Review Question - QID 108701

The most likely diagnosis in this patient is left-sided congestive heart failure (CHF), a condition in which the heart cannot sufficiently pump blood into the systemic circulation. In left-sided heart failure, the ejection fraction is decreased and left ventricular end-diastolic volume is increased.

CHF is a condition characterized by an inability of the heart to meet the circulatory demands of the body. There are two types of CHF: left-sided and right-sided. Left-sided heart failure arises because the left ventricle is less efficient at pumping blood into the systemic circulation (decreased ejection fraction). This leads to volume accumulation in the left ventricle (increased left ventricular end-diastolic volume), which backs up into the pulmonary circulation. Clinically, this manifests with exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and persistent coughing due to pulmonary edema. Physical examination and auscultation may reveal bibasilar crackles, a diffuse displaced PMI, and an early diastolic gallop (S3 heart sound).

Figure A demonstrates an enlarged heart silhouette (greater than 1/2 the chest diameter). This indicates volume overload due to a decreased ability to pump blood out of the heart into the systemic circulation.

Incorrect Answers:
Answer 1: An increased ejection fraction and decreased left ventricular end-diastolic volume would be seen in a state of volume depletion. In these cases, preload will be decreased (decreased left ventricular end-diastolic volume) so the heart will attempt to compensate by increasing contractility and ejection fraction.

Answer 2: A preserved ejection fraction and normal compliance are seen in a normal healthy heart. In this patient with exertional dyspnea, orthopnea, and multiple physical exam signs suggestive of heart failure, the ejection fraction would likely be decreased.

Answer 3: A preserved ejection fraction and decreased compliance are seen in diastolic heart failure. This condition arises due to hypertrophic cardiomyopathy and infiltrative myopathies. In these situations, the ejection fraction is preserved but the heart cannot fill completely (decreased compliance).

Answer 5: In this patient with obvious signs of volume overload (pulmonary edema, radiograph, S3 heart sound, and displaced PMI), the left ventricular diastolic volume would be higher, not lower, than normal.

Bullet Summary:
Patients with left-sided CHF often present with exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. Left-sided CHF arises because the heart cannot pump blood effectively into the systemic circulation (decreased ejection fraction) leading to a buildup of volume in the left heart and pulmonary circulation (increased left ventricular end-diastolic volume).