Introduction: We are facing, daily, with patients presenting with heart failure-like symptoms. It is difficult to differentiate a cardiac origin from extracardiac causes of the complaints.
Case presentation: An 80 years old women presented to our emergency room for rest dyspnea and orthopnea.
She was hipertensive and had a history of hospitalizati-on for acute heart failure five month ago, when she has been diagnosed with atrial fibrilation and pulmonary hypertension of unclear cause. On admision in the emergency room: severe dyspnea, neck-vein distension, moderate ankle edema, diffuse crackles, BP 165/70 mmHg, HR 110/min, hypoxemia (oxygen saturation 78% in aa.). Laboratory tests showed: NT-proBNP 2588 pg/ml, compensated respiratory acidosis (PaO2 45 mmHg, PaCO2 51%, normal PH), no anemia, normal renal function. Echocardiography showed normal LVEF and pulmonary hypertension. She was admitted in the cardiology department for acute heart failure.
The pacient received specific treatment for heart failure plus oxygen. The evolution is unfavorable, with hypoxemia and dyspnea. We repeated ecocardiography: normal LV volumes, no hypertrophy, LVEF 60%, stroke volume 60 ml, cardiac index 3l/min/m2, no wall motion abnormalities except flat interventricular septum, left atrium enlargement, pulmonary hypertension (estima-ted PASP 85 mmHg), TAPSE 20 mm, elevated left ventricular filling pressures (E/E´=15,7), mild mitral regurgitation. Chest CT excluded pulmonary embolism and showed pulmonary „ground glass“ infiltrates and pleural effusion that was transudative. Transesophageal echo excluded intracardiac shunt. We cannot explain the etiology of hypoxia. The patient was referred to the pneumologist. Repeated evaluations with pulmonary function tests and blood gases revealed severe obstructive pulmonary dysfunction and possible asthma. She received oral and inhaled corticosteroids, inhaled beta-agonists with some improvement. She goes home without indication for home oxygen use. After a month: little improvement in clinical status, oxygen saturation 90% in aa., NT-proBNP 1751 pg/ml, PASP 65 mmHg, E/E´=10, s septal 6cm/s, more severe obstructive dysfunction. The pneumologist said that the inhalation te-chnique was deficient.
Conclusions: Patients that come in the emergency room for dyspnea have a lot of comorbidities. The ethyological diagnosis and the optimal therapeutic approach for each pacient are very difficult.