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%.