atypical presentation of heart failure

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Heart failure occurs when the heart muscle doesn't pump blood as well as it should. When this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath.

Certain heart conditions gradually leave the heart too weak or stiff to fill and pump blood properly. These conditions include narrowed arteries in the heart and high blood pressure.

Proper treatment may improve the symptoms of heart failure and may help some people live longer. Lifestyle changes can improve quality of life. Try to lose weight, exercise, use less salt and manage stress.

But heart failure can be life-threatening. People with heart failure may have severe symptoms. Some may need a heart transplant or a device to help the heart pump blood.

Heart failure is sometimes called congestive heart failure.

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Heart failure occurs when the heart muscle doesn't pump blood as well as it should. Blood often backs up and causes fluid to build up in the lungs and in the legs. The fluid buildup can cause shortness of breath and swelling of the legs and feet. Poor blood flow may cause the skin to appear blue or gray. Depending on your skin color, these color changes may be harder or easier to see. Some types of heart failure can lead to an enlarged heart.

If you have heart failure, your heart can't supply enough blood to meet your body's needs.

Symptoms may develop slowly. Sometimes, heart failure symptoms start suddenly. Heart failure symptoms may include:

• Shortness of breath with activity or when lying down.
• Fatigue and weakness.
• Swelling in the legs, ankles and feet.
• Rapid or irregular heartbeat.
• Reduced ability to exercise.
• A cough that doesn't go away or a cough that brings up white or pink mucus with spots of blood.
• Swelling of the belly area.
• Very rapid weight gain from fluid buildup.
• Nausea and lack of appetite.
• Difficulty concentrating or decreased alertness.
• Chest pain if heart failure is caused by a heart attack.

When to see a doctor

See your health care provider if you think you might have symptoms of heart failure. Call 911 or emergency medical help if you have any of the following:

• Chest pain.
• Fainting or severe weakness.
• Rapid or irregular heartbeat with shortness of breath, chest pain or fainting.
• Sudden, severe shortness of breath and coughing up white or pink, foamy mucus.

These symptoms may be due to heart failure. But there are many other possible causes. Don't try to diagnose yourself.

At the emergency room, health care providers do tests to learn if your symptoms are due to heart failure or something else.

Call your health care provider right away if you have heart failure and:

• Your symptoms suddenly become worse.
• You develop a new symptom.
• You gain 5 pounds (2.3 kilograms) or more within a few days.

Such changes could mean that existing heart failure is getting worse or that treatment isn't working.

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Chambers and valves of the heart

A typical heart has two upper and two lower chambers. The upper chambers, the right and left atria, receive incoming blood. The lower chambers, the more muscular right and left ventricles, pump blood out of the heart. The heart valves, which keep blood flowing in the right direction, are gates at the chamber openings.

Enlarged heart, in heart failure

If the heart weakens, as it can with heart failure, it begins to enlarge. This forces the heart to work harder to pump blood to the rest of the body.

Heart failure can be caused by a weakened, damaged or stiff heart.

• If the heart is damaged or weakened, the heart chambers may stretch and get bigger. The heart can't pump out the needed amount of blood.
• If the main pumping chambers of the heart, called the ventricles, are stiff, they can't fill with enough blood between beats.

The heart muscle can be damaged by certain infections, heavy alcohol use, illegal drug use and some chemotherapy medicines. Your genes also can play a role.

Any of the following conditions also can damage or weaken the heart and cause heart failure.

Coronary artery disease and heart attack. Coronary artery disease is the most common cause of heart failure. The disease results from the buildup of fatty deposits in the arteries. The deposits narrow the arteries. This reduces blood flow and can lead to heart attack.

A heart attack occurs suddenly when an artery feeding the heart becomes completely blocked. Damage to the heart muscle from a heart attack may mean that the heart can no longer pump as well as it should.

• High blood pressure. Also called hypertension, this condition forces the heart to work harder than it should to pump blood through the body. Over time, the extra work can make the heart muscle too stiff or too weak to properly pump blood.
• Heart valve disease. The valves of the heart keep blood flowing the right way. If a valve isn't working properly, the heart must work harder to pump blood. This can weaken the heart over time. Treating some types of heart valve problems may reverse heart failure.
• Inflammation of the heart muscle, also called myocarditis. Myocarditis is most commonly caused by a virus, including the COVID-19 virus, and can lead to left-sided heart failure.
• A heart problem that you're born with, also called a congenital heart defect. If the heart and its chambers or valves haven't formed correctly, the other parts of the heart have to work harder to pump blood. This may lead to heart failure.
• Irregular heart rhythms, called arrhythmias. Irregular heart rhythms may cause the heart to beat too fast, creating extra work for the heart. A slow heartbeat also may lead to heart failure. Treating an irregular heart rhythm may reverse heart failure in some people.
• Other diseases. Some long-term diseases may contribute to chronic heart failure. Examples are diabetes, HIV infection, an overactive or underactive thyroid, or a buildup of iron or protein.

Causes of sudden heart failure also include:

• Allergic reactions.
• Any illness that affects the whole body.
• Blood clots in the lungs.
• Severe infections.
• Use of certain medicines.
• Viruses that attack the heart muscle.

Heart failure usually begins with the lower left heart chamber, called the left ventricle. This is the heart's main pumping chamber. But heart failure also can affect the right side. The lower right heart chamber is called the right ventricle. Sometimes heart failure affects both sides of the heart.

Risk factors

Diseases and conditions that increase the risk of heart failure include:

• Coronary artery disease. Narrowed arteries may limit the heart's supply of oxygen-rich blood, resulting in weakened heart muscle.
• Heart attack. A heart attack is a form of coronary artery disease that occurs suddenly. Damage to the heart muscle from a heart attack may mean the heart can no longer pump as well as it should.
• Heart valve disease. Having a heart valve that doesn't work properly raises the risk of heart failure.
• High blood pressure. The heart works harder than it has to when blood pressure is high.
• Irregular heartbeats. Irregular heartbeats, especially if they are very frequent and fast, can weaken the heart muscle and cause heart failure.
• Congenital heart disease. Some people who develop heart failure were born with problems that affect the structure or function of their heart.
• Diabetes. Having diabetes increases the risk of high blood pressure and coronary artery disease.
• Sleep apnea. This inability to breathe properly during sleep results in low blood-oxygen levels and an increased risk of irregular heartbeats. Both of these problems can weaken the heart.
• Obesity. People who have obesity have a higher risk of developing heart failure.
• Viral infections. Some viral infections can damage to the heart muscle.

Medicines that may increase the risk of heart failure include:

• Some diabetes medicines. The diabetes drugs rosiglitazone (Avandia) and pioglitazone (Actos) have been found to increase the risk of heart failure in some people. Don't stop taking these medicines without first talking to your health care provider.
• Some other medicines. Other medicines that may lead to heart failure or heart problems include nonsteroidal anti-inflammatory drugs (NSAIDs) and some medicines used to treat high blood pressure, cancer, blood conditions, irregular heartbeats, nervous system diseases, mental health conditions, lung and urinary problems, and infections.

Other risk factors for heart failure include:

• Aging. The heart's ability to work decreases with age, even in healthy people.
• Alcohol use. Drinking too much alcohol may weaken the heart muscle and lead to heart failure.
• Smoking or using tobacco. If you smoke, quit. Using tobacco increases the risk of heart disease and heart failure.

Complications

If you have health failure, it's important to have regular health checkups, even if symptoms improve. Your health care provider can examine you and run tests to check for complications.

Complications of heart failure depend on your age, overall health and the severity of heart disease. They may include:

• Kidney damage or failure. Heart failure can reduce the blood flow to the kidneys. Untreated, this can cause kidney failure. Kidney damage from heart failure can require dialysis for treatment.
• Other heart problems. Heart failure can cause changes in the heart's size and function. These changes may damage heart valves and cause irregular heartbeats.
• Liver damage. Heart failure can cause fluid buildup that puts too much pressure on the liver. This fluid backup can lead to scarring, which makes it more difficult for the liver to work properly.
• Sudden cardiac death. If the heart is weak, there is a risk of dying suddenly due to a dangerous irregular heart rhythm.

One way to prevent heart failure is to treat and control the conditions that can cause it. These conditions include coronary artery disease, high blood pressure, diabetes and obesity.

Some of the same lifestyle changes used to manage heart failure also may help prevent it. Try these heart-healthy tips:

• Don't smoke.
• Get plenty of exercise.
• Eat healthy foods.
• Maintain a healthy weight.
• Reduce and manage stress.
• Take medicines as directed.
• Heart failure. National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health-topics/heart-failure. Accessed Nov. 30, 2022.
• Ferri FF. Heart failure. In: Ferri's Clinical Advisor 2023. Elsevier; 2023. https://www.clinicalkey.com. Accessed Nov. 30, 2022.
• Colucci WS. Determining the etiology and severity of heart failure or cardiomyopathy. https://www.uptodate.com/contents/search. Accessed Nov. 30, 2022.
• Colucci WS. Evaluation of the patient with suspected heart failure. https://www.uptodate.com/contents/search. Accessed Nov. 30, 2022.
• Heart failure (HF). Merck Manual Professional Version. https://www.merckmanuals.com/professional/cardiovascular-disorders/heart-failure/heart-failure-hf. Accessed Nov. 28, 2022.
• Vasan RS, et al. Epidemiology and causes of heart failure. https://www.uptodate.com/contents/search. Accessed Nov. 28, 2022.
• Goldman L, et al., eds. Goldman-Cecil Medicine. 26th ed. Elsevier; 2020. https://www.clinicalkey.com. Accessed Nov. 28, 2022.
• AskMayoExpert. Heart failure with reduced ejection fraction (HFrEF) (adult). Mayo Clinic; 2022.
• Rakel D, ed. Heart failure. In: Integrative Medicine. 4th ed. Elsevier; 2018. https://www.clinicalkey.com. Accessed Nov. 28, 2022.
• AskMayoExpert. Heart failure with preserved ejection fraction (HFpEF) (adult). Mayo Clinic; 2022.
• Allen L. Palliative care for patients with advanced heart failure: Decision support, symptom management, and psychosocial assistance. https://www.uptodate.com/contents/search. Accessed Nov. 28, 2022.
• The dying patient. Merck Manual Professional Version. http://www.merckmanuals.com/professional/special-subjects/the-dying-patient/the-dying-patient. Accessed Nov. 28, 2022.
• Ami TR. Allscripts EPSi. Mayo Clinic. Oct. 4, 2022.
• Mancini D. Heart transplantation in adults: Indications and contraindications. https://www.uptodate.com/contents/search. Accessed Nov. 28, 2022.
• Sawalha K, et al. Systematic review of COVID-19 related myocarditis: Insights on management and outcome. Cardiovascular Revascularization Medicine. 2021; doi:10.1016/j.carrev.2020.08.028.
• Armstrong PW, et al. Vericiguat in patients with heart failure and reduced ejection fraction. The New England Journal of Medicine. 2020; doi:10.1056/NEJMoa1915928.
• Armstrong PW, et al. A multicenter, randomized, double-blind, placebo-controlled trial of the efficacy and safety of the oral soluble guanylate cyclase stimulator. Journal of the American College of Cardiology: Heart Failure. 2018; doi:10.1016/j.jchf.2017.08.013.
• Verquvo (approval letter). New Drug Application 214377. U.S. Food and Drug Administration. https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm?event=overview.process&ApplNo=214377. Accessed Nov. 28, 2022.
• Heidenreich PA, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022; doi:10.1161/CIR.0000000000001063.
• Clarke JD, et al. Effect of inotropes on patient-reported health status in end-stage heart failure: A review of published clinical trials. Circulation: Heart Failure. 2021; doi:10.1161/CIRCHEARTFAILURE.120.007759.
• Lopez-Jimenez F (expert opinion). Mayo Clinic. Dec. 2, 2021.
• Types of heart failure. American Heart Association. https://www.heart.org/en/health-topics/heart-failure/what-is-heart-failure/types-of-heart-failure. Accessed Nov. 28, 2022.
• Zannad F, et al. SGLT2 inhibitors in patients with heart failure with reduced ejection fraction: a meta-analysis of the EMPEROR-Reduced and DAPA-HF trials. Lancet. 2020; doi:10.1016/S0140-6736(20)31824-9.
• Sodium-glucose cotransporter-2 (SGLT2) inhibitors. U.S. Food and Drug Administration. https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/sodium-glucose-cotransporter-2-sglt2-inhibitors. Accessed Jan. 10, 2022.
• Lee MCH, et al. Clinical efficacy of SGLT2 inhibitors with different SGLT1/SGLT2 selectivity in cardiovascular outcomes among patients with and without heart failure: A systematic review and meta-analysis of randomized trials. Medicine (Baltimore). 2022; doi:10.1097/MD.0000000000032489.
• Mankad R (expert opinion). Mayo Clinic. Jan. 12, 2023.
• ACC, AHA, HFSA issue heart failure guideline. American Heart Association. https://newsroom.heart.org/news/acc-aha-hfsa-issue-heart-failure-guideline. Accessed Jan. 31, 2023.
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Associated Procedures

• Cardiac catheterization
• Chest X-rays
• Coronary angiogram
• Coronary artery bypass surgery
• Echocardiogram
• Electrocardiogram (ECG or EKG)
• Heart transplant
• Implantable cardioverter-defibrillators (ICDs)
• Palliative care
• Stress test
• Ventricular assist device

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FADI SHAMSHAM, M.D., AND JUDITH MITCHELL, M.D.

Am Fam Physician. 2000;61(5):1319-1328

Although heart failure is a common clinical syndrome, especially in the elderly, its diagnosis is often missed. A detailed clinical history is crucial and should address not only current signs and symptoms of heart failure but also signs and symptoms that point to a specific cause of the syndrome, such as coronary artery disease, hypertension or valvular heart disease. It is important to determine whether the patient has had a previous cardiac event, in particular a myocardial infarction. The physical examination should include Valsalva's maneuver, a test that is highly specific and sensitive for the detection of left ventricular systolic and diastolic dysfunction in patients with heart failure. An electrocardiograph and a chest radiograph should also be obtained. Two-dimensional echocardiography of the heart helps differentiate systolic from diastolic dysfunction. Coronary angiography is indicated in patients with heart failure and anginal chest pain and should be strongly considered in patients with an electrocardiogram suggestive of ischemia or myocardial infarction.

Heart failure affects an estimated 4.9 million Americans, 1 or 1 percent of adults 50 to 60 years of age and 10 percent of adults in their 80s. 2 Each year, about 400,000 new cases of heart failure are diagnosed in the United States. 1 This clinical syndrome is the most frequent cause of hospitalizations in the elderly and is responsible for 5 to 10 percent of all hospital admissions. 1 Heart failure causes or contributes to approximately 250,000 deaths every year. 3

The clinical syndrome of heart failure manifests when cellular respiration becomes impaired because the heart cannot pump enough blood to support the metabolic demands of the body, or when normal cellular respiration can only be maintained with an elevated left ventricular filling pressure. 4

The Framingham, 5 Duke 6 and Boston 7 criteria were established before noninvasive techniques for assessing systolic and diastolic dysfunction became widely available. The three sets of criteria were designed to assist in the diagnosis of heart failure. The Boston criteria ( Table 1 ) 8 have been shown to have the highest combined sensitivity (50 percent) and specificity (78 percent ) . All of these criteria are most helpful in diagnosing advanced or severe heart failure, a condition that occurs in 20 to 40 percent of patients with a decreased ejection fraction. 9

Early diagnosis of heart failure is essential for successfully addressing underlying diseases or causes and, in some patients, preventing further myocardial dysfunction and clinical deterioration. However, initial diagnosis may be difficult because the presentations of heart failure can change from no symptoms to pulmonary edema with cardiogenic shock. It is estimated that heart failure is correctly diagnosed initially in only 50 percent of affected patients. 10 , 11 A systematic approach can improve overall accuracy in diagnosing this condition.

The first step in diagnosing heart failure is to obtain a complete clinical history. The patient should be questioned about dyspnea, cough, nocturia, generalized fatigue and other signs and symptoms of heart failure.

Dyspnea, a cardinal symptom of a failing heart, often progresses from dyspnea on exertion to orthopnea, paroxysmal nocturnal dyspnea and dyspnea on rest. Cough, usually nocturnal and nonproductive, may accompany dyspnea and often occurs in similar settings (i.e., on exertion or when the patient is supine).

Nocturia, also a frequent sign of heart failure, occurs secondary to increased renal perfusion when the patient is supine. 12 Generalized fatigue (caused by the low perfusion state) and peripheral edema with inability to wear usual footwear are frequent complaints.

As heart failure progresses, gastrointestinal symptoms (e.g., abdominal bloating, anorexia and fullness in the right upper quadrant) are occasionally seen. With severe, longstanding heart failure, cardiac cachexia (emaciation resulting from heart disease) may develop secondary to protein-losing enteropathy and increased levels of certain cytokines, such as tumor necrosis factor. Cardiac cachexia may mimic the cachexia seen in patients with disseminated malignant disease.

Confusion and altered mental status may occur because of decreased cerebral perfusion or cardiac cirrhosis. In heart failure, cirrhosis develops secondary to chronic passive congestion of the liver.

The patient should be asked about previous chest pain or myocardial infarction because coronary artery disease is responsible for up to 75 percent of cases of heart failure with decreased left ventricular function. 13 A history of myocardial infarction has a better combination of sensitivity, specificity and positive and negative predictive value for heart failure compared with other symptoms or aspects of the medical history. 14

It is important to identify a history of hypertension, in that high blood pressure is the second most frequent cause of heart failure. Information about other possible causes of heart failure should also be sought ( Table 2 ) .

Once heart failure is suspected, the functional class of the patient should be determined. The New York Heart Association (NYHA) functional classification of congestive heart failure is presented in Table 3 . 15

Physical Examination

A complete physical examination is the second component in the diagnosis of heart failure. The patient's general appearance should be assessed for evidence of resting dyspnea, cyanosis and cachexia.

BLOOD PRESSURE AND HEART RATE

The patient's blood pressure and heart rate should be recorded. High, normal or low blood pressure may be present. The prognosis is worse for patients who present with a systolic blood pressure of less than 90 to 100 mm Hg when not receiving medication (angiotensin-converting enzyme [ACE] inhibitors, beta blockers or duretics). 16 Tachycardia may be a sign of heart failure, especially in the decompensated state. The heart rate increases as one of the compensatory ways of maintaining adequate cardiac output. A decrease in the resting heart rate with medical therapy can be used as a surrogate marker for treatment efficacy. A weak, thready pulse and pulsus alternans are associated with decreased left ventricular function. The patient should also be monitored for evidence of periodic breathing (Cheyne-Stokes respiration).

JUGULAR VENOUS DISTENTION

Jugular venous distention is assessed while the patient is supine with the upper body at a 45-degree angle from the horizontal plane. The top of the waveform of the internal jugular venous pulsation determines the height of the venous distention. An imaginary horizontal line (parallel to the floor) is then drawn from this level to above the sternal angle. A height of more than 4 to 5 cm from the sternal angle to this imaginary line is consistent with elevated venous pressure ( Figure 1 ) .

Elevated jugular venous pressure is a specific (90 percent) but not sensitive (30 percent) sign of elevated left ventricular filling. The reproducibility of the jugular venous distention assessment is low. 17

POINT OF MAXIMAL IMPULSE

The point of maximal impulse of the left ventricle is usually located in the midclavicular line at the fifth intercostal space. With the patient in a sitting position, the physician uses fingertips to identify this point. Cardiomegaly usually displaces the cardiac impulse laterally and downward.

At times, the point of maximal impulse may be difficult to locate and therefore loses sensitivity (66 percent). Yet the location of this point remains a specific indicator (96 percent) for evaluating the size of the heart. 14

THIRD AND FOURTH HEART SOUNDS

A double apical impulse can represent an auscultated third heart sound (S 3 ). Just as with the displaced point of maximal impulse, a third heart sound is not sensitive (24 percent) for heart failure, but it is highly specific (99 percent). 14 Patients with heart failure and left ventricular hypertrophy can also have a fourth heart sound (S 4 ). The physician should be alert for murmurs, which can provide information about the cause of heart disease and also aid in the selection of therapy.

PULMONARY EXAMINATION

Physical examination of the lungs may reveal rales and pleural effusions. Despite the presence of pulmonary congestion, rales can be absent because of increased lymphatic drainage and compensatory changes in the perivascular structures that have occurred over time. Wheezing may be the sole manifestation of pulmonary congestion. Frequently, asthma is erroneously diagnosed in patients who actually have heart failure.

LIVER SIZE AND HEPATOJUGULAR REFLUX

The key component of the abdominal examination is the evaluation of liver size. Hepatomegaly may occur because of right-sided heart failure and venous congestion.

The hepatojugular reflux can be a useful test in patients with right-sided heart failure. This test should be performed while the patient is lying down with the upper body at a 45-degree angle from the horizontal plane. The patient keeps the mouth open and breathes normally to prevent Valsalva's maneuver, which can give a false-positive test. Moderate pressure is then applied over the middle of the abdomen for 30 to 60 seconds. Hepatojugular reflux occurs if the height of the neck veins increases by at least 3 cm and the increase is maintained throughout the compression period. 18

LOWER EXTREMITY EDEMA

Lower extremity edema, a common sign of heart failure, is usually detected when the extracellular volume exceeds 5 L. The edema may be accompanied by stasis dermatitis, an often chronic, usually eczematous condition characterized by edema, hyperpigmentation and, commonly, ulceration.

VALSALVA'S MANEUVER

Valsalva's maneuver is rarely used in the evaluation of patients with heart failure. Yet this test is simple to perform and carries one of the best combinations of specificity (91 percent) and sensitivity (69 percent) for the detection of left ventricular systolic and diastolic dysfunction in patients with heart failure. 19 , 20

Valsalva's maneuver is performed with the blood pressure cuff inflated 15 mm Hg over the systolic blood pressure. While the physician auscultates over the brachial artery, the patient is asked to perform a forced expiratory effort against a closed airway (the Valsalva's maneuver).

A normal response would be an initial rise in systolic blood pressure at the onset of straining (phase I) with Korotkoff's sounds heard ( Figure 2 ) . While the maneuver is maintained (phase II), a decrease in the blood pressure occurs with loss of Korotkoff's sounds. Release of the maneuver (phase III) is followed by an overshoot of blood pressure and the reappearance of heart sounds (phase IV). Abnormal responses occurring in patients with heart failure are maintenance of beats throughout Valsalva's maneuver (square wave) or lack of reappearance of Korotkoff's sounds after release of the maneuver (absent overshoot).

DIAGNOSTIC CHALLENGES

Diagnosing heart failure in elderly patients may be particularly challenging because of the atypical presentations in this age group. Anorexia, generalized weakness and fatigue are often the predominant symptoms of heart failure in geriatric patients. Mental disturbances and anxiety are also common.

When older persons become symptomatic on exertion, they decrease their level of activity to the point of becoming relatively asymptomatic. A cycle of symptoms on exertion and consequent decrease in activity frequently continues as the disease progresses, until the patient finally becomes symptomatic at rest (i.e., NYHA class IV).

The physical findings in older patients with heart failure may be difficult to interpret accurately. Resting tachycardia is uncommon, and pulse contour abnormalities are difficult to assess secondary to peripheral arteriosclerotic changes. At times, auscultatory findings on the lung examination are atypical because of concomitant pulmonary disease. 21

Laboratory Findings

Most patients with heart failure have normal electrolyte levels. However, extended use of kaliuretic diuretics can lead to hypokalemia, and the use of potassium-sparing diuretics and ACE inhibitors may result in hyperkalemia. Blood urea nitrogen and creatinine levels may become elevated, reflecting prerenal azotemia. Hyponatremia may be present in patients with advanced heart failure.

When the liver becomes congested, serum transaminase and bilirubin levels may become elevated, and jaundice may be present. With chronic congestive hepatomegaly, cardiac cirrhosis may occur and cause hypoalbuminemia, hypoglycemia and an increased prothrombin time.

The prognosis is worse in patients with hyponatremia or abnormalities secondary to congested hepatomegaly.

Anemia may contribute to worsening heart failure. When severe, anemia may even cause heart failure.

In all patients with newly diagnosed heart failure, thyroid function tests should be performed to rule out hypothyroidism or hyperthyroidism.

It may soon be possible to routinely obtain serum measurements of two plasma enzymes secreted by the overloaded heart. Plasma atrial natriuretic peptide is secreted in response to increased intra-atrial pressure, and brain natriuretic peptide (BNP) is secreted by the failing ventricle. Levels of these enzymes, but specifically BNP, are elevated in patients with dyspnea resulting from heart failure. In one study, elevated BNP levels had more than a 90 percent specificity and sensitivity for heart failure. 22

Diagnostic Tests

Electrocardiography.

An electrocardiogram (ECG) should be obtained in all patients who present with heart failure. No specific ECG feature is indicative of heart failure, but atrial and ventricular arrhythmias are common findings. For example, atrial fibrillation is present in 25 percent of patients with cardiomyopathy, especially elderly patients with advanced heart failure. 23 The prognosis is worse for patients with atrial fibrillation, atrial or ventricular tachycardia, or left bundle branch block. 16 , 24

Low voltage on the ECG in association with conduction disturbances may suggest the presence of amyloidosis.

CHEST RADIOGRAPHY

Chest radiographs can be helpful in the diagnosis of heart failure. Cardiomegaly is usually manifested by the presence of an increased cardiothoracic ratio (greater than 0.50) on a posteroanterior view. However, patients with predominantly diastolic dysfunction may have normal heart size, one of the distinguishing markers of diastolic versus systolic dysfunction. Right ventricular enlargement is suggested by the loss of free space between the cardiac silhouette and the sternum on a lateral view.

Signs of increased pulmonary venous pressure seen on chest radiographs may progress from redistribution of blood flow from the bases of the lungs to the apices to linear densities reflecting interstitial edema (Kerley's lines) to a hazy appearance concentrated mostly around the hila of the mediastinum and presenting a butterfly pattern.

Chest radiographs are also helpful in detecting pleural effusion secondary to heart failure.

ECHOCARDIOGRAPHY

Transthoracic two-dimensional echocardiography with Doppler flow studies is highly recommended for all patients with heart failure. 25 This test helps in the assessment of left ventricular size, mass and function.

The ejection fraction can be calculated by several methods, including visual estimation, which has good correlation with ejection fractions obtained by angiography 26 or radionuclide cineangiography. 27 Regional wall motion and valvular integrity can also be evaluated.

Transesophageal echocardiography offers higher quality images than transthoracic studies. However, this technique is invasive and is best reserved for use when the quality of the two-dimensional echocardiogram is unacceptable.

ANGIOGRAPHY

Radionuclide angiography is another non-invasive method for assessing systolic and diastolic function. This imaging technique is used when two-dimensional echocardiography is not diagnostic because adequate images could not be obtained or the findings do not agree with the clinical picture. Radionuclide angiography provides a reliable and quantitative measurement of the left ventricular ejection fraction and the regional wall motion. However, ectopic activity and atrial fibrillation adversely affect the accuracy of its measurements. 28

Left ventricular angiography can be used to assess the ejection fraction, the left ventricular volume and the severity of valvular regurgitation or stenosis. In addition, detailed measurements of ventricular filling pressures and indices of left ventricular diastolic relaxation rate can be helpful in confirming diastolic dysfunction.

OTHER TECHNIQUES

Magnetic resonance imaging (MRI) 29 and ultrafast or cine computed tomography (CT) 30 can measure the ejection fraction and assess regional wall motion. However, assessment of cardiac function using these studies is only performed in a limited number of centers, and the superiority of the studies to echocardiography and angiography has not been proved.

Sometimes coronary artery disease must be excluded as a causal factor in patients with heart failure. Cardiac catheterization and coronary angiography should be strongly considered in all patients with heart failure and angina who are candidates for interventional procedures. In patients with known coronary artery disease and heart failure but no angina, coronary arteriography or noninvasive testing (i.e., a thallium stress test or stress echocardiogram), followed by coronary arteriography in those patients with ischemia, should be considered. The intensity of the search for ischemic heart disease in patients with heart disease depends on the patient's probability of having coronary artery disease.

If imaging techniques cannot confirm the cause of cardiac dysfunction, an endomyocardial biopsy may provide important information in patients receiving cardiotoxic drugs and in patients suspected of having infectious (i.e., acute or chronic viral myocarditis), genetic or systemic diseases with possible cardiac involvement. 25 However, the diagnostic yield of this procedure is typically less than 10 percent. 31

Systolic vs. Diastolic Dysfunction

As many as 40 percent of patients with clinical heart failure have diastolic dysfunction with normal systolic function. 32 In addition, many patients with systolic dysfunction have elements of diastolic dysfunction. With systolic dysfunction, the pumping ability of the ventricle is impaired. With diastolic dysfunction, ventricular filling is defective.

Ventricular diastolic function depends on the pressure-to-volume relationship in the left ventricle. Decreased compliance of the left ventricular wall leads to a higher pressure for a given diastolic volume. The end result is impaired ventricular filling, inappropriately elevated left atrial and pulmonary venous pressure, and decreased ability to increase stoke volume. These dysfunctions lead to the clinical syndrome of heart failure.

Findings suggestive of diastolic dysfunction on the two-dimensional echocardiogram are left ventricular hypertrophy, a dilated left atrium, a normal or nearly normal ejection fraction and reversal of the normal pattern of flow velocity (measured by Doppler flow studies) across the mitral valve ( Figures 3 and 4 ) .

Differentiating between systolic and diastolic dysfunction is essential because their long-term treatments are different 33 ( Table 4 34 and Figure 5 ) . The treatments of choice in patients with systolic dysfunction are ACE inhibitors, digoxin, diuretics and beta blockers. In patients with diastolic dysfunction, the cornerstones of treatment depend on the underlying cause. Beta blockers and calcium channel blockers are frequently used when diastolic dysfunction is secondary to ischemia or hypertension.

The history, physical examination, ECG and chest radiographs provide some clues that can be helpful in differentiating systolic and diastolic dysfunction. For example, predominantly systolic dysfunction is suggested by a history of myocardial infarction and younger patient age, a displaced point of maximal impulse and an S 3 gallop on the physical examination, the presence of Q waves on the ECG and the finding of cardiomegaly on the chest radiograph. In contrast, diastolic dysfunction is suggested by a history of hypertension and older patient age, a sustained point of maximal impulse and an S 4 gallop on the physical examination, left ventricular hypertrophy on the ECG and a normal-sized heart on the chest radiograph. 36 However, the findings can overlap considerably, and echocardiography of the heart is usually necessary.

Heart and stroke statistical update. Dallas: American Heart Association, 1997.

Kannel WB, Belanger AJ. Epidemiology of heart failure. Am Heart J. 1991;121(3 pt 1):951-7.

Heart failure: evaluation and care of patients with left ventricular systolic dysfunction Rockville, Md: US Dept of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1994; AHCPR publication no. 94-0612.

Colucci W, Braunwald E. Pathophysiology of heart failure. In: Braunwald E, ed. Heart disease: a textbook of cardiovascular medicine. 5th ed. Philadelphia: Saunders, 1997:394–420.

McKee PA, Castelli WP, McNamara PM, Kannel WB. The natural history of congestive heart failure: the Framingham study. N Engl J Med. 1971;285:1441-6.

Harlan WR, Oberman A, Grimm R, Rosati RA. Chronic congestive heart failure in coronary artery disease: clinical criteria. Ann Intern Med. 1977;86:133-8.

Carlson KJ, Lee DC, Goroll AH, Leahy M, Johnson RA. An analysis of physicians' reasons for prescribing long-term digitalis therapy in outpatients. J Chron Dis. 1985;38:733-9.

Marantz PR, Tobin JN, Wassertheil-Smoller S, Steingart RM, Wexler JP, Budner N, et al. The relationship between left ventricular systolic function and congestive heart failure diagnosed by clinical criteria. Circulation. 1988;77:607-12.

Redfield MM. Diagnosis and evaluation of heart failure. In: Murphy J, ed. Mayo Clinic cardiology review. Armonk, N.Y.: Futura, 1997:597–611.

Remmes J, Miettinen H, Reunanen A, Pyorala K. Validity of clinical diagnosis of heart failure in primary health care. Eur Heart J. 1991;12:315-21.

Wheeldon NM, MacDonald TM, Flucker CJ, McKendrick AD, McDevitt DG, Struthers AD. Echocardiography in chronic heart failure in the community. Q J Med. 1993;86:17-23.

Braunwald E, Grossman W. Clinical aspects of heart failure. In: Braunwald E, ed. Heart disease: a textbook of cardiovascular medicine. 5th ed. Philadelphia: Saunders, 1997:445–70.

Studies of left ventricular dysfunction (SOLVD)—rationale, design and methods: two trials that evaluate the effect of enalapril in patients with reduced ejection fraction. Am J Cardiol. 1990;66:315-22 1990;66:1026]

Davie AP, Francis CM, Caruana L, Sutherland GR, McMurray JJ. Assessing diagnosis in heart failure: which features are any use?. Q J Med. 1997;90:335-9.

Criteria Committee, New York Heart Association. Dieases of the heart and blood vessels. Nomenclature and criteria for diagnosis. 6th ed. Boston: Little, Brown, 1964:114.

Cleland JG, Dargie HJ, Ford I. Mortality in heart failure: clinical variables of prognostic value. Br Heart J. 1987;58:572-82.

Stevenson LW, Perloff JK. The limited reliability of the physical signs for estimating hemodynamics in chronic heart failure. JAMA. 1989;261:884-8.

Ducas J, Magder S, McGregor M. Validity of hepatojugular reflux as a clinical test for congestive heart failure. Am J Cardiol. 1983;52:1299-303.

Zema MJ, Masters AP, Margouleff D. Dyspnea: the heart or the lungs? Differentiation at bedside by use of the simple Valsalva maneuver. Chest. 1984;85:59-64.

Zema MJ, Restivo B, Sos T, Sniderman KW, Kline S. Left ventricular dysfunction—bedside Valsalva manoeuvre. Br Heart J. 1980;44:560-9.

Tresch DD. The clinical diagnosis of heart failure in older patients. J Am Geriatr Soc. 1997;45:1128-33.

Davis M, Espiner E, Richards G, Billings J, Town I, Neill A, et al. Plasma brain natriuretic peptide in assessment of acute dyspnoea. Lancet. 1994;343:440-4.

Wenger NK, Abelman WH, Roberts WC. Cardiomyopathy and specific heart muscle disease. In: Hurst JW, ed. The heart, arteries and veins. 7th ed. New York: McGraw-Hill, 1990:1278–1347.

Middlekauff HR, Stevenson WG, Stevenson LW. Prognostic significance of atrial fibrillation in advanced heart failure. A study of 390 patients. Circulation. 1991;84:40-8.

Guidelines for the evaluation and management of heart failure. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Evaluation and Management of Heart Failure). J Am Coll Cardiol. 1995;26:1376-98.

Mueller X, Stauffer JC, Jaussi A, Goy JJ, Kappenberger L. Subjective visual echocardiographic estimate of left ventricular ejection fractions as an alternative to conventional echocardiographic methods: comparison with contrast angiography. Clin Cardiol. 1991;14:898-902.

Amico AF, Lichtenberg GS, Reisner SA, Stone CK, Schwartz RG, Meltzer RS. Superiority of visual versus computerized echocardiographic estimation of radionuclide left ventricular ejection fraction. Am Heart J. 1989;118:1259-65.

Rumberger JA, Behrenbeck T, Bell MR, Breem JF, Johnston DL, Holmes DR, et al. Determination of ventricular ejection fraction: a comparison of available imaging methods. The Cardiovascular Imaging Working Group. Mayo Clin Proc. 1997;72:860-70.

Stratemeier EJ, Thompson R, Brady TJ, Miller SW, Saini S, Wisner GL, et al. Ejection fraction determination by MR imaging: comparison with left ventricular angiography. Radiology. 1986;158:775-7.

Rumberger JA, Sheedy PF, Breen JF. Use of ultrafast (cine) x-ray computed tomography in cardiac and cardiovascular imaging. In: Giuliani ER, Gersh BJ, McGoom MD, Hayes DL, Schaff HV, eds. Mayo Clinic practice of cardiology. 3d ed. St. Louis: Mosby, 1996:303–24.

Chow LC, Dittrich HC, Shabetai R. Endomyocardial biopsy in patients with unexplained congestive heart failure. Ann Intern Med. 1988;109:535-9.

Soufer R, Wohlgelernter D, Vita NA, Amuchestegui M, Sostman HD, Berger HJ, et al. Intact systolic left ventricular function in clinical congestive heart failure. Am J Cardiol. 1984;55:1032-6.

Coodley E. Newer drug therapy for congestive heart failure. Arch Intern Med. 1999;159:1177-83.

Young JB. Assessment of heart failure. In: Brauwnwald E. Atlas of heart disease. Vol 4. Philadelphia: Current Medicine, 1995:7.1–7.2.

Pitt B, Zannad F, Remme WJ, Cody R, Castaigne A, Perez A, et al. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. N Engl J Med. 1999;341:809-17.

Goldsmith SR, Dick C. Differentiating systolic from diastolic heart failure: pathophysiologic and therapeutic considerations. Am J Med. 1993;95:645-55.

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Treating Patients with Atypical Cardiac Presentations

This clinical review feature article is presented in conjunction with the Department of Emergency Medicine Education at the University of Texas Southwestern Medical Center, Dallas.

Glossary Terms ACE inhibitor: A medication that inhibits the angiotensin-converting enzyme. The result is the relaxation of smooth muscles, which can be found in arteries and arterioles, and lowering of blood pressure. BiPAP: Bilevel positive pressure.  Comorbidities: Two or more coexisting medical conditions. Cortical failures: Failure of cortical synapses that can be associated with stroke. CPAP: Continuous positive airway pressure. Hydrostatic pressure: A capillary pressure exerted against vessel walls. This pressure is driven from cardiac contractions (or blood pressure) and forces some water out of the plasma through the capillary wall and into the interstitial space. Hypokalemia: Lower than normal potassium levels. Neuropathies: A functional disturbance and/or pathological change in the peripheral nervous system. Orthopnea: Difficulty breathing when lying in a supine position. Prodromal symptoms: A symptom indicating an onset of a disease. Learning Objectives

• Discuss the contributing factors for a patient experiencing an atypical cardiac event.
• Describe various atypical presentations for patients who are suffering a myocardial infarction.
• Describe the currently accepted treatment for a patient suffering a myocardial infarction.
• Describe the basic pathophysiology of congestive heart failure (CHF) and discuss recent changes in prehospital therapy.
• Recognize the signs and symptoms of cardiogenic shock and currently

  You’re called to the residence of an 85-year-old female with mild dyspnea that increases with exertion. She’s very weak and is accompanied by her daughter, who reports that she’s been taking care of her. The daughter reports changes in mentation and increasing weakness over the past three days. She reports no fever, nausea, vomiting, diarrhea, chest pain or other remarkable symptoms. 

The patient has a history of congestive heart failure (CHF) and dementia. Vitals include BP of 182/98, HR 104, RR 18 and SpO2 90% on room air. Auscultation of the lungs reveals coarse and fine crackles over the perihilar regions of each lung and the bases. You also hear mild bronchial wheezing. ECG reveals sinus tachycardia with a right bundle branch block. The patient appears to be in moderate distress, and you believe she’s experiencing an acute exacerbation of her CHF. You begin to treat the patient with oxygen at 15 l/min via nonrebreather mask, sublingual nitroglycerin, morphine sulfate and furosemide. Several minutes later, the patient appears to have decreased respiratory distress, and her crackles become fainter. She is delivered to the local emergency department (ED) without additional issues. Hours later, you return to the same ED with another patient only to find that your patient didn’t have CHF and has since been intubated and admitted to the ICU. Her prognosis looks poor. You’re informed that she had severe pneumonia affecting both lungs.

Cardiac Misdiagnoses & Their Causes Between 2—27% of cardiac patients are misdiagnosed in EDs in the developed world. These misdiagnoses lead to severe complications, one in four of which are lethal.1 In fact, diagnosing a myocardial infarction (MI) in the elderly can be so difficult that in one study, only half of the elderly who had died of an MI had been correctly diagnosed before their deaths.2 The main factors behind these misdiagnoses are lack of the typical presentation of chest pain as a symptom and lack of ST elevation. The risk of death in cardiac patients who don’t experience chest pain is three times higher than in patients experiencing it. The one-year mortality of patients with a “silent MI” is double.1 Studies reveal that 43% of women, 43.7% of patients older than 65 and the majority of those older than 85 didn’t experience chest pain during an MI.2-4 Factors contributing to an atypical cardiac presentation involve advanced age, female gender, underlying disease and even the patient’s race. One study found that Asians are 64—69% more likely than Caucasians to present atypically. These patients are 70% less likely to seek emergency care in a timely manner (within three hours of onset) and are less likely to have a favorable outcome.5 Similarly, women and those older than 85 tend to delay seeking emergency care.6 Women in general, as well as our older patients, often have atypical symptoms that lead them to delay seeking care or lead health-care personnel down the wrong clinical pathway, resulting in greater delays in diagnosis and treatment. These delays in treatment are significant; the 30-day mortality of acute myocardial infarction (AMI) in patients who arrived at the hospital within one hour of onset is 5.6%, while those patients who delayed treatment for more than four hours have an 8.6% jump in mortality rate.6 Delays cost many lives and significantly contribute to poor outcomes.

AMI Acute myocardial infarction (AMI) is often overlooked or misdiagnosed. Those who present atypically often have “anginal equivalent complaints” that providers should be aware of. These include epigastric discomfort, general weakness and other nonspecific complaints. In fact, only 25% of the elderly present with the classic triad of chest pain, ECG abnormalities and serum markers corresponding to their MIs. Nondiagnostic ECG findings are present for 50—75% of elderly patients experiencing MI.2,7 Further, certain medications (like digoxin) can alter the ST segment such that a patient won’t have ST elevation.2 Patients who have an AMI often delay going to the hospital, with 40% waiting longer than six hours past symptom onset.6 This means that the patient has potentially experienced an expanded myocardial injury during this period. EMS providers must attempt to compensate for delay by quickly recognizing the AMI, treating it appropriately and transporting the patient to the appropriate facility. Neuropathies of the autonomic nervous system, cortical failure, damage to cardiac sensory nerves caused by heart disease, increased pain threshold and any comorbidities, including dementia, all contribute to atypical presentations. The most common atypical presentation of the silent AMI is dyspnea. Other likely presentations include general weakness, fatigue, cold sweats or dizziness. Providers also shouldn’t dismiss a syncopal episode as the primary symptom of an MI, as this occurs in 3% of elderly patients and is correlated with high mortality.4 A common site for the referred pain in patients with cardiac ischemia who aren’t experiencing chest pain is the craniofacial area (38—60%). For 6% of patients, this was the only complaint. The most common location is the upper throat (82%). This is followed by the mandible (45%) or the left temporomandibular joint/ear (18%). After craniofacial pain, cardiac patients tend to have referred pain in the left arm or shoulder (20%), followed by the stomach or back (12%).1 High-flow oxygen, 12-lead ECG monitoring, pulse oximetry and capnography should be promptly initiated. Aspirin, a nitrate and morphine should be given as indicated. Fentanyl or heparin are also commonly indicated. Hypotension potentially indicates worsening of the hypoperfusion of cardiac tissues, and a hypotensive MI patient should be transported immediately. Beta blockers and ACE inhibitors are important components in treating an MI and should be utilized when in the provider’s scope of practice. Fibrinolytic treatment is beneficial in the prehospital setting, and patients who are given prehospital fibrinolytics are much more likely to receive them in the two-hour period following symptom onset.8 Fibrinolytics increase the risk of hemorrhage, especially in the elderly, but are shown to be more beneficial than withholding their use in appropriate patients.2 Prehospital providers should keep in mind the goals of door-to-needle fibrinolytic therapy within 30 minutes and door-to-balloon inflation (percutaneous coronary intervention) of 90 minutes.9 In one study of women with AMI, 95% reported prodromal symptoms at least one month before their AMI. The most common symptom was unusual fatigue, which occurred in 70.7% of women. This was followed by sleep disturbances (47.8%), increased dyspnea (42.1%), the feeling of indigestion (39%), anxiety (36%), chest discomfort (30%) and increased confusion or nausea (each as the only symptom in 3% of the elderly).3 These vague symptoms are often benign taken alone but should be taken into consideration when making a field diagnosis.

Congestive Heart Failure CHF is one of the most commonly encountered cardiac emergencies in the prehospital setting. It affects 3 million people in the U.S. every year and is the most common cause of hospitalization in the elderly.10 Typically, pulmonary edema is associated with hypertension or left ventricular damage of such a nature that fluid backs up into the pulmonary system, causing an increased hydrostatic pressure that overwhelms the ability of the lymphatic system to remove the fluid. The fluid then accumulates in the alveoli, causing pulmonary edema and leading to dyspnea, orthopnea, cough, tachypnea and crackles or rales. Other symptoms associated with left-sided heart failure are diaphoresis and altered mental status as the brain becomes increasingly deprived of oxygen. Left-sided heart failure is the most common cause of right-sided (right ventricular) heart failure, which causes fluid to back up into systemic circulation. This backup leads to signs, such as peripheral edema, jugular venous distention, weight gain and tachycardia (in response to decreased cardiac output). Most CHF patients have a combination of left- and right-sided heart failure. CHF is a condition that requires careful monitoring because further deterioration of the heart’s pumping ability has the potential to lead to cardiogenic shock, a condition in which the heart can no longer meet the body’s metabolic needs. CHF is such a sensitive condition that half of all CHF patients die within five years of diagnosis.10 Prehospital treatment of CHF works toward improving oxygenation and increasing cardiac output.10 Capnography, pulse oximetry, oxygen and 12-lead ECG monitoring are indicated early on in treating these patients. However, the former gold standards of EMS treatment of CHF has changed dramatically. It had been thought that BiPAP increases the risk of AMI when used in patients with severe CHF. However, recent studies demonstrate that neither BiPAP nor CPAP contribute to a greater risk of AMI when compared to the oxygen mask.11,12 Patients with severe CHF who are placed on BiPAP and CPAP have a lower intubation rate than those on an oxygen mask. CPAP patients have greater improvement in respiratory rate, arterial pH and increased stroke volume, as well as decreased intubation rates 30 minutes into treatment. Patients who don’t require intubation have lower morbidity and shorter hospital stays than patients who require intubation.11 CPAP is becoming a standard in prehospital respiratory care and providers who have access to CPAP or BiPAP should strongly consider taking advantage of them when indicated. Another factor believed to contribute to poor outcomes in patients with CHF is morphine. CHF patients given morphine are more likely to require mechanical ventilation and have longer hospitalizations and a much greater mortality rate (13% versus 2.4% in acute decompensated heart failure).10,13 Morphine was recommended for these patients because of its effects in reducing preload and afterload as well as decreasing heart rate and anxiety.13 Many clinicians are now arguing that morphine hasn’t been proven to have a clinically beneficial effect on CHF patients, and its continued use in these situations is uncertain.13 Providers should always follow their local protocols. Diuretics, such as furosemide, are also associated with poor short-term outcomes in patients with acute CHF, which some experts believe is the result of toxicity. This leads to hypokalemia, decreased renal function and hypotension.10,12,14 Almost half of all illnesses believed to be CHF in the prehospital setting are misdiagnosed, and most are eventually discovered to be pneumonia. This creates another problem, because furosemide may be detrimental to the pneumonia patient.15 Several studies have suggested that when furosemide is given as a lower dose along with a hypertonic saline solution, the detrimental effects associated with the furosemide may be lessened.16—18 A loading dose of furosemide followed by an infusion might be less detrimental than a high-dose bolus.23 Research in this area is ongoing, and providers should follow local protocols when determining treatment. Normotensive patients without contraindications should receive 0.4 mg nitroglycerin early into treatment; hypertensive patients (systolic BP 140—180 mmHg) should receive a “stacked” dose of 0.8 mg nitroglycerin; and very hypertensive patients (systolic BP higher than 180 mmHg) should receive a stacked dose of 1.2 mg nitroglycerin.10,12 A dose of a nitrate should be repeated every three to five minutes as long as the patient is symptomatic and maintains an adequate blood pressure. Sublingual nitroglycerin is among the best options in CHF because of its speed and efficacy. However, if the patient can’t tolerate the nitrate by mouth (as in a severely dyspneic patient on CPAP) and IV is not available, topical nitrates should be considered.10 Angiotensin-converting enzyme, or ACE, inhibitors are beneficial in the treatment of CHF because they reduce afterload and cause vasodilation. Following the administration of a nitrate, an ACE inhibitor should be administered to the patient when protocols allow.9,10

Cardiogenic Shock Cardiogenic shock is a condition in which the heart is no longer able to maintain the metabolic needs of the body. It typically occurs when greater than 40% of the left ventricle is damaged, and it has a very high mortality rate even with treatment. The prehospital provider can assume that a patient is in cardiogenic shock if they have signs or symptoms of an MI along with a BP of less than 90 mmHg systolic. Altered mental status is common, as are tachydysrhythmias, especially those that are atrial in nature. A lack of peripheral pulses; cool, clammy skin; peripheral edema; and recent history of an MI are also common.9,10 Cardiogenic shock requires prompt recognition and rapid transport to a hospital with advanced cardiac capabilities in order to offer the patient the best chance of recovery. Correct any major dysrhythmias in order to eliminate the dysrhythmia as the cause of the hypotension.10 Pressor support (dopamine) should be administered, along with high-flow oxygen by mask or BVM if ventilatory support is necessary (CPAP should not be used, as it can worsen hypotension), and aspirin if indicated.10,19

Conclusion Cardiac calls are common in EMS and are often considered routine. However, the treatment of cardiac complaints is rapidly changing. As our population ages and becomes more diverse, the typical presentations are no longer typical. EMS providers should be aware of the latest trends in assessment and treatment. JEMS

• Kreiner M, Okeson JP, Michelis V, et al. Craniofacial pain as the sole symptom of cardiac ischemia: A prospective multicenter study. J Am Dent Assoc. 2007;138:74—79.
• Meldon SW, Ma OJ, Woolard R. Geriatric Emergency Medicine. McGraw-Hill: Upper Saddle River, N.J., 2004.
• McSweeney JC, Cody M, O’Sullivan P, et al. Women’s early warning symptoms of acute myocardial infarction. Circ. 2003;108:2619—2623.
• Woon VC, Lim KH. Acute Myocardial Infarction in the Elderly-the differences compared with the young. Singapore Med J. 2003;44:414—418.
• King KM, Khan NA, Quan H. Ethnic variation in acute myocardial infarction presentation and access to care. Am J Cardiol. 2009;103:1368—1373.
• Gurwitz JH, McLaughlin TJ, Willison DJ, et al. Delayed hospital presentation in patients who have had acute myocardial infarction. Ann Intern Med. 1997;126:652—653.
• Hickey CN, Pang PS. How to evaluate the patient with syncope. Emerg Med. 2006;38:15.
• Bjorklund E, Stenestrand U, Lindback J, et al. Pre-hospital thrombolysis delivered by paramedics is associated with reduced time delay and mortality in ambulance-transported real-life patients with ST-elevation myocardial infarction. Eur Heart J. 2006;27:1146—1152.
• Bledsoe BE, Porter RS, Cherry RA. Paramedic Care Principles and Practice. 3rd edition. Pearson, New York, 2009.
• Bledsoe BE. Mastering CHF: Current strategies for the prehospital care of congestive heart failure. JEMS. 2003;34:60—68.
• Levitt MA. A prospective, randomized trial of BiPAP in severe acute congestive heart failure. J Emerg Med. 2001;21:363—369.
• Peacock WF, Fonarow GC. Society of Chest Pain Centers Recommendations for the evaluation and management of the observation stay acute heart failure patient: A report for the Society of Chest Pain Centers Acute Heart Failure Committee. Crit Pathw Cardiol. 2008;7:83—121.
• Peacock WF; Hollander JE, Diercks DB; et al. Morphine and outcomes in acute decompensated heart failure: An ADHERE analysis. Emerg Med J. 2008;25:205—209.
• Butler J, Forman DE, Abraham WT, et al. Relationship between heart failure treatment and development of worsening renal function among hospital patients. Am Heart J. 2004;147:193—194.
• Dobson T, Jensen JL, Karim S; et al. Correlation of paramedic administration of furosemide with emergency physician diagnosis of congestive heart failure. www.jephc.com/full_article.cfm?content_id=539
• Licata G, Di Pasquale P, Parrinello G, et al. Effects of high-dose furosemide and small-volume hypertonic saline solution infusion in comparison with a high dose of furosemide as bolus in refractory congestive heart failure: long-term effects. Am Heart J. 2003;145:459—466.
• Paterna S, Di Pasquale Pietro, et al. Effects of high dose furosemide and small volume hypertonic saline solution infusion in comparison with a high dose of furosemide as a bolus, in refractory congestive heart failure. Eur Journal Heart Fail. 2000;2:305—313.
• Paterna S, Parrinello G, Amato P, et al. Tolerability and efficacy of high dose furosemide and small volume hypertonic saline solution in refractory congestive heart failure. Adv Ther. 1999;16:219—228.
• Goss JF, Zygowiec J. Positive pressure: CPAP in the treatment of pulmonary edema. JEMS. 2006;31:48—58.

End Statement: This article originally appeared in July JEMS as “Anything but Typical.”

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Chapter 16:  Atypical Presentations of Illness

Michael Goldrich; Amit Shah

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General principles, defining atypical presentations.

• Examples of Common Atypical Presentations
• Atypical Presentations of Common Conditions
• An Approach to the Older Adult with Nonspecific Symptoms
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Traditional education of clinicians hinges on typical presentations of common illnesses. The teaching of these classic presentations influences clinicians’ “illness scripts,” or preformed outlines on how a patient should present with a particular disease. Yet, what is often left out from medical training is the frequent occurrence of atypical presentations of illness in older adults. These presentations are termed atypical because they lack the usual signs and symptoms characterizing a particular condition or diagnosis. In older adults, so-called “atypical” presentations are actually quite common and can range from one-fifth to one-half of all presentations. For example, a change in behavior or functional ability is often the only sign of a new, potentially serious illness. Failure to recognize atypical presentations may lead to worse outcomes, missed diagnoses, and missed opportunities for treatment of common conditions in older patients. As in other illnesses, some of the reasons for delayed recognition may also be caused by social factors, such as lack of caregiver, lack of transportation, the fear of being hospitalized, and the risk of losing independence.

The lack of specificity of some atypical presentations, however, can also lead to unnecessary workups, treatments, and hospitalizations. For example, always treating the feared possibility of a bacterial infection in the setting of nonspecific symptoms can prompt improper use of antibiotics that can cause harm to the patient and create drug resistance in the long run. Awareness of atypical presentations of common diseases is fundamental to high-quality care of older adults and also offers a unique opportunity to introduce key geriatric principles to trainees at all levels. Furthermore, identifying atypical presentations of common diseases in the older adult is a recommended minimum geriatrics competency for medical students, internal medicine residents, family medicine residents, surgery residents, and geriatric medicine fellows.

One definition of an atypical presentation of illness in an older person is: when an older adult presents with a disease state that is missing some of the traditional core features of the illness usually seen in younger patients . Atypical presentations usually include one of three features: (1) vague presentation of illness, (2) altered presentation of illness, or (3) nonpresentation of illness (ie, underreporting).

IDENTIFYING PATIENTS AT RISK

The prevalence of atypical presentation of illness in older adults increases with age. With the aging of the world’s population, atypical presentations of illness will represent an increasingly large proportion of illness presentations. The most common risk factors include:

Increasing age (especially age 85 years or older)

Multiple medical conditions (“multimorbidity”)

Multiple medications (or “polypharmacy”)

Cognitive impairment

Residing in a care institution or functional dependence

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Atypical Presentations of CHF

• Published: October 2010
• Cite Icon Cite
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Features of CHF

Pearl: clues and “misclues” to left ventricular failure, mechanisms of left ventricular failure, mechanics of pulmonary edema.

History, Physical and Laboratory Findings, and Course

History and course.

History and Histologic Findings

Two reports of concern.

Only 15% of internal medicine residents are able to detect a phonocardiographically confirmed third heart sound

Left ventricular ejection fraction (EF) is normal in 50% of patients with CHF who are older than 60 years

Typically, EF is normal in older women who have CHF without a history of myocardial infarction

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Chronic heart failure in the elderly: still a current medical problem

Affiliations.

• 1 Department of Medical Education, Jagiellonian University Medical College, Kraków, Poland. [email protected].
• 2 Department of Medical Education, Jagiellonian University Medical College, Kraków, Poland.
• 3 John Paul II Hospital, Kraków, Poland.
• 4 John Paul II Hospital, Kraków; Department of Coronary Disease, Institute of Cardiology, Jagiellonian University Medical College Kraków, Poland.
• PMID: 30745601

Congestive heart failure (CHF) is the final stage in several heart diseases. The diagnosis of CHF in older patients is a challenge. Preserved left ventricular systolic function is a characteristic type of CHF in seniors. The purpose of the study was to characterize elderly patients with CHF and to highlight specific features of the conditions in seniors. e most common etiology of HF in this group of patients is hypertension and coronary heart disease. In seniors atypical presentations of chronic heart failure is much more common than in younger patients. Malnutrition, limitations of exercise and sedentary lifestyles or comorbid diseases have an influence on asymptomatic, early stage of HF. There are better outcomes of treatment in obese individuals. It is called the obesity paradox. Open communication with a patient and his/her family may improve their response to therapy. When heart failure becomes an incurable disease and aggressive treatment is ineffective, palliative care should be considered in end-of-life heart failure patients. The goal of treatment in the remaining moments of life last moments of life should be maximizing the patient's comfort.

Keywords: cachexia; congestive heart failure; palliative care; seniors.

• Aged, 80 and over
• Chronic Disease / therapy*
• Heart Failure / diagnosis*
• Heart Failure / physiopathology
• Heart Failure / therapy*
• Risk Factors

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• J Midlife Health
• v.12(3); Jul-Sep 2021

Atypical Manifestations of Women Presenting with Myocardial Infarction at Tertiary Health Care Center: An Analytical Study

Neethu maria joseph.

Department of Medical Surgical Nursing, College of Nursing, JIPMER and Department of Cardiology, JIPMER, Puducherry, India

Lakshmi Ramamoorthy

Santhosh satheesh.

1 Department of Cardiology, JIPMER, Puducherry, India

Introduction:

Typical chest pain symptoms are the cause that requires individuals to seek out medical care in Acute coronary syndrome(ACS). Evidence suggests, symptoms labelled as 'atypical 'is more common in women with ACS. The present study focuses on the need for the implementation of a gender specific approach in the current scenario by identifying gender based differences that exist in clinical presentations of the patients with ACS. Early identification of women's prodromal and acute symptoms of Myocardial Infarction is an important step in provision of appropriate treatment modality. Present study focus on need for implementation of gender-specific approach in current scenario by identifying gender based differences that exist in risk factors, clinical manifestations in patients presenting with MI.

Methodology:

Cross- sectional analytical study was conducted among 240 Participants (120 males and 120 females). Both men and women diagnosed with MI, who survived, stabilized after admission was included in the study. Consecutive sampling technique was used to select the participants. Data was collected on risk factors profile, clinical manifestations by administering structured questionnaire.

Risk factors such as history of diabetes, history of dyslipidemia was found to be homogenous among both men and women. 60% of men were ever smokers. Hypertension and known IHD was noted to be significant in women (p<0.002, p <0.001) but men presented with higher BMI (p<0.030). Females increasingly presented with atypical presentations when compared to males (p<0.005). Women commonly had squeezing and tightness type of pain and men reported tightness, burning, pricking type of pain (p<0.003). The majority of the women reported the onset of pain occurrence between 6am to 12 pm(p<0.004), whereas men significantly reported the onset of pain between 12 am -6 am(p<0.001).

Conclusion:

Gender based differences in risk factors and clinical presentation in men and women with myocardial infarction had been a focus in researches that emphasized need for focused assessment for women as they increasingly presents with atypical symptoms. The current study also supports the need of a gender specific approach to avoid delay in diagnosis and care of them.

I NTRODUCTION

Cardiovascular diseases (CVDs) are a major threat to the living society as its growth is devastating since decades. Primarily, these diseases occur due to interaction of many risk factors that are associated with an individual and modification of lifestyle plays an important role in improving heart disease.

Coronary artery disease (CAD) develops as a result of plaque deposition within coronary arteries. Formation of blood clot can result due to rupture of plaque causing ischemic changes in myocardium.[ 1 ] Myocardial infarction (MI) occurs as result of prolonged myocardial cell ischemia with involvement of myocardial necrosis. The statistics revealed by the WHO showed an estimation of 17.5 million people died with the cause of CVD, which constitutes about 31% of all global deaths, and cardiac diseases will be leading causes of disability.[ 2 , 3 , 4 ]

Several studies have been conducted in analyzing the epidemiology and case fatality of MI to identify the declining trends of mortality in CVD.[ 5 ] Evidence shows sex-specific patterns and a diverged trend in the incidence of MI with an increased incidence in women and elderly. The cardiovascular disease has perceived to be primarily concerned with men. However, mortality and morbidity of this disease are taking a leading role in women who constitute about 48% of Indian population. Women mostly present with atypical presentations, and higher index of suspicion is required while evaluating women with MI.[ 6 , 7 , 8 ]

M ETHODOLOGY

Cross-sectional analytical study was done among 120 males and 120 females who were admitted with MI in a tertiary care center in south India for the period of 1 year to identify difference in clinical presentation of patients with MI between men and women.

Typical chest pain is defined as sensation of pain in chest, mostly in the retrosternal region with nature of either squeezing, pressing, tightness, burning, heaviness which is radiating to neck, shoulder, and left arm. Other than these symptoms such as dizziness, sweating, shortness of breath, vomiting, palpitation, fainting, back pain, and fatigue was considered as atypical chest pain in this study.

Sample size was calculated in “n master 2.0” by using proportion of atypical clinical features in male and female as 29% and 42%, and considering finite population of MI patients in our settings during study period to be 250, and relative precision of 20%, with power as 80%, it was calculated to be sample size of 120 in each arm including 5% attrition.

Inclusion criteria were both men and women diagnosed with MI, who survived and stabilized. Consecutive sampling technique was used to select the participants. Structured questionnaire was developed as data collection tool. The tool consisted section A which included sociodemographic data, section B included risk factor survey including body mass index (BMI), blood pressure (BP), nature of work, family history of CAD, level of physical exercise, dietary pattern. history of smoking and alcoholism, comorbid illness. Section C included clinical presentation survey deals with description of pain, intensity of pain, location of pain, nature of pain, history of atypical presentation, time and circumstance of onset of pain. Permission was obtained from the Institute ethical committee, human studies, Reg. No: JIP/IEC/2016/1110. Ethical issues involved in the study were less than minimal risk. Informed consent was obtained from every participant after a brief explanation regarding the study by the investigator.

Statistical analysis

To compare the means of BP and weight, independent sample t -test was used. Chi-square/Fisher's exact test was used to compare the clinical characteristics, risk factors profile, location/nature of pain, and comparison of atypical manifestations. Mann–Whitney U-test was used for comparison of description of pain among men and women with MI.

The mean age of the participants was 54 versus 56 years among men and women. Groups were comparable in both systolic and diastolic pressure mean values. The male gender preponderance was noted in regard to higher BMI when compared to women ( P < 0.030). Sedentary lifestyle pattern was prominent in women when compared to men which was significant at P < 0.000. The groups were found to be homogenous in other factors including family history of CAD, exercise pattern, dietary history, and previous history of MI [ Table 1 ].

Clinical characteristics

# Independent sample t -test, *Fisher’s exact test, $ Chi square. SD: Standard deviation, BP: Blood pressure, MI: Myocardial infarction, CAD: Coronary artery disease

History of percutaneous coronary intervention, history of diabetes, and history of dyslipidemia were found to be homogenous among both men and women. Sixty percent of men were ever smokers. With regard to hypertension as comorbidity, there was increased frequency noted in women ( P < 0.002). Furthermore, known ischemic heart disease was observed as comorbidity among women than men ( P < 0.001). Further, 78.3% of female participants have attained menopause. Seventeen had hypertensive disorder during pregnancy, among them 70.6% had taken treatment regimen for hypertensive disorders [ Table 2 ].

Risk factor profile in both genders

# Chisquare test, ** P <0.001, *Bronchial asthma, hypothyroidism, COPD. COPD: Chronic obstructive pulmonary disease, PCI: Percutaneous coronary intervention, IHD: Ischemic heart disease

Location of pain during MI did not vary among men and women including typical symptom of retrosternal pain radiating down left arm (23.7% vs. 24.3%). Although no statistical significance was noted in relation to atypical symptom between the groups, the increased frequency of pain was noted in the upper chest and intrascapular region among women (12.6% vs. 4.4%) [ Table 3 ].

Comparison of location of pain among both genders with myocardial infarction

# Chi-square test

The onset of pain was very abrupt for both men and women. Constant mild chest pain was predominantly reported by men when compared to women, 28.3% versus 15% ( P < 0.011). About 85% of females were presented with atypical manifestations such as dizziness, sweating, shortness of breath, vomiting, palpitation, fainting, back pain, and fatigue ( P < 0.005) compared to 70% in men ( P < 0.005) [ Table 4 ].

Comparison of description of pain among men and women with myocardial infarction ( n =240)

# Mann–Whitney U-test, * P <0.05

The groups were comparable in the perception of severe pain. However, women had more perception of moderate pain, whereas men had more perception of mild pain and overall, it was statistically significant at P < 0.032 [ Figure 1 ].

Comparison of intensity of pain among men and women with myocardial infarction # Mann–Whitney U-test, * P < 0.05. Numerical pain scale (scoring: 1–3 mild pain, 4–6 moderate pain, 7–10 severe pain)

Majority of women reported the onset of pain occurrence between 6 am and 12 pm ( P < 0.004), whereas men significantly reported the onset of pain during 12 am to 6 am ( P < 0.001). Women commonly had squeezing (23.2%) and tightness (40.4%) type of pain whereas men reported tightness (42.6%), burning (34.8%), pricking (4.5%) type of pain which was statistically significant at P < 0.003 [Figures ​ [Figures2 2 and ​ and3 3 ].

Comparison of nature of pain among men and women with

Comparison of time of onset of pain among men and women with myocardial infarction

D ISCUSSION

Age distribution in the current study shows that the mean age of women is higher than men, however, there was no statistical significance in age distribution in both genders ( P < 0.10). This distribution was comparable to findings of a European study where women had presentation of MI in later stage of life.[ 8 ] Duraes et al . had similar findings which showed that the mean age of women was higher compared to men, 60.5 years versus 56.3 years, respectively. The later presentation of MI among women is possibly due to the effect of protective hormone, estrogen in premenopausal stage which slows the progression of atherosclerosis.[ 9 , 10 , 11 ]

The current study shows that mean systolic and diastolic BP is higher among female participants when compared to men but was found statistically nonsignificant. Similar findings reported by Butala et al . showed that mean systolic BP among women was 134.1 and among men was 130.6 ( P < 0.091).[ 12 ] Several contradicting studies reported gender-specific association of higher mean BP among women compared to men. The rising pattern of mean BP among female is assumed to be due to declining estrogen in postmenopausal stage.[ 13 , 14 ]

The present study findings reported higher BMI among males. In contrast to this, numerous studies showed similarity in BMI distribution among men and women.[ 12 , 14 ] The contradicting study findings in regard to BMI distribution may be possibly due to heterogeneity among population in terms of lifestyle, socioeconomic status, and dietary patterns.[ 15 ] Hypertension was significantly noted in women ( P < 0.002). Many previous studies had consistent results showing hypertension as a major risk factor among women.[ 16 , 17 , 18 ]

The study findings show that predominant symptom exhibited by men and women is chest pain. When compared to men, females increasingly presented with atypical presentations such as dyspnea, nausea, vomiting, dizziness, sweating, and back pain ( P < 0.005). In contrast to these findings, Berg et al . reported no significance in atypical presentations such as dyspnea, fatigue, neck pain, and vomiting but showed significant prevalence of nausea, back pain, dizziness, and palpitation among women.[ 19 ]

The present study did not find any gender-specific association in location of pain but shows higher presentation of females with intrascapular pain, this is contrast to earlier results which suggested increased pain in the right upper chest, sternum, and left side of chest in men whereas in women frequently reported pain in jaw, neck, throat, shoulder, left scapula had more frequency pain among men.[ 20 , 21 ]

Women commonly had squeezing and tightness type of pain whereas men reported tightness, burning, pricking type of pain which was significant at P < 0.003. In consistent to the current findings, male presentation of burning type of pain was reported by Bösner et al .[ 22 ]

The present study shows that majority of men had presented with STEMI ( P < 0.004). Several studies reported similar findings of the current study, showing higher prevalence of STEMI among men when compared to women.[ 22 , 23 , 24 , 25 , 26 ]

C ONCLUSION

The current study supports the need of a gender-specific approach in treatment and nursing care of the patients with MI, as the study revealed differences in presentation of MI that leads to the use of over-the-counter drugs and hospitalization delays. An insight to the public has to be made as disparities still exist in the treatment delay even though a complex health-care sector has evolved. This study can be a future reference since primary care physicians should be empowered about these differences so that they can refer the patients in time and the awareness that has to be made into the outskirts of the public regarding the disease presentations so that the treatment delays can be solved to an extent.

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Conflicts of interest.

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