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Long-term smoking
9%
19/222
Uncontrolled Hypertension
82%
182/222
Obesity
2%
5/222
Sleep Apnea
1%
3/222
Acute Myocardial Infarction
5%
10/222
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This patient is presenting with diastolic heart failure secondary to long-term uncontrolled hypertension. The extra heart sound or S4 occurs due to decreased compliance of the left ventricle. Diastolic heart failure occurs in the setting of uncontrolled hypertension due to left ventricular hypertrophy. The left ventricle is forced to generate increased pressure to overcome increased systemic blood pressure. Over time the walls of the left ventricle will remodel to accommodate the increased pressures. The result is a noncompliant left ventricle that is unable to expand and fill appropriately during diastole. The S4 heart sound is a result of the atria attempting to contract against a noncompliant left ventricle. Over time patients will begin to suffer with symptoms of congestive heart failure such as shortness of breath and paroxysmal nocturnal dyspnea. Ebell discusses a risk stratification tool that is currently used to better decipher the risk of mortality during an acute exacerbation of chronic heart failure. Concomitant hepatic cirrhosis appeared to be the biggest risk factor for mortality in these complex patients. McCullough et al. have studied the effect of anemia in patients with chronic heart failure. Their results show that anemia is an independent factor for all-cause mortality and all-cause hospitalization in there patients. Figure A depicts a common EKG finding of left ventricular hypertrophy. Note the increased QRS amplitudes in leads V3, V4, V5, V6. Figure B depicts a characteristic chest X-ray of left ventricular hypertrophy with an enlarged cardiac silhouette. Illustration A depicts a gross heart specimen with left ventricular hypertrophy. Incorrect Answers: Answer 1, 3, 4: While obesity, sleep apnea and smoking all contribute to hypertension, it is the control of the hypertension that is the most significant contributor to this patient's diastolic heart failure. Answer 5: This scenario does not appear to be an acute event. History of myocardial infarction often results in systolic heart failure.
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