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Last year, I had a 52 year old man come in with shortness of breath.

This is a fairly common complaint in the urgent care. Asthma attacks help keep the lights on at a clinic like this (our accountant asks parents to yes, please, keep smoking around your kids), and the patient did have a history of mild asthma. However, his usual inhaler pump isn’t working. His shortness of breath (yes, we abbreviate it “SOB”; giggle away) has been getting progressively worse over the past 2 weeks or so. It is much worse at night time or when he has to take the stairs. He also noted a weight gain of “at least” 25 pounds over the past month. He denied any pains, fevers, urinary or stool problems, head or sinus congestion, or recent travel. He maybe had a slight cough. He’s also had swelling of the ankles develop. His chronic medical issues included mild asthma and mild hypertension. His blood pressure today was 138/90. His oxygen level was 94%.

BY THIS POINT I WAS 100% SURE OF THE DIAGNOSIS. WHAT IS YOUR GUESS?

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New-onset congestive heart failure (CHF)

traffic jam

I was fortunate to have ultrasound available that day, so I had the tech do an echocardiogram while awaiting the ambulance to arrive. One measure of heart function is something called “ejection fraction,” which is a measure of how much of the blood volume of the heart’s biggest chamber gets pumped out into your body with each heartbeat. This is normally above 60%; you definitely want it above 50%. The patient’s EF was 26%.

I explained to the patient that when your heart stops being able to do its job, its best to think of your blood turning into a worsening and worsening traffic jam. Imagine there is one major highway in your town; only there is a massive pileup. Cars get slowed down and congested behind the pileup; too little traffic is flowing after it.

This leads to all kinds of complications when the “pileup” is your ticker quitting on you. For one thing, not enough blood gets out to your body, leaving you overly exhausted from even mild exertion. But on the other hand, that blood is still there in your body. It didn’t just disappear. So, it gets backed up the worsening wreck of your left ventricle. But what’s behind the ventricle?

labeled_internal_heart_anatomy

The left side of the heart receives its blood flow from the lungs. This is because, as Captain Obvious could tell you, it is the job of the lungs to provide your blood with oxygen before it gets pumped out to the rest of your body.

But if the left ventricle has decided it’s just tired of its whole “pumping” job, that blood from your lungs is not getting pushed out fast enough. So, just like with a traffic jam, it gets backed up the pulmonary veins, all the way to the lungs.

And your blood is majority-water, which becomes an issue when it’s not moving, as any homeowner who’s ever had a sewage overflow can attest. Whenever you have a situation where blood is just sitting there in part of your body, not moving, a common side effect is the water escaping out of the blood vessels into a nearby organ. In this case, the lungs.

It turns out, water in the lungs is NOT conducive to breathing well. Hence, the patient’s SOB.

But if his blood is having trouble moving throughout his body (because the right ventricle is also embracing the part-time-employment lifestyle), water escapes his blood vessels just all over the place, like car drivers getting sick of the traffic jam and leaving the highway to use the side roads. This leads to generalized swelling or, in medical parlance, “third spacing,” usually most evident in the belly and the ankles. The patient is able to replace the lost water by drinking more, but that water just leaks out of the blood vessels again, to be replaced by more water… so the edema leads to weight gain.

Now, there are other ways to get rid of all this excess water. The kidneys, for instance. But they must be induced to get rid of far more water than they’re used to. Thus, the introduction of the diuretic, or “water pill,” that is such an essential part of a CHF patient’s med list. He gets rid of all that fluid in his lungs, belly and legs by literally peeing it out.

How else do you treat CHF, once you get the water off? Your first instinct may be to look for medicines to get the heart pumping harder again, and in fact, that was indeed what cardiologists once did. But by making your heart slave away harder than it really can, it wears out faster… so patients on such medications like digoxin actually can wind up dying sooner than expected. It can still be used in selected cases to reduce CHF symptoms, but most cardiologists are averse to increasing the heart’s workload if they can help it.

So paradoxically, most cases of CHF are treated by resting the heart as much as possible, to preserve its remaining function for as long as possible. This is typically done with beta blockers such as Coreg, the cardiologist’s favorite. (In fact, if you see a new patient who’s on that specific beta-blocker, you can assume something’s wrong with her ticker until proven otherwise).

Now, there’s one question still lingering with this patient: what exactly caused his CHF to begin with? Being an urgent care doctor, I never got to find out as usual. Uncontrolled hypertension and heart attacks are two of the most common causes, although there are plenty of others. Many are avoidable; some, unfortunately, are not. If you have family members who developed heart disease, especially at a younger age (< 65), you must let your primary care provider know to see what kinds of screenings you may require.

Either way, CHF patients can often enjoy a long life with only mild restrictions as long as they stay on top of their lifestyle changes and their meds. A good cardiologist is a requirement, but as with all chronic conditions, the biggest determinant of how well a patient fares is the patient. And if worse comes to worse and the heart is ready to quit entirely, there still remain more dramatic options.

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