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Acute decompensated heart failure in a 56-year old female patient with hypertension, type-2 diabetes, and hyperlipidemia: A clinical case report.



Abstract


This is a case of a 56-year-old woman who has had high blood pressure for 8 years, type 2 diabetes for 6 years, and high cholesterol. She started experiencing worse symptoms, including trouble breathing when active and even when resting, difficulty breathing while lying down, sudden nighttime breathing problems, a dry cough, tiredness, a 3 kg weight gain, and mild chest pain. The initial evaluation of the cardiovascular examination revealed JVD (jugular vein distension), a displaced apex, an S3 gallop suggestive of right-sided heart failure, cardiomegaly, and fluid overload. Respiratory examination, peripheral/NT-proBNP (N-terminal pro-brain natriuretic peptide), creatinine, troponin 1, and BNP/NT-proBNP (B-type natriuretic peptide) have clearly indicated acute heart failure and atrial fibrillation. Treatment included initially administering oxygen, followed by injecting the potent loop diuretic IV furosemide to rapidly remove excess fluid. IV amiodarone is used for rhythm control in AFib (atrial fibrillation).


Keywords: Hypertension, type 2 diabetes mellitus, hyperlipidemia, dyspnea, orthopnea, PND (paroxysmal nocturnal dyspnea), JVD, displaced apex, S3 gallop, cardiomegaly, bibasal crackles, bilateral pitting oedema, atrial fibrillation, and heart failure.


Introduction


Hypertension is a leading cause of heart attacks and strokes. The most visible organ damage related to high blood pressure is left ventricular hypertrophy (LVH). LVH gradually leads to systolic and diastolic heart failure and risk of stroke. To quantify LVH, cardiac MRI (magnetic resonance imaging) is more reproducible and accurate. Regression in LVH is associated with improved cardiovascular outcomes. LVH can be treated by restricting salt, regular exercise and weight loss. Blockade of RAAS (renin-angiotensin-aldosterone system) is effective in LVH regression and decreased atrial fibrillation. Reduction in blood pressure is a vital factor to prevent progression. Mortality and risk of HF (heart failure) hospitalisation remain high.


ARNi (Angiotensin Receptor-Neprilysin Inhibitor), beta-blockers, mineralocorticoid receptor antagonists (MRA) and sodium–glucose cotransporter 2/1 inhibitors (SGLT2/1i) antagonise or modulate neurohormonal activation and additionally have favourable effects on the heart, kidney, vasculature, inflammation, and metabolism. The clinical effects extend to important improvements in quality of life and reductions in the risk of hospitalisation for HF and cardiovascular (CV) or all-cause mortality. Left ventricular hypertrophy (LVH) progresses with age, and is more common in women after menopause. Hypertension, Diastolic dysfunction and LVH are risk factors for stroke and for heart failure in women more than in men. Women are more likely to have a better left ventricular systolic function than men with similar heart failure symptoms. Reversing LVH is a major goal in the treatment of hypertensive patients. The cardioprotective, antifibrotic, and antiarrhythmic effects of spironolactone and eplerenone have proved to be effective in treating symptomatic heart failure and reduced systolic function.


Case Presentation


The patient is a 56-year-old female schoolteacher, urban, and lives with her spouse. She had hypertension for the past 8 years and type 2 diabetes mellitus for the past 6 years and is conditioned with hyperlipidemia. Her father had an MI (myocardial infarction) at 63 years of age; her mother is alive and has hypertension. The patient is a non-smoker, drinks alcohol occasionally, and does not use illicit drugs. The patient is experiencing progressive shortness of breath.


Her physical examination findings are dyspnoea at rest, orthopnoea, PND, dry cough, fatigue, 3.3 kg weight gain, and mild intermittent chest pressure. Temp: 36.7°C, HR: 112 bpm (irregular), BP: 160/80 mmHg, RR: 24, SpO₂: 89%. The patient is experiencing moderate respiratory distress and is conscious and oriented.


Investigations and Diagnostic Tests


Investigations and diagnostic tests have reflected JVD (jugular vein distension), displaced apex, S3 gallop, and no murmur. Bibasal crackles, no consolidation. soft, non-tender, no organomegaly, bilateral pitting edema to mid-shin, cool peripheries. Atrial fibrillation with rapid ventricular response and LVH (left ventricular hypertrophy) criteria. cardiomegaly, bilateral interstitial edema, and small pleural effusions. LVEF (left ventricular ejection fraction) is approximately 35%, with global hypokinesia, moderate left atrial enlargement, and mild functional mitral regurgitation MI.


On admission, her initial reports have shown:


  • CBC normal

  • Hb 12.8 g/dL

  • Na 138 mmol/L and K 4.6 mmol/L

  • Creatinine 1 mg/dL

  • Troponin 1 mildly elevated

  • BNP/NT-proBNP markedly elevated

  • Glucose 180 mg/dL

  • LFTs normal


Treatment Approach


Immediately after her admission to hospital, she was provided oxygen, given IV furosemide and IV amiodarone, and started on oral heart failure medications ACEi (angiotensin-converting enzyme inhibitors), ARNI (angiotensin receptor neprilysin inhibitor) and beta-blockers.


She reacted well to the treatment and showed improved breathlessness, SpO₂ 96% on room air, weight reduced by 4 kg, HR 70 bpm, and AF with controlled rate.


She was asked to have an outpatient review in 2 weeks, a repeat echocardiogram at 6–8 weeks, and a cardiac rehabilitation referral and was advised to have lifestyle counselling for weight, BP, and diabetes.


Discussion


ACE inhibitors are now firmly established as the primary therapy for HFrEF (heart failure with reduced ejection fraction). ARBs' (angiotensin II receptor blockers) primary role is as a replacement for ACE inhibitors in those who are intolerant. Diabetes mellitus exacerbates mechanisms underlying atherosclerosis and heart failure.


Acute Heart failure (AHF) is defined as the appearance or worsening of symptoms and of congestion or systemic hypoperfusion due to a structural or functional heart disease. PPVs are considered best for NT-proBNP to diagnose acute heart failure (AHF). New biomarkers are focused on improving both the diagnostic and prognostic assessment of AHF patients.

HFABP (heart-type fatty acid-binding protein) binding protein ) was shown to be associated with chronic heart failure (CHF) patients. Atrial fibrillation is a sustained arrhythmia, and its occurrence is increasing globally. The ageing population experiences an increased prevalence of atrial fibrillation (AF). In ADHF patients, intravenous diuretics are the best care due to the changes in the absorption of oral diuretics. Subcutaneous furosemide use will replace the need to place intravenous lines and enable management of ADHF at home. The new NT-proBNP test showed it works very well for diagnosing and ruling out acute heart failure in patients who have trouble breathing, and it performed just as well as other trusted tests used in hospitals. For patients with a left ventricular ejection fraction above 40%, beta-blockers have no effect on the incidence of death from any cause, including reinfarction and heart failure.


Sacubitril/valsartan was effective at reducing cardiovascular death and heart failure (HF) hospitalisation throughout the left ventricular ejection fraction (LVEF) spectrum. Amiodarone is an effective antiarrhythmic drug to maintain sinus rhythm for patients with atrial fibrillation. CRP, or C-reactive protein, was associated with all-cause death in patients with AHF, which stands for acute heart failure. β-blockers and ACEi are known to reverse impairments in LV function caused by pathologic remodelling. LCZ696 is very beneficial irrespective of glycaemic status. This case supports the existing observations and research into underlying causes and therapies in HF and recovering systematically from additional lifestyle changes. However, it raises concerns about the complications and side effects of drugs that are intended to be lifesavers but also pose a threat. According to observed data, our case also had given a positive response to the treatments mentioned above, like oral ACE inhibitors, oral inhibitors, oral ARNIs, beta blockers, DOACs, statins and mineralocorticoid receptor antagonists. Besides the best part, the only area to be worked on is lowering the risks of transient hypotension upon usage of high dosages of ACE inhibitors, diuretics, vasovagal syncope, orthostatic hypotension and heavy usage of DOACs, which have a likelihood of haemorrhagic strokes increasing ischemic strokes.


Conclusion


This case underscores that pharmacological therapy alone cannot guarantee optimal outcomes without sustained lifestyle and dietary modifications. Long-standing diabetes and hypertension can silently accelerate cardiovascular deterioration and contribute to multisystem involvement if not addressed early. Timely recognition through appropriate diagnostic evaluation, combined with guideline-directed therapies such as ACE inhibitors (angiotensin-converting enzyme inhibitors), ARNI (angiotensin receptor neprilysin inhibitor), beta-blockers, and DOACs (direct oral anticoagulants), can significantly improve clinical outcomes. However, durable recovery ultimately depends on addressing the underlying metabolic burden through holistic lifestyle interventions. This case emphasises the necessity of early preventive strategies and further research into novel therapeutic approaches that may reduce complications and improve long-term disease management.


Patient Consent and Confidentiality


A written consent form was taken from the patient herself. All identifying data is removed from the report; images used only after ensuring case identity are also kept private. Ethical standards and journal guidelines are strictly followed.


Abbreviations


PND: Paroxysmal nocturnal dyspnoea; LVH: Left ventricular hypertrophy; MRI: Magnetic resonance imaging; RAAS: Renin-angiotensin-aldosterone system; HF: Heart failure; ARNi: angiotensin receptor-neprilysin inhibitor; SGLT2/1i: Sodium glucose cotransporter 2/1 inhibitors; CV: Cardiovascular; LVEF: Left ventricular ejection fraction; BNP: B-type natriuretic peptide; NT-proBNP: N-terminal pro-B-type natriuretic peptide; ACEi: Angiotensin-converting enzyme inhibitors; DOACs: Direct oral anticoagulants; HFrEF: Heart failure with reduced ejection fraction; ARBs: Angiotensin II receptor blockers; MI: Myocardial infarction;


References




About the author


Pallavi is a postgraduate in Microbiology from Kakatiya University and has been teaching NEET aspirants for over 20 years. Engaging deeply with case reports and clinical narratives has allowed her to explore the intricacies of medicine in a meaningful way. Through this work, she combines her scientific background with a passion for storytelling, finding immense satisfaction in translating complex medical insights into accessible and impactful content.


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