Case 01/2015 - 66 Year Old Woman with Hypertensive Cardiopathy and Acute Decompensated Heart Failure

In April 2007, laboratory tests revealed the following values: red blood cell 4.7 million /mm3, hemoglobin 13.4 g/dL, mean corpuscular volume 83 fL, leukocytes 7,700/mm3 (51% neutrophils, 2% eosinophils, 39% lymphocytes, and 8% monocytes), platelets 236,000/mm3, cholesterol 196 mg/dL, high density lipoproteincholesterol (HDLC) 39 mg/dL, low density lipoprotein-cholesterol (LDLC) 102 mg/dL, triglycerides 350 mg/dL, glucose 100 mg/dL, creatinine 0.97 mg/dL, urea 41 mg/dL, sodium 143 mEq/L, potassium 4.5 mEq/L, glycosylated hemoglobin 6.3%, thyroid stimulating hormone (TSH) 5.49 μUI/mL, free T4 1.0 ng/dL, AST 22 U/L, ALT 30 U/L, brain natriuretic peptide (BNP) 115 pg/mL, and uric acid 7.3 mg/dL. Serological testing for Chagas disease was negative. Medications included spironolactone 25 mg, carvedilol 6.25 mg, furosemide 40 mg, losartan 100 mg (cough was reported with use of captopril), allopurinol 100 mg, simvastatin 20 mg, acetylsalicylic acid 100 mg, metformin 2,550 mg, glibenclamide 10 mg, and NPH insulin 30 U per day. An echocardiogram on April 26, 2007 showed aortic diameter of 32 mm and left atrial diameter of 44 mm, interventricular septum thickness of 9 mm, posterior wall thickness of 10 mm, left ventricular diameter (systolic/diastolic) of 81/74 mm, ejection fraction of 18%, diffuse hypokinesia of the left ventricle, and normal valves. Myocardial scintigraphy conducted in November 2008 revealed discrete fixed hypercaptation in medial and apical portions of the anteroseptal wall, and there was no redistribution of thallium-201 reinjection. There was diffuse hypokinesia and anteroapical dyskinesia, and the ejection fraction was 11% (Figures 2 and 3). The patient was asymptomatic with controlled blood pressure and no edema until an outpatient consultation in December 2012. In February 2012, another echocardiograph was conducted which showed aortic diameter of 33 mm, left atrial diameter of 54 mm, right ventricular diameter of 27 mm, interventricular septum thickness of 10 mm and rear wall thickness of 11 mm with a left ventricular diameter (systolic/diastolic) of 83/75 mm, left ventricular ejection fraction of 20%, diffuse hypokinesia of the left ventricle, and moderate failure of the mitral valve. Laboratory tests conducted in November 23, 2012 revealed the following values: hemoglobin 13 g/dL, hematocrit 41%, mean corpuscular volume 89 fL, leukocytes 6.040/mm3 (63% neutrophils, 5% eosinophils, 27% lymphocytes, and 5% monocytes), platelet 209,000/mm3, cholesterol 164 mg/dL, triglycerides 275 mg/dL, glucose 125 mg/dL, urea 43 mg/dL, creatinine 0.96 mg/dL, sodium 142 mEq/L, potassium 4.4 mEq/L, AST 17 UI/L, ALT 29 U/L, glycosylated hemoglobin 6.1%, TSH 4.14 μUI/mL, free T4 1.06 ng/dL, prothrombin activation time (PAT) according to the International Normalized Ratio (INR) of 1.1, and activated partial thromboplastin time (aPTT) times of 0.98. An X-ray on June 3, 2012 revealed accentuated cardiomegaly and cephalization of the pulmonary vasculature (Figures 4 and 5). The patient sought emergency medical attention for worsening of dyspnea, which had begun 3 days prior, accompanied by a dry cough and no fever. Patient was taking carvedilol 25 mg, furosemide 40 mg, spironolactone 25 mg, atorvastatin 20 mg, ciprofibrate 100 mg, metformin 2550 mg, acetylsalicylic acid 100 mg, and 30 IU of NPH insulin.