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Elsie Kugel: Discussion

Elsie is an 88 year-old woman with a long history of hypertension who develops pedal edema and shortness of breath on a cruise. The physical examination indicates the syndrome of biventricular congestive heart failure (CHF) with a 10 pound weight gain, elevated blood pressure, elevated jugular venous pressure, cardiac enlargement, gallop rhythm, a new systolic murmur consistent with mitral regurgitation secondary to left ventricular dilation, and dependent edema.

The EKG shows sinus rhythm and left bundle branch bloc identified by wide QRS complexes of .12 seconds or greater, QS complexes in the anteroseptal leads, and absence of S waves in leads 1 and V6. ST elevation noted in the precordial leads is non-specific and can be a persistent finding resulting from the conduction delay alone.

Common causes of LBBB are hypertension and coronary artery disease. LBBB can occur acutely in association with myocardial infarction. The chest x-ray shows cardiomegaly and a pulmonary edema pattern with interstitial and alveolar infiltrates and Kerley B lines in the peripheral mid lung fields.

There are a number of reasons why Elsie may have developed CHF, including an increase in sodium intake in the shipboard meals, and expansion of body water triggered by ambient heat. Physical stress resulting from shipboard activities may have led to ventricular dysfunction or to silent or symptomatic myocardial infarction heralded by nocturnal indigestion on the last night.

If the LBBB is new this may be further evidence of an MI. Finally, the calcium channel blocker nifedipine may have aggravated or precipitated ventricular dysfunction because of it tendency to promote water retention and to inhibit contractility.

Dr. Grey should hospitalize Elsie emergently for monitored diuresis and diagnostic evaluation including cardiac enzymes and an echocardiogram to assess ventricular function. Treatment should include, initially, furosemide to promote diuresis and an ACE inhibitor to reduce blood pressure and improve cardiac performance.

Once CHF has resolved, decisions can be made about adding a low dose selective beta blocker, digoxin, or spironolactone, all of which have been shown to provide benefit to patients with CHF.

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