Cardiovascular Patient D


This patient was presented in the N Engl J Med November, 2016; 375:1868-1877.


A 73-year-old woman with a history of dyspnea on exertion presents for a follow-up visit after hospitalization for acute worsening of dyspnea ... On admission to the hospital, the patient had atrial fibrillation with a ventricular rate of 120 beats per minute, and chest radiography revealed pulmonary venous hypertension. Despite anticoagulation, rate control with a beta-blocker, and administration of loop diuretics during the hospitalization, she continues to have fatigue and exertional dyspnea.

On physical examination, the body-mass index (BMI; the weight in kilograms divided by the square of the height in meters) is 39, pulse 76 beats per minute, and blood pressure 160/70 mm Hg. There is jugular venous distention and lower-extremity edema but no third heart sound, murmurs, or rales.

The serum creatinine level is 1.4 mg/deciliter (124 micromole/liter), estimated glomerular filtration rate (GFR) 37 ml per minute per 1.73 m2 of body-surface area, and natriuretic peptide level 300 pg/milliliter (age-specific and sex-specific normal range, 10 to 218 pg/milliliter).

Echocardiography reveals an ejection fraction of 70%, a normal left ventricular cavity dimension and wall thickness, and left atrial enlargement. Doppler echocardiography shows elevated left atrial pressure (flow can be used to estimate pressure gradients)..... and an estimated pulmonary-artery systolic pressure of 52 mm Hg.





QUESTION: The atrial fibrillation followed secondarily after the patient's other symptoms appeared. Given that, can you make a tentative diagnosis?

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QUESTION: Given the disorder, along with the atrial fibrillation, do the medications appear to be typical?

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QUESTION: What might be a stronger step for the atrial fibrillation?

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QUESTION: Which jugular vein in involved in the sign "jugular venous distension", and what does this sign tell you?

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QUESTION: Is the lower extremity edema expected?

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QUESTION: What is the role of natriuretic hormone?

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QUESTION: Is there pulmonary artery hypertension in addition to systemic arterial hypertension?

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Conclusions and Recommendation

The patient has heart failure with a preserved ejection fraction, exacerbated by, but probably predating, the onset of atrial fibrillation. The dose of diuretics should be increased to reduce clinical congestion of the patient. Given her hypertension and renal dysfunction, an angiotensin antagonist should be added and other agents used as needed to achieve a blood pressure of less than 140/90 mm Hg. She should receive education regarding self-care for heart failure. Anticoagulation should be continued. If symptoms persist, a trial of rhythm control should be considered. The patient's atherosclerotic risk and the presence of coronary disease should be assessed to guide the use of statins and other treatments for coronary disease. Evaluation for sleep apnea may also be reasonable, given her obesity, fatigue, hypertension, and atrial fibrillation. Once her condition is stable, exercise and weight-loss programs should be commenced. Persistent symptoms or recurrent hospitalizations should prompt referral to a disease management program for patients with heart failure. She should be informed about clinical trials of therapeutic strategies for heart failure with a preserved ejection fraction.



QUESTION: What is meant here by "congestion"?

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QUESTION: Why would the angiotensin antagonist lower the blood pressure?

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QUESTION: What drug might be used for rhythm control?

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