5 March 2012
Unless you are on the ball, it is easy to forget heart failure. Yet it is so important to diagnose it because, in its more severe stages, heart failure carries a very high mortality.
A friend of mine has had asthma all her life. In the last eighteen months, she suffered several episodes of cough and shortness of breath. Each time these symptoms were put down to infections and treated with antibiotics. Each time the symptoms seemed to settle down for a few weeks.
After a year, she had had five courses of clarithromycin until, at last, someone made the decision to perform an ECG and an Echocardiogram. The secret was revealed and treatment with ACE inhibitors was started. Surprise, surprise, she has had no further attacks of coughing and dyspnœa since then.
There are several lessons to be gathered from this short tale.
Firstly, infections are no more common in someone who has asthma than in anyone else. On the other hand virus infections are one of the commonest triggers of asthma.
Secondly, it is easy to blame symptoms on an existing condition.
The remainder of the lessons can be gleaned from two extracts from our course Cardiovascular Disease Management in Primary Care:
The diagnosis of heart failure is difficult clinically, the traditional signs of œdema, orthopnœa and paroxysmal nocturnal dyspnœa being by no means always present.
Breathlessness, lethargy, ankle swelling and confusion are among the symptoms reported by people with heart failure. Among the common signs are a raised jugular venous pressure, tachycardia with a third heart sound and crackles in the lungs.
However, neither the symptoms nor the signs are always present and can also be found in other conditions.
The ultimate gold standard test is the echocardiogram.
Although an ECG may be abnormal in many people with heart failure, everyone in whom heart failure is suspected should have an echocardiogram. This identifies incomplete emptying of the left ventricle that is so characteristic of heart failure.
My friend had the common reaction when told that she had heart failure. She thought that she was going to die because her heart was failing. It took a lot of explaining before she understood that her heart was not packing up but merely failing to pump out all the blood from the ventricle that was arriving at the atrium.
It reminded me what a poor name “heart failure” is. Certainly, it describes what is going on but in words that frighten the patient unnecessarily.