Answer to MA Case Study

The MA Case Study (Part 1 and Part 2) has led to a couple of responses.

Huajern and reader Tien Lee replied.

What is your working diagnosis?
HJ: CCF
TL: LVF/CHF secondary to long-standing diabetes and/or long-standing hypertension

What initial investigations would you order?
HJ: CXR, Echo, renal profile, HbA1c
TL: In order

i. Bed-side ECG, can give indications of CCF aetiology (e.g. LVH for hypertensive changes, conduction problems e.g. heart blocks, etc.)
ii. CXR, looking for cardiomegaly, pulmonary oedema, pleural effusions; helps to also rule-out resp causes, including exacerbation by a lower resp tract infection.
iii. Lab tests:
FBE for anaemia (high output failure), WBC+differentials for signs of possible exacerbating infection -- unlikely otherwise ESR/CRP is also indicated, Renal Function (Urea/Creatinine), EUC (glucose for diabetes, any potential electrolyte causes for heart-failure, e.g. calcium/potassium), HbA1c (for diabetic control). LFT can be done now to assess liver metabolism of later drug treatment.

3. How would you manage this patient?

TL:Patient sounds like he is asymptomatic at rest at the time of presentation.
Frusemide oral 40mg/day.
Aspirin 100mg/day.
Treat diabetes if not controlled with biguanides/sulphonylureas/glitazones.
Treat hypertension with one of the three proven beta-blockers (metoprolol, cardivelol, or bisoprolol) for improved mortality in CCF, in combination with ACE-I.
I would start metoprolol (carvidelol if no regulatory/pricing considerations) and enalapril, after excluding bilateral renal stenosis (bruit?).
Consider Spironolactone, Statin. I would start simvastatin unless there is liver dysfunction; consider pravastatin in that case.
Consider admission for 24-48 hours due to acute development of CHF symptoms. (I would do so.)
Schedule for TTE (trans-thoracic echo) f/u
If investigations discover anything, treat those as appropriate, e.g. arrhythmias, etc.
HJ: frusemide, Ace inhibitors, aspirin

What minor procedure was done 1 year ago?
TL: Not sure. What is meant by dizzy here? Was there any surgical scar on P/E? Perhaps it was a carotid revascularisation, i.e. this patient is suspicious for atherosclerotic disease.

What ECG abnormality is shown in the ECG?
TL: Not sure where the ECG is, but I suspect a left-axis deviation with tall R waves in V5-V6, and tall S waves in V1-V2, adding to over 35mm to suggest LVH; tall left-sided R waves, e.g. >11mm in Lead I. There might be reverse tick/check strain marks (st-depression) on the left-ward leads, e.g. Leads I, AVL, V5-V6. There might also be some signs of left-atrial enlargement with p-waves >3mm on leads II, and inverted p-waves on lead V1.

Huajern also responded to the second post.

First off, we would like to congratulate those who can figure out the ECG without actually seeing it. Psychic doctors are always needed, not so forgetful ones who forget to post a screen grab of the ECG...

Thanks, for the investigations, I would have done the HB, PCV, TWBC. Simple lab test must I need to be sure that he is not anemic and, there is no occult infections like UTI, or pneumonia. Of course, Echo and CXR is correct. I would use IV lasix for rapid diuresis, and oral lasix to follow. The other medications must be to prolong life, once the symptoms come under control, like ACE-I, aldosterone antagonist and perhaps also a beta-blocker like carvidelol. Aspirin will not be important at this stage.

Part 2

I think that ACE-I, oral lasix, aldosterone antagonist, and carvidelol would be reasonable, even to be used longterm Digoxin may not help, as he is in pace-maker rhythm (not AFib) and has not been shown to improve mortality. Coronary angiogram would be reasonable as we try and find a reversible cause for this patient. If Angioplasty is possible, it would offer a reasonable means of revascularisation. Bypass graft surgery is a major undertaking but may be a good choice, if the anatomy is suitable. ACE-I and ARBs are both good agents to improve heart failure, as they have both been shown to improve symptoms and also improve mortality. Usually if my patients has a troublesome cough, I would use an ARB, otherwise ACE-I like captopril (shortterm) and ramipril, in the longterm, would be reasonable.

Once again, apologies for forgetting the ECG.