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Case 380


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A 72-year-old male was admitted to the hospital after presenting with chest pain, progressive dyspnea, nausea and peripheral edema. Physical examination demonstrated adequate blood pressure levels and peripheral perfusion. Electrocardiography did not indicate any acute abnormality, and troponin levels were normal. Transthoracic echocardiography showed left ventricular ejection fraction of 42%, left ventricle segmental contractility alterations and mild systolic dysfunction. Previous history of two myocardial infarctions without ST elevation and right coronary angioplasty. Chest radiograph was performed.

Considering the previous history and the current clinical-hemodynamic repercussions, what is the most appropriate therapeutic approach?

a) Intravenous vasodilator and diuretics


b) Vasodilator, diuretics, inotropic/vasopressor agents and intensive care support


c) Fluid replacement and inotropic agents


d) Angioplasty


Image analysis


Image 1 - Analysis: Chest radiograph, posteroanterior view, demonstrates radiographic features linked to pulmonary congestion, which can be graded into stages:

- Redistribution: Imaging shows enlarged cardiac area (increased cardiothoracic ratio, which corresponds to the ratio of maximal horizontal cardiac diameter to maximal horizontal thoracic diameter). It also demonstrates increased pulmonary vascular network with redistribution of the pulmonary veins, which is also known as cephalization (red arrows).

- Interstitial edema: Subtle interlobular septal thickening - Kerley B (yellow arrow) and C (purple arrows) lines.

- Alveolar edema: Bilateral pleural effusion - left (in blue) and right (in green).


  • Image 2 - Analysis: Chest radiograph, lateral view, demonstrates subtle septal thickening (Kerley D lines, orange arrows) and bilateral pleural effusion, highlighted in blue (left) and green (right). Non-absorbable sternal surgical sutures are marked in pink.



  • - Acute decompensated heart failure is a clinical syndrome of new or worsening signs and symptoms of heart failure.

  • - The main precipitating factors include nonadherence with drugs and diet, infection, rhythm disturbances, myocardial ischemia and severe physical or emotional stress.

  • - Clinical manifestations include progressive dyspnea, peripheral edema and other symptoms of congestion.

  • - Clinical and hemodynamic presentations may vary. They can be categorized according to adequacy of peripheral perfusion (“warm” or “cold”) and the presence of congestion;

  • - The diagnosis is based on clinical investigation and supported by further testing, which should include electrocardiogram, serum troponin, chest radiograph and echocardiography. Natriuretic peptide levels may help if the diagnosis is uncertain.



Meyer TE. Approach to diagnosis and evaluation of acute decompensated heart failure in adults [internet]. 2019. [Accessed: February, 2020]. Available in:

Colucci WS. Treatment of acute decompensated heart failure: Components of therapy [internet]. 2020. [Accessed: February, 2020]. Available in:

Cremers S, Bradshaw J, Herfkens F. Chest X-Ray - Heart Failure [internet]. 2010. [Accessed: March, 2020]. Available in:

Mangini S, Pires PV, Braga FGM, Bacal F. Insuficiência cardíaca descompensada. Einstein (São Paulo); 2013 Set 01; 11(3):383-91. [Accessed: March, 2020]. Available in:



Ana Luísa Melgaço Almeida, 6th year medical student at Universidade Federal de Minas Gerais.

E-mail: analuisamelgaco[at]




Vinícius Tostes Carvalho, Echocardiography Specialist and Adjunct Professor of the Department of Internal Medicine at the Medical School of Universidade Federal de Minas Gerais

E-mail: v-tostes[at]


Júlio Guerra Domingues, Professor of the Department of Anatomy and Imaging at Medical School of Universidade Federal de Minas Gerais

E-mail: jgdjulio[at]



Larissa Rezende, Mirella Diniz, Mateus Nardelli


Translated by

Ana Luísa Melgaço Almeida, 6th year medical student at Universidade Federal de Minas Gerais.

E-mail: analuisamelgaco[at]

Test question

UDI HOSPITAL – MA (2017) Which are the main precipitating factors of cardiac decompensation in chronic hypertensive heart failure?

a) Progressive cardiomyopathy and right ventricle infarction


b) Infection and nonadherence to diuretics and vasodilator therapy


c) Pericarditis and chronic systemic inflammation


d) Anemia and myocardial infarction


e) Acute myocarditis and worsening of myocardial ischemia



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