A Case Presentation of Acute CHF Exacerbation in the Presence of Several Co-mobordities




Wong, Long
Amlani, Farah M.
Colmenero, Evan


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Purpose: To highlight clinical features and management of congestive heart failure (CHF) exacerbation in a patient with several co-morbidities such as chronic kidney disease (CKD), hypertension (HTN), and diabetes (DM). Methods: A 66 year old African American male with a history of systolic CHF, CKD with anemia, DM, HTN, hyperlipidemia, and tobacco abuse presented to his primary care physician with complaints of fatigue, a cough productive of pink sputum, and intermittent chest pain. For 9 months, he had worsening dyspnea with exertion, cough with chest pain, and orthopnea. On physical exam, lung auscultation revealed 50% rales with diminished breath sounds. 2+ edema was present on the lower extremities bilaterally. An EKG in clinic showed left ventricular hypertrophy. The patient was sent to Plaza Medical for evaluation of CHF exacerbation due to fluid overload while on high dose Lasix and a history of CKD. Results: Labs showed an elevated BUN, creatinine, and BNP. He was anemic with a Hgb of 10.3. Troponins were negative. Initial CXR showed interstitial edema with cardiomegaly and pleural effusions. IV Lasix was started. During his hospital stay, his Hgb dropped to 8.3 and he was started on procrit. Cardiology and nephrology consults were ordered. An echocardiogram showed a dilated left ventricle with an ejection fraction of 25-30% with diffuse hypokinesis. The cardiologist began him on nitrates and digoxin. The nephrologist diagnosed end stage renal disease. A permcath was placed for dialysis. He received 3 treatments of inpatient dialysis. After 6 days, the patient was discharged home and put on outpatient dialysis. Procrit, isosorbide mononitrate, digoxin, hydralazine, and lisinopril were prescribed. The doses of furosemide and simvastatin were increased. Conclusions: Community based studies show that 30-40% of patients die within 1 year of diagnosis of CHF, 60-70% die within 5 years. NYHA class IV patients have a 30-70% annual mortality rate, while NYHA class II patients have an annual mortality rate of 5-10%. Thus, functional status is an important predictor of patient outcome. In our case, the functional status of the patient had deteriorated to the point of hospitalization. In addition, the patient had co-morbidities that affected the functionality of the heart. HTN, CKD, and DM can all play a role in the functional and morphological changes in the heart resulting in CHF. Management of all co-morbidities is imperative to improve patient outcomes.