- Explain the pathophysiology of these findings.
Left heart failure is leading to pulmonary edema and orthopnea. The lower leg edema is more a feature of right heart failure. The "flutter" is a cardiac arrhythmia, often runs of paroxysmal atrial tachycardia (PAT).
- What conditions may have led to this set of findings?
Chronic heart disease: there are many forms of heart disease, all of which eventually lead to cardiac enlargement and heart failure. Damaged, enlarged hearts are more likely to generate dysrhythmias (arrhythmias).
Ischemic heart disease: coronary atherosclerosis of one or more branches can lead to acute events (acute myocardial infarction) or more subtle, chronic damage to the myocardium with cumulative damage from myocardial fiber loss that is more generalized.
Hypertensive heart disease: the increased pressure load leads to increased work for the left ventricle. Thus, left heart failure occurs first, but eventually the right heart fails.
Rheumatic heart disease: the mitral and the aortic valves are most commonly affected. Mitral valvular stenosis with some element of insufficiency develops, with an enlarged left atrium. Aortic involvement with stenosis and/or insufficiency leads to left heart enlargement and failure.
Valvular (stenosis): the most common condition affecting older persons is senile calcific aortic stenosis. The aortic valve leaflets gradually calcify, leading to stenosis and left heart failure.
Minor arrhythmias are more common in the elderly, including a substantial prevalence of supraventricular ectopic beats (atrial ectopic beats) and ventricular ectopic beats.
- What is the role of hospice care in this case?
The underuse of hospice is a big ethical issue. Any patient with CHF will eventually progress to a bedridden state, or if the patient is not bed bound is unable to do anything more than transfer to a chair and to the bathroom. At that point it is likely that survival is less than a year, and one should suggest things like a referral to hospice as well as making out a will and a 'living will.'
Some may think hospice is a place, but it is a treatment philosophy. It may mean going to a hospice facility (and those are often very nice places), but over half of hospice patients now stay at home and receive hospice care delivered in their home by visiting nurses and an occasional house call by the medical director. What distinguishes hospice care is usually the inclusion of things like spiritual counseling, art and music therapy, and aggressive pain control, especially the generous use of opioids when called for and the correct management of their side-effects. While you may think opiates just for pain, they are also important for treating air hunger, the most distressing symptom of CHF.
