Once the heart has experienced CHF (Congestive Heart Failure) and finds it’s balance, there will always be culprits waiting in the shadows to make it come undone. Acute on chronic congestive heart failure or CHF exacerbation is a common admission diagnosis. Our roles do not end with just diuresing the patients & sending them packing home, but also involves deciphering the trigger causing the cardiac decompensation. This is not only important in preventing recurrences but also in unconvering other critcal medical issues.
I had a 85 year old patient with known chronic diastolic heart failure & A-Fib controlled on Diltiazem, Metoprolol, Lasix & anticoagulated on Apixaban after a past TIA history. He was admitted with CHF exacerbation despite controlled heart rate & good adherence to meds. No infection evidence, ECHO done was similar to 2 years ago with preserved EF, no new structural defects. EKG without ischemic changes, Troponin mildly elevated. Other Labs showed Hemoglobin at 10.5 g/dL despite diuresis (baseline was 13-14 until 2 months ago, hemodilution with CHF edema can bring it down some). He did not recall any black or bloody stools but he didn’t always look & check either. He had a black stool on day 3 of his inpatient stay right when he was ready to discharge after diuresis had made him feel normal again. EGD showed a oozing duodenal AVM that was treated.
This case demonstrates why it’s useful to try indentifying the culprit triggering exacerbation in your patients with known Chronic CHF . I recall the common CHF exacerbation causes using ‘HEART FAILS’ Mnemonic 💡 :
H* – Hypertension uncontrolled
E – Emotional distress (stress, anger, severe grief)
A* – AFib & other arrthymias, Acute MI
R – Renal Failure (acute or progressive chronic)
T – Thyroid excess
F* – Failure / Forgetting to comply with diet ( Na, excess fluid ) & meds including using NSAIDs
A – Anemia
I* – Infection, IV Fluids outpatient or previous admission
L – Lung disease (PE , COPD , Pulm HTN)
S – Stenosis / Regurge or Heart valves (progressive)
P. S:The ones marked with “*” are more common.
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