Matters of the Heart

Feb 13 2020

Today in the Cardiology Clinic, I saw a patient who was being followed for his valvular disease and had undergone a transcatheter aortic valve replacement (TAVR) a few years ago. He had recently developed worsening symptoms of dyspnea and orthopnea which had actually led him to be hospitalized. His presentation was consistent with congestive heart failure and after responding to diuresis, he was sent home with a new prescription for furosemide. His echocardiogram done in hospital showed normal left ventricular systolic function, and no issues with his aortic valve prosthesis.

Today in clinic, his symptoms were much improved, although his exam still demonstrated signs of fluid overload. In reviewing his case, my preceptor helped guide me through the rationale for his new onset symptoms of heart failure. I realized that although the patient had undergone a valve replacement for his aortic stenosis, the reality is that his heart had been subjected to several decades of high afterload conditions as a result of his obstructive valve disease. In response to this increased afterload, his heart had undergone concentric remodelling and hypertrophy over the years. This was now causing diastolic dysfunction and leading to his symptoms of heart failure.

Knowing the physiologic changes causing his presentation, the key principles for acute management of his impaired diastolic function also become clear. Namely we had to 1) reduce his ventricular rate, using a beta-blocker, to help prolong diastolic filling time and 2) relieve his volume overload, using a diuretic, to help reduce preload. Longer term management options also included treatment of any underlying atrial fibrillation, controlling any hypertension, and use of ACEi/ARBs and aldosterone antagonists to regress left ventricular hypertrophy and optimize circulating volume.

By analyzing the physiology of his disease, I was able to understand what had led to his current presentation, as well as determine the most effective treatment options. I really appreciated that my preceptor encouraged me to explain my thinking process and work through this case. With his guidance, I was able to more fully grasp the case and gained a fulfilling learning experience.

-MB-