. This finding is commonly associated with systolic heart failure and indicates that the ventricle is not functioning properly, often due to increased volume load or decreased contractility. In clinical practice, an S3 sound is often a marker of worsening heart failure and correlates with poorer prognosis.
• Ejection fraction of 25%: The ejection fraction (EF) is a measure of the percentage of blood that is pumped out of the ventricles with each contraction. A normal EF ranges from 55% to 70%. An ejection fraction of 25% is significantly below normal and is indicative of severe systolic dysfunction, as seen in systolic heart failure. This low EF suggests that the heart’s ability to pump blood effectively is severely compromised, leading to inadequate perfusion of tissues and organs. Patients with an EF of 25% are at increased risk for complications such as arrhythmias, heart failure progression, and sudden cardiac death. Management often involves optimizing heart failure treatment with medications such as ACE inhibitors, beta-blockers, and possibly implantable devices like a defibrillator, depending on the overall clinical picture.

Conclusion:

In this case study, the patient exhibits classic signs and symptoms of systolic heart failure, including dyspnea on exertion, pitting edema, jugular vein distention, a third heart sound, and a reduced ejection fraction of 25%. These findings point to significant ventricular dysfunction, which requires prompt and aggressive management to improve outcomes and prevent further deterioration of cardiac function. Treatment would typically involve a combination of lifestyle modifications, pharmacotherapy, and possibly device therapy, tailored to the individual patient’s needs.

References:

1. Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Drazner, M. H., … & Wilkoff, B. L. (2013). 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Journal of the American College of Cardiology, 62(16), 1495-1539. Retrieved from https://www.jacc.org/doi/full/10.1016/j.jacc.2013.05.020

1. McMurray, J. J., Adamopoulos, S., Anker, S. D., Auricchio, A., Böhm, M., Dickstein, K., … & Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. (2012). ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. European journal of heart failure, 14(8), 803-869. Retrieved from https://academic.oup.com/eurheartj/article/33/14/1787/487209