A 72-year-old man comes to the office due to progressive shortness of breath. Over the past year, the patient has been unable to perform many of his usual outdoor activities, including afternoon walks and working in the yard. During the last several weeks, he has frequently become easily fatigued and short of breath, and at night he needs several pillows to sleep comfortably. He has also had ankle swelling. The patient has had no chest pain, syncope, abdominal pain, or cough. He is a lifetime nonsmoker. Bibasilar crackles are heard on physical examination. Echocardiography reveals no valvular disease and a nondilated left ventricle with an ejection fraction of 55%. Which of the following is most strongly associated with this patient's current condition?

Question

A 72-year-old man comes to the office due to progressive shortness of breath.  Over the past year, the patient has been unable to perform many of his usual outdoor activities, including afternoon walks and working in the yard.  During the last several weeks, he has frequently become easily fatigued and short of breath, and at night he needs several pillows to sleep comfortably.  He has also had ankle swelling.  The patient has had no chest pain, syncope, abdominal pain, or cough.  He is a lifetime nonsmoker.  Bibasilar crackles are heard on physical examination.  Echocardiography reveals no valvular disease and a nondilated left ventricle with an ejection fraction of 55%.  Which of the following is most strongly associated with this patient's current condition?

Quizplus · Accepted Answer

11ec160b_3a8a_5bfd_9249_c5580be09fbd_MD0001_00 This patient has clinical signs and symptoms of decompensated heart failure (eg, dyspnea, fatigue, orthopnea, lower extremity edema, bibasilar crackles); however, echocardiography shows a preserved left ventricular (LV) ejection fraction (>50%) without chamber dilation. Heart failure with preserved ejection fraction (HFpEF) develops due to diastolic dysfunction, which frequently occurs in the setting of prolonged systemic hypertension (ie, increased afterload). Over time, increased pressure load causes the left ventricle to undergo concentric hypertrophy with the addition of myocardial contractile fibers in parallel to increase contractile strength. The thickened LV walls become stiff and less compliant, leading to impaired diastolic relaxation and increased LV end-diastolic pressure (point 1). Gradually, the elevated pressure transmits back to the pulmonary veins and capillaries, resulting in pulmonary edema. There is also an eventual decline in LV end-diastolic volume (also indicated at point 1) leading to reduced cardiac output and further decompensation (stroke volume decreases despite preserved ejection fraction). (Choice A) The decreased cardiac output in heart failure leads to reduced renal perfusion pressure and glomerular hypofiltration. To compensate, the renin-angiotensin-aldosterone system is activated, and angiotensin II constricts glomerular efferent arterioles in an effort to increase glomerular filtration rate back to normal. (Choice C) Diastolic dysfunction involves a decrease in LV compliance. LV compliance may increase with eccentric hypertrophy, as occurs in response to LV volume overload (eg, dilated cardiomyopathy). (Choice D) LV thrombus typically results from localized stagnation of blood as can occur with an LV aneurysm or in the setting of a severely dilated LV cavity with systolic dysfunction. It is not typically associated with diastolic dysfunction and HFpEF. (Choice E) Atrial and ventricular septal defects are often asymptomatic but can eventually lead to right-to-left intracardiac shunting (Eisenmenger syndrome), typically characterized by cyanosis. This patient's orthopnea, lower extremity edema, and bibasilar crackles suggesting pulmonary edema are more consistent with heart failure. Educational objective: Diastolic dysfunction is a common cause of heart failure with preserved ejection fraction. It typically results from concentric left ventricular hypertrophy in response to prolonged systemic hypertension (ie, increased afterload). __________ References: Management of chronic heart failure in primary care: what evidence do we have for heart failure with preserved systolic function? (http://www.ncbi.nlm.nih.gov/pubmed/25606191)

A 72-Year-Old Man Comes to the Office Due to Progressive