Thursday, June 05, 2008


It was rather busy at the clinic today. Among some of the patients seen today was a lady whom I had seen about 1 month ago on follow up for management of heart failure. She is a septuagenarian, and has severe coronary artery disease with previous heart attacks, which had left her heart muscle severely damaged and unable to contract well. I first saw her a year ago when she was in gross heart failure, got her out of that heart failure with a short hospital stay, and since last year, has been on regular follow-up. Her son is well educated and very concerned about his mother's health ( good son ). He basically supervises her therapy at home. This helps alot as 70 year olds can be rather difficult to be consistent at taking their medications and also their diet. I like usually to allow senior citizens to eat their favourate foods so that they can have a good quality of life. I ask this nice lady to abstain from salt and sauce. There was no restriction on fats ( what is the need for low cholesterol at 70+ years ). When I last saw her in early May 2008, she was well, and weight about 51kg. Her weight today was 58kg. A simple weigh before seeing the doc, will allow me to know quickly that she is not well. Putting on 7 kg in 1 month? Of course, when I begin to take a history, she quickly tell me that she is not well. She had obvious leg swelling, and a history of orthopnea ( breathlessness and coughing when lying down flat at night ). She was obviously breathless and was wheeled into my consult room. Clinical examination revealed obvious signs of heart failure. I tried to probe ( through my history taking ) to try and fond out why she had gone into heart failure over 1 months. There was no clue from her or her son. After explaining to the son, I decided to increase her dose of diuretics, and also started her on an ARB ( Angiotensin Receptor Blocking agent ) and an aldosterone antagonist as well. I wish use this case to illustrate a few points. Firstly, the signs and symptoms of heart failure, which was detailed. Body weight is a simple way to know that the patient is water logged. Acute weight gain must make any medical practitioner think about water retention. Weight assessment is also a good way to assess effectiveness of therapy. Secondly, if is important to make sure that the rapid onset of heart failure in someone who is stable must make you want to know why? Did the patient default on therapy? ( seventy year olds can forget and get mixed up ). Did she take an incidental infection like s URTI, which may have topped her into heart failure? Did she take an incidental heart attack? Well, she had non of the above. The third point that I would like to make is that heart failure is a malignant condition. Patient with class 3 and 4 heart failure, has a 5 year survival rate of 30-40%, almost like that of some cancers. This point is often not well appreciated, and we sometimes do not give heart failure the due respect and intensive attention that it required. I suppose, mild ambulatory heart failure may not fall into this category. Therapy for heart failure is now very good. Diuretics are very effective decongestive agents and allows for rapid symptom relief. ARBs and aldosterone antagonist have been well know to prolong survival. I would have like to use a bit of beta-blocker like bisoprolol or carvidelol, except that I usually like to start them in-patient. I did not feel that this patient merit to be admitted. I suppose that I could also use an ACE-I ( Angiotensin converting enzyme inhibitor ), but I must say that the possibility of cough worries me. If I am in public hospital or if this patient is poor, I may have considered an ACE-I.
Well, I asked her to return to see me in 6 weeks and let us see, how she fares. I hope that she will recover well.

1 comment:

Dan Walter said...

Here is a case of health system failure: