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IM1.1-27 | Heart Failure — PBL Case

CLINICAL SETTING

Rajan Kumar is a 52-year-old welder from Cuddalore who presents to the General Medicine ward at a government teaching hospital in Tamil Nadu. His wife accompanies him and tells the admitting intern: 'He has had a swollen belly and legs for the past two weeks, and now he cannot sleep lying flat.' Rajan himself adds: 'I stopped my tablets about three months ago because I ran out and couldn't afford to see the doctor. I also had a fever with cough last month — I took some tablets from the pharmacy and it settled. I smoke a pack a day.' His only medical history is 'heart weakness' diagnosed five years ago at a private hospital in Chennai, where he was told his 'heart pump was low' and was started on multiple medications. He brings a single old echocardiogram report from four years ago showing an LVEF of 32% and 'global hypokinesia.' His current resting SpO2 on room air is 88%. His BP is 160/95 mmHg, HR is 110/min and irregular. Respiratory rate is 26/min.

Trigger 1: First Contact: Piecing Together the History

The intern begins a structured history. Rajan reports he has been breathless climbing even a few steps for the past six months but puts up with it because of work demands. In the past two weeks he has developed orthopnoea requiring three pillows, paroxysmal nocturnal dyspnoea twice this week, and increasing abdominal distension. He has been making less urine than usual. He denies chest pain. His wife mentions he has been coughing at night and 'sounds bubbly.' The intern notes that Rajan's ankle swelling now extends to the mid-calf. The pulse is irregularly irregular with a rate of 110/min. JVP is raised at 5 cm above the sternal angle. There is a soft pansystolic murmur at the apex. Bilateral fine crackles are heard up to the mid-zones. The liver is palpable 4 cm below the right costal margin, non-tender. There is 2+ pitting oedema to the mid-calf bilaterally.

DISCUSSION POINTS

  • What is Rajan's current NYHA functional class, and what features in the history justify your classification?
  • List the precipitants that may have caused decompensation in this patient with known chronic HF. Which single precipitant is MOST likely the primary driver of his current presentation?
  • What is the haemodynamic significance of the irregularly irregular pulse in the context of his known heart failure? How does atrial fibrillation specifically worsen ventricular function in a heart with LVEF 32%?
Click to reveal Trigger 2: Investigations Return: A Deeper Picture (discuss previous trigger first!)

Trigger 2: Investigations Return: A Deeper Picture

The investigation results come back. ECG: atrial fibrillation with a ventricular rate of 108/min, left bundle branch block (QRS duration 148 ms), no acute ST changes. Chest radiograph: cardiomegaly (cardiothoracic ratio 0.62), upper lobe pulmonary venous diversion, bilateral Kerley B lines at the bases, small bilateral pleural effusions. BNP: 1,840 pg/mL. Serum creatinine: 1.9 mg/dL (baseline was 1.1 mg/dL four years ago). Serum potassium: 3.2 mmol/L. Haemoglobin: 10.8 g/dL (normocytic normochromic). Thyroid function tests: euthyroid. Echocardiogram (performed today): LVEF 24%, dilated LV (LVEDD 68 mm), global hypokinesia, moderate mitral regurgitation (secondary, functional), dilated LA (LA diameter 48 mm), mildly elevated RVSP 42 mmHg, no regional wall motion abnormality to suggest ischaemic territory. The attending physician tells the students: 'Look at the whole picture — this patient has more than one problem contributing to where he is today.'

DISCUSSION POINTS

  • The echocardiogram shows LVEF 24% with global hypokinesia and no regional wall motion abnormality. What aetiological category does this pattern suggest, and what are the three most common causes in India for this pattern?
  • The BNP is 1,840 pg/mL. At what threshold does BNP support the diagnosis of heart failure, and does the magnitude of elevation correlate with severity? What non-cardiac conditions can also elevate BNP significantly?
  • Rajan's potassium is 3.2 mmol/L. He is likely to be restarted on spironolactone. What is the risk of hyperkalaemia in this patient specifically, and how should his potassium level and renal function be monitored after initiating spironolactone alongside an ACE inhibitor?
Click to reveal Trigger 3: The Febrile Episode Revisited: Infective Endocarditis or Respiratory Infection? (discuss previous trigger first!)

Trigger 3: The Febrile Episode Revisited: Infective Endocarditis or Respiratory Infection?

As Rajan stabilises over 48 hours with IV furosemide and rate control (metoprolol 25 mg twice daily given cautiously), the physician decides to review the febrile episode from three months ago more carefully. Rajan says: 'The fever lasted about three weeks — I felt very weak and lost weight. I sweated a lot at night. My teeth hurt at the same time — I had a tooth pulled out at a local clinic a week before the fever started.' Blood cultures taken on admission (two sets, 30 minutes apart, before any antibiotics) are reported as growing Streptococcus viridans from both sets at 48 hours. The physician pulls up the echocardiogram report and calls the cardiologist: 'There are two small mobile echogenic densities (4 mm and 5 mm) on the posterior mitral valve leaflet. This was not in the initial report — it was seen on review.' He turns to the students and says: 'We may have missed something. Let us revisit the original febrile illness and apply the Duke criteria.'

DISCUSSION POINTS

  • Apply the modified Duke criteria to Rajan's clinical picture. Which major and minor criteria are met? What is the final diagnostic classification — definite, possible, or rejected infective endocarditis?
  • The bacteraemia followed a dental extraction in a patient with known cardiomyopathy. Which patients with cardiac disease require antibiotic prophylaxis before dental procedures according to current guidelines, and does dilated cardiomyopathy qualify?
  • What is the appropriate antibiotic regimen for streptococcal endocarditis of the mitral valve, and when should surgery be considered in this patient, given that he now has moderate functional mitral regurgitation and vegetations?
Click to reveal Trigger 4: Building the Management Plan: The Whole Patient (discuss previous trigger first!)

Trigger 4: Building the Management Plan: The Whole Patient

The multidisciplinary team — general medicine, cardiology, and infectious diseases — meets to plan Rajan's management. The attending physician summarises: 'We have a 52-year-old with non-ischaemic dilated cardiomyopathy, LVEF 24%, new-onset AF (ventricular rate now 88/min after rate control), probable completed infective endocarditis with small residual mitral vegetations on background moderate functional MR, and NYHA Class III symptoms on admission — improving to NYHA Class II with initial diuresis. He has mild AKI (creatinine 1.9 mg/dL, improving to 1.6 mg/dL today), mild anaemia, and stopped all his cardiac medications three months ago.' The cardiology fellow asks the students to draft a structured long-term management plan addressing each problem. The fellow also raises the question of CRT-D given the QRS duration of 148 ms, LBBB morphology, and LVEF 24%.

DISCUSSION POINTS

  • Construct the four-pillar pharmacotherapy plan for Rajan's HFrEF (ACE inhibitor/ARB/ARNI, beta-blocker, aldosterone antagonist, SGLT2 inhibitor). For each pillar, state the drug class, one example drug, the key contraindication or caution relevant to THIS patient (given his renal function, potassium, and BP), and the monitoring parameter.
  • Rajan meets CRT criteria: LVEF 24%, QRS 148 ms, LBBB, NYHA Class II-III on optimal therapy. Explain the physiological rationale for CRT — why does a wide QRS with LBBB morphology cause cardiac dysfunction, and how does biventricular pacing correct it?
  • Non-pharmacological management is often underprescribed. List the specific evidence-based non-pharmacological interventions for Rajan's heart failure, including the target sodium intake, the role of physical activity, and the benefit of daily weight monitoring.

Group Task Assignments

  • Using the clinical details in trigger 3, formally apply the modified Duke criteria and prepare a written diagnostic classification (definite/possible/rejected IE) with each criterion clearly annotated.
  • Draft the complete structured management plan for Rajan: list each active problem, and for each problem state the immediate (48-hour), short-term (2-week), and long-term (6-month) management goals. Include medication names, doses, monitoring, and referral decisions.
  • Debate the proposition: 'CRT-D implantation should be deferred in Rajan until 3 months of optimal medical therapy has been given, rather than planned immediately.' What is the evidence for reassessing LVEF and QRS duration after 3-6 months of pharmacological optimisation before committing to device therapy?
  • Prepare a patient education summary for Rajan in simple Tamil Nadu regional language terms: explain what heart failure is, why his heart is weak, what each of his medications does, the warning signs requiring immediate hospital attendance (sudden weight gain of >2 kg in 48 hours, orthopnoea, reduced urine output), and the sodium target for his diet.

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [IM1.3] What are the exact LVEF thresholds that define HFrEF, HFmrEF, and HFpEF, and how does this classification determine pharmacological management decisions?
  2. [IM1.6] What are the most common precipitants of acute decompensation in a patient with stable chronic heart failure, and how should each be identified and addressed in the management plan?
  3. [IM1.7] How does atrial fibrillation worsen heart failure haemodynamically, and what are the treatment options for rate control versus rhythm control in a patient with HFrEF and new-onset AF?
  4. [IM1.19] What are the modified Duke criteria for infective endocarditis, how are they applied to classify a case as definite, possible, or rejected, and what is the optimal antibiotic regimen for streptococcal mitral valve endocarditis?
  5. [IM1.22] What are the four pharmacological pillars of HFrEF management, what is the neurohormonal rationale for each, and what are the key monitoring parameters required after initiation of each agent?
  6. [IM1.23] What are the indications for CRT, ICD, and cardiac transplantation in heart failure, and what criteria must be met before each is considered?