Congestive Heart Failure (CHF)


Article Author:
Ahmad Malik
Daniel Brito


Article Editor:
Lovely Chhabra


Editors In Chief:
Chaddie Doerr


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
6/3/2019 2:26:23 PM

Introduction

Heart failure is a common and complex clinical syndrome that results from any functional or structural heart disorder, impairing ventricular filling or ejection of blood to the systemic circulation to meet the body's needs. Heart failure can be caused by diseases of the endocardium, myocardium, pericardium, heart valves, vessels or metabolic disorders. Most patients with Heart failure have symptoms due to impaired left ventricular myocardial function. Patients usually present with dyspnea and fatigue limiting exercise tolerance, fluid retention characterized by pulmonary and peripheral edema.

Heart failure due to left ventricular dysfunction is categorized according to left ventricular ejection fraction (LVEF) into heart failure with reduced ejection fraction (LVEF 40% or less), known as HFrEF and heart failure with preserved ejection fraction (LVEF greater than 40%); known as HFpEF.

Etiology

Heart failure is caused by several disorders, including diseases affecting the pericardium, myocardium, endocardium, cardiac valves, vasculature, or metabolism.

The most common causes of systolic dysfunction (HFrEF) are idiopathic dilated cardiomyopathy (DCM), coronary heart disease (ischemic), hypertension, and valvular disease. For diastolic dysfunction (HFpEF), similar conditions have been described as common causes, adding hypertrophic obstructive cardiomyopathy, and restrictive cardiomyopathy.

Epidemiology

Approximately 5.1 million people in the United States have clinically manifest heart failure, and the prevalence continues to increase. Heart failure incidence has remained stable over the past decades, with more than 650,000 new cases heart failure cases diagnosed annually, especially for individuals greater than 65 years of age. Because prevalence is greater in this age group, heart failure is expected to worsen in the future.Epidemiological differences have been noted. Black men have the highest incidence rate (1000 person-years) for heart failure and the greatest five-year mortality rate when compared to whites. White women represent the lowest incidence. Heart failure in non-Hispanic black males and females has a prevalence of 4.5% and 3.8%, respectively, versus 2.7% and 1.8% in non-Hispanic white males and females, respectively. Although survival has improved, the absolute mortality rates for patients with heart failure remain approximately 50% within five years of diagnosis.

By 2013, heart failure costs in the United States exceeded $30 billion.

Pathophysiology

The adaptive mechanisms that may be adequate to maintain the overall contractile performance of the heart at relatively normal levels become maladaptive when trying to sustain adequate cardiac performance. The primary myocardial response to chronically increased wall stress is myocyte hypertrophy, death due to apoptosis, and regeneration. This process eventually leads to remodeling, usually the eccentric type, and reduced cardiac output, causing a cascade of the neurohumoral and vascular mechanism.

Decreased carotid baroreceptor stimulation and renal perfusion will activate the sympathetic nervous system and Renin-Angiotensin-Aldosterone system. 

Sympathetic nervous system activation will cause increased heart rate and inotropy, leading to myocardial toxicity. Renin-Angiotensin-Aldosterone system activation leads to vasoconstriction, increasing afterload (angiotensin II) and hemodynamic alterations, increasing preload (aldosterone).

All of these mechanisms will cause negative remodeling and worsen the left ventricular function, causing symptoms of heart failure.

History and Physical

Symptoms of heart failure include those due to excess fluid accumulation (dyspnea, orthopnea, edema, pain from hepatic congestion, and abdominal distention from ascites) and those due to a reduction in cardiac output (fatigue, weakness) that is most pronounced with physical exertion.

Acute and subacute presentations (days to weeks) are characterized by shortness of breath at rest and/or with exertion, orthopnea, paroxysmal nocturnal dyspnea, and right upper quadrant discomfort due to acute hepatic congestion (right heart failure). Palpitations, with or without lightheadedness can occur if patient develops atrial or ventricular tachyarrhythmias

Chronic presentations (months) differ in that fatigue, anorexia, abdominal distension, and peripheral edema may be more pronounced than dyspnea. The anorexia is secondary to several factors including a poor perfusion of the splanchnic circulation, bowel edema, and nausea induced by hepatic congestion. 

Characteristic features:

  • Pulsus alternans phenomenon characterized by evenly spaced alternating strong and weak peripheral pulses.
  • Apical impulse: laterally displaced past the midclavicular line, usually indicative of left ventricular enlargement.
  • S3 gallop: a low-frequency, brief vibration occurring in early diastole at the end of the rapid diastolic filling period of the right or left ventricle. It is the most sensitive indicator of ventricular dysfunction.

Evaluation

Tests include:

  • Electrocardiogram (ECG): important for identifying evidence of acute or prior myocardial infarction or acute ischemia, also rhythm abnormalities, such as atrial fibrillation. 
  • Chest x-ray: characteristic findings are cardiac-to-thoracic width ratio above 50%, cephalization of the pulmonary vessels, Kerley B-lines, and pleural effusions.
  • Blood test: Cardiac troponin (T or I), complete blood count, serum electrolytes, blood urea nitrogen, creatinine, liver function test and brain natriuretic peptide (BNP). BNP (or NT-proBNP) level adds greater diagnostic value to the history and physical examination than other initial tests mentioned above.
  • Transthoracic Echocardiogram:  to determine ventricular function and hemodynamics.

Treatment / Management

Diuretics, beta-blockers, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor neprilysin inhibitor, hydralazine plus nitrate, digoxin, and aldosterone antagonists can produce an improvement in symptoms

Prolongation of patient survival has been documented with beta blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor neprilysin inhibitor, hydralazine plus nitrate, and aldosterone antagonists. More limited evidence of survival benefit is available for diuretic therapy. Replace an angiotensin converting enzyme inhibitors or angiotensin receptor blockers by angiotensin receptor neprilysin inhibitor in chronic symptomatic patients with CHF NYHA class II-III with an adequate blood pressure who are tolerating an optimal dose of these medications. Angiotensin receptor neprilysin inhibitor should not be given within 36 hrs of angiotensin converting enzyme inhibitors dose.

In African-Americans, hydralazine plus oral nitrate is indicated in patients with persistent NYHA class III to IV HF and LVEF less than 40%, despite optimal medical therapy (beta-blocker, angiotensin converting enzyme inhibitors, ARB, aldosterone antagonist (if indicated), and diuretics.

Device therapy: implantable cardioverter-defibrillator (ICD) is used for primary or secondary prevention of sudden cardiac death. Cardiac resynchronization therapy with biventricular pacing can improve symptoms and survival in selected patients who are in sinus rhythm and have a reduced left ventricular ejection fraction and a prolonged QRS duration. Most patients who satisfy criteria for cardiac resynchronization therapy implantation are also candidates for an implantable cardioverter-defibrillator and receive a combined device.

A ventricular assist device (bridge to transplant or as a destination therapy) or cardiac transplant are reserved for those with severe disease despite all other measures.

Pearls and Other Issues

To reduce heart failure hospitalizations, it is reasonable (class IIa) to use Ivabradine in patients with NYHA II-III with guideline-directed medical therapy (including a beta-blocker) and heart rate of more than 70 bpm.

Heart failure disease management is a complex condition that requires a multidisciplinary framework for the care of patients, including discharge planning, patient education, and frequent outpatient assessment.

Enhancing Healthcare Team Outcomes

Heart failure is a serious disorder that is best managed by a multidisciplinary team that includes the primary care physician, emergency department physician, cardiologist, radiologist, cardiac nurses, internist, and a cardiac surgeon. It is imperative to treat the cause of heart failure. Healthcare workers who look after these patients must be familiar with current guidelines on treatment. The risk factors for heart disease must be modified and the pharmacist should educate the patient on the importance of medication compliance. When the condition is not managed appropriately, it is associated with high morbidity and mortality, including a poor quality of life.[1]


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Congestive Heart Failure (CHF) - Questions

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What diagnosis is suggested by a chest radiograph that shows peribronchial cuffing, pleural effusions, septal lines, symmetrical bilateral perihilar batwing distribution of air-space disease, and cardiomegaly?



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A patient with congestive heart failure is hemodynamically stable but still symptomatic. Which of the following should be started?



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A patient with congestive heart failure is started on furosemide. He should also be placed on what other drug?



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A radiologist reports that there is peribronchial cuffing in a patient one day post abdominal surgery. What is the most likely cause?



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A patient has uncontrolled congestive heart failure, but has no insurance and neither does he have reliable transport to the doctor's office. He is on digoxin for tachyarrhythmias. Which medication would be the best treatment?



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In a 65-year-old patient with congestive heart failure, symptoms can be treated with several medications. What is often combined with diuretics?



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In an individual who has hemosiderin-laden macrophages in the bronchoalveolar lavage, what one would suspect?



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A 68-year-old had a bowel resection surgery four days ago. She is now breathless and has basilar crepitus. Urine output over past 12 hrs is about 100 ml and she is in positive balance. Her weight is up by 2.3 kg since her surgery. What is the next best step in her management?



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A 71-year-old has suddenly developed congestive heart failure. An echocardiogram shows an ejection fraction greater than 25%. Which of the following drugs is most likely to precipitate acute heart failure?



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A 69-year-old patient with diabetes mellitus and severe chronic obstructive pulmonary disease develops congestive heart failure. The echocardiogram shows an ejection fraction of less than 30%. Which group of medications would be used to extend life?



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What is the most beneficial effect of angiotensin-converting enzyme inhibitors in patients with congestive heart failure?



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What is the best way to differentiate acute respiratory distress syndrome (ARDS) from congestive heart failure (CHF)?



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Which of the following groups of drugs has been shown to reduce mortality in patients with congestive heart failure?



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What heart sound would one expect to hear in a patient with congestive heart failure (CHF)?



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What does a positive hepatojugular reflex indicate?



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A 71-year-old with congestive heart failure is admitted to the intensive care unit. He is treated with diuretics, oxygen, and a nitroglycerin drip. Over the next few days, he improves and is transferred to a medical floor. The practitioner places him on a drug class that has been shown to reduce mortality in patients with congestive heart failure. What is the most likely drug class?



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What additional medication should be initiated in the case of a elderly male recently hospitalized for shortness of breath and diagnosed with congestive heart failure who is on aspirin and simvastatin?



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Which of the following adjustment should be made to the regimen of an elderly white female with history of congestive heart failure with an ejection fraction of 30% on an ACE inhibitor, a beta-blocker, and a loop diuretic with a well controlled blood pressure but who is experiencing orthopnea and is found to have pulmonary rales and pitting edema peripherally?



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Of the following medications, which one has been shown to decrease mortality in cases of congestive heart failure (CHF)?



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A 72-year-old man with a recent history of a large anterior wall myocardial infarction presents with complaints of dyspnea on exertion, orthopnea, and increasing pedal edema. There is concern about congestive heart failure. Which of the following would support the diagnosis?



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Which is the most common cause of congestive heart failure in a 70-year-old male?



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A 65-year-old female has been diagnosed with New York Heart Association (NYHA) class I heart failure. She currently is taking aspirin and simvastatin. What additional medication should be initiated?



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A symptomatic patient presents with shortness of breath and a history of left ventricular hypertrophy. His b-type natriuretic peptide (BNP) is elevated at 518 pg/mL. Which of the following is the most likely diagnosis?



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According to the New York Heart Association classifications for congestive heart failure, which of the following describes Class I heart failure?



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In a patient with congestive heart failure, alcohol use disorder, anemia, hypertension, and diabetes mellitus, treatment of which of her comorbid diseases is most likely to result in functional improvement of her congestive heart failure?



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Which of the following would facilitate the outpatient care of a patient with congestive heart failure (CHF)?



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What lung pathology is associated with crackles on auscultation?



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A 65-year-old patient presents with basilar rales and is also found to have cool, clammy skin, elevated jugular venous pressure, rales and a third heart sound. The physical findings are best characterized as which of the following?



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What is the goal in the treatment of a 72-year-old with congestive heart failure?



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What additional medication should be initiated in a 66-year-old male recently hospitalized for dyspnea and diagnosed with systolic congestive heart failure (CHF) who is on aspirin and atorvastatin?



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A 73-year-old female with a history of congestive heart failure (CHF) has an ejection fraction of 30 percent. She is on an angiotensin converting enzyme (ACE) inhibitor, a beta blocker, and a loop diuretic with a well-controlled blood pressure. However, she is still experiencing orthopnea. On physical exam, she has pulmonary rales and pitting peripheral edema. What is the next best step?



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A patient presents with shortness of breath. Rales are heard in the lower lung fields. There is an S4. Hepatojugular reflux is present. Chest radiograph shows cardiomegaly and enlargement of the mediastinal veins. Congestive heart failure is suspected. Reduced blood in the ascending aorta would not cause decreased blood flow in which of the following arteries?



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A white male patient is diagnosed with congestive heart failure (CHF). Current medications include carvedilol and furosemide. But he continues to be symptomatic. What medication should be added?



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Which medication should be added to metoprolol and hydrochlorothiazide in a patient with congestive heart failure (CHF) and uncontrolled hypertension?



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A 70-year-old patient complains of dyspnea, especially with exertion, orthopnea, and swelling in the legs. On exam the findings are jugular venous distension (JVD), a large apical impulse, and crackles in the bases of both lungs, as well as bilateral pedal edema. Which of the following is the best treatment?



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Which of the following diuretics prolongs survival in patients with congestive heart failure?



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A 60-year-old female has had a 4-month history of progressive symptoms including dyspnea on exertion, pedal edema, and 2 pillow orthopnea. The exam is consistent with congestive heart failure. Echocardiogram shows left ventricular dilation, mitral regurgitation, and an ejection fraction of 25 percent. Select the least probable finding.



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Select the intervention for congestive heart failure (CHF) that reduces hospital admissions and health care costs.



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What is the most common cause of acute left ventricular heart failure?



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The New York Heart Association (NYHA) Class III states which of the following regarding physical activity?



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Patients with heart failure with no limitation of physical activity are in which New York Heart Association (NYHA) class?



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Which New York Heart Association (NYHA) class best describes patients with heart failure symptoms at rest who are unable to carry out any activity without discomfort?



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The reduction in cardiac output seen in congestive heart failure is a consequence of which of the following?



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In what New York Heart Association (NYHA) category is a patient with congestive heart failure (CHF) who has marked limitation of physical activity?



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A patient is seen at home following hospitalization for pneumonia. At the initial visit, the patient still has a dry cough and uses one pillow because she cannot lie flat. Two days later, the patient is short of breath at rest, has gained 5 pounds, and can only sleep using three pillows. What is the most likely diagnosis?



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Which cardiac condition is most likely to have ankle edema?



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The diagnosis of congestive heart failure depends on which of the following key diagnostic tests?



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What is the most common cause of congestive heart failure?



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A 72-year-old man with a history of ischemic heart disease requires an elective surgical procedure. Which of the following is a valid reason for delaying surgery?



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What is the major goal in the treatment of a patient with heart failure?



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A man is admitted to the hospital. On exam, he has three plus pitting edema of the legs bilaterally and shortness of breath with minimal exertion. No chest pain or fever. What is the most likely diagnosis?



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Upon discharging a patient admitted for heart failure exacerbation, which of the following may facilitate care of the patient's heart failure in the future?



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Which of the following lung findings would be expected in a patient with pulmonary edema secondary to congestive heart failure?



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Which electrolyte is retained with congestive heart failure (CHF)?



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Which of the following types of drugs have been shown to decrease mortality in patients with systolic heart failure?



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Which of the following, when elevated, will result in filtration of serum out of pulmonary capillaries and into alveoli?



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A 67-year old with a history of ischemic heart disease is undergoing surgery for an incarcerated inguinal hernia. Postoperative he is a little confused, and his urine output diminishes to 100 ml/day on the third post-operative day. Late that night he becomes dyspneic, but his ECG reveals only non-specific changes. Chest auscultation reveals basilar crackles. A central line reveals a CVP of 10 and his BP is 110/80, P 110, and pulse oximeter reading of 91. What is the ideal treatment for him?



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A 65-year old male recently underwent a difficult colon resection and is in the intensive care unit with signs of heart failure. His urine output had dropped to less than 10 mL/hr, and he has developed significant edema and ascites. His ejection fraction is about 40%, but his renal function seems intact. Which of the following may be of the most benefit to him?



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Which of the following is an expected finding in a patient with congestive heart failure exacerbation?



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An elderly male is in the clinic for his monthly blood workup. He has had chronic heart failure for several years with an ejection fraction of 35%. He has been treated by his primary provider for years with many types of cardiac medications. Based on current literature evidence, to reduce his morbidity, which of the following combination therapy is now recommended?



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A patient suffered an anterior wall acute myocardial infarction. Which of the following are expected signs and symptoms of left-sided heart failure? Select all that apply.



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An elderly client has been admitted to the cardiology floor with heart failure. During the physical assessment, what features will the nurse most likely notice? Select all that apply.



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A client is being seen in the emergency department and heart failure is suspected. What diagnostic study would be expected for the initial evaluation in the emergency department? Select all that apply.



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A 68-year old female with diabetes mellitus is admitted to the intensive care unit with shortness of breath. A workup reveals the client has developed severe congestive heart failure. Nursing assessment findings supporting this medical diagnosis include weight gain of 3 kg in 2 days, a respiratory rate of 32 and labored, and the presence of profuse diaphoresis. Which of the following nursing interventions and prescriptions may be of benefit for this particular client? Select all that apply.



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A patient presents with chronic fatigue and trouble breathing. Upon inspection, you note peripheral edema and significant jugular venous pressure. The patient has had longstanding hypertension with exertional fatigue, which has been worsening over the past several years. The patient has not been adherent to medications. What is the most common cause of this patient's heart failure?



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A patient presents with complaints of fatigue and shortness of breath. The patient says this has been worsening for the past several months, and they have begun to notice swelling in their legs. The past medical history includes a myocardial infarction with subsequent heart catheterization 6 years ago. The patient also has longstanding hypertension and is not adherent with medications at this time. An echocardiogram shows an ejection fraction of 35%. What is the most likely diagnosis?



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A 60-year-old obese female with congestive heart failure (CHF) presents to her primary care provider with a complaint of increased abdominal girth. She has noticed this take place over the last week and is making her feel self-conscious of her appearance. She reports shortness of breath, constipation, and abdominal discomfort, but denies nausea and vomiting, or any changes in appetite. She also reports a history of cholecystectomy and frequently experiences constipation. Physical examination reveals jugular venous distension, pulmonary crackles, a distended abdomen that is non-tender, and bulging flanks. The liver is non-palpable. Which of the following is the best assessment of this patient?



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Congestive Heart Failure (CHF) - References

References

Shu Q,Wu L,Zhang R,Zhang Q,Huang J,Meng Y, Age-dependent changes in cardiac performance, motor function, QoL, and mental status in metoprolol-treated chronic heart failure patients. Scientific reports. 2019 Jan 24;     [PubMed]

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