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- 1. Congestive Heart Failure The Stories of Ruth and Oscar
Notas del editor
- You are about to learn about Congestive Heart Failure in a new way. This is not a powerpoint presentation full of bullet points and lists of etiologies, symptoms, and treatment protocols. This is the story of two real people who suffer from congestive heart failure.
- This is Ruth. She is 72 years old and is living with Congestive Heart Failure. She is a mother to three and grandmother to seven. She spent most of her adult life raising a family and teaching third graders. She had to retire early from the job she loved because she did not have the stamina to make it through the day. She became winded just walking across the classroom floor.
- Ruth always knew that she would eventually develop Congestive Heart Failure. When she was just three years old the doctors diagnosed her with a leaky heart valve. She has mitral valve prolapse. This means that her mitral valve doesn’t make a tight seal when it closes. Every time her heart contracts, blood from her left ventricle leaks backward into her left atria. After 73 years the entire left side of her heart is enlarged and it can no longer pump effectively.
- Since the mitral valve is between the left atria and left ventricle, only a portion of the blood from the left ventricle is ejected with each beat. A lot of the blood remains in the ventricle or is pushed back up into the atria. Since the left ventricle is responsible for pumping oxygenated blood to her body, all of the cells in Ruths body are chronically starved for oxygen. She tires easily and has never been able to exercise much.
- All that damage to her left atria has caused her EKG to look like this. This is called p mitrale. You can identify it by the M shaped p wave in lead I and the biphasic p wave in V1. It is easy to remember, p mitrale. The p wave is shaped like an M. Not all patients with congestive heart failure have p mitrale.
- Ruth used to get a manicure about once a month as a treat to herself. But she hasn’t done that in years. She is too embarassed to have the ladies at the nail salon see her fingers. This happened slowly. Over time, the tissues in her nailbeds and fingertips became deformed from being deprived of oxygen. Her doctor says that she has clubbed fingers. He told her that this can happen to people with chronic lung or heart problems.
- But her fingernails aren’t the only thing that has been affected by her Congestive Heart Failure. This is a picture of Ruth’s alveoli. As her left ventricle became progressively weaker, pressure began to back up in her left atria, then in her pulmonary veins and finally, in the little vessels in her lungs. The high pressure in those vessels have caused fluid to leak out of the vessels and in her alveoli. Now, Ruth is literally breathing through water.
- Normally, oxygen and carbon dioxide are exchanged across the alveolar membrane. Blood that comes to the lungs from the right side of the heart is high in carbon dioxide and low in oxygen. Oxygen in the alveoli crosses the membrane and enters the capillaries where it will be sent back to the left side of the heart and will be distributed to the body. Because Ruth has fluid in her alveoli, the oxygen has difficulty crossing the membrane to enter her blood and she is chronically hypoxic.
- Ruth has four pillows stacked on her bed. She needs them to sleep. If she lays down flat she feels like she is drowning and can’t breath. He doctors calls this four pillow orthopnea. She also wakes up several times each night, coughing and gasping for breath. She never feels rested and falls asleep several times during the day while she sits in her recliner.
- Ruth’s cosmetic cabinet has been replaced with these. She takes the Lasix to help remove the fluid that backs up in her lungs. The nitroglycerin helps the angina that sometimes flairs up when she isn’t getting enough oxygen to her heart muscle. The Lanoxin helps her weakened left ventricle pump just a little harder. She uses the oxygen every day to combat the chronic hypoxia. This is how Ruth lives.
- This is Oscar. He also has congestive heart failure He just called 911 because he couldn’t breath. The paramedics found him sitting in his recliner, leaning forward, trying to open up his chest just a little bit more so he could get a breath. When they found him, he could only speak two words at a time. The paramedics put him on CPAP to help him breath.
- Oscar always thought he was a really healthy guy. He was a mailman and walked about 9 miles every day. Then one day, while he was in the middle of his route, he felt like an elephant kicked him in the chest and he couldn’t catch his breath. This was his first myocardial infarction and was located in his left ventricle. Over the next 10 years two more that affected his right ventricle.
- When the paramedics obtained a 12 lead they could tell he has had some previous damage to his heart muscle. The Q waves are indicative of previous myocardial infarctions. The paramedics can see them in the inferior and lateral leads, where most of Oscar’s heart muscle was destroyed. This is the cause of his heart failure.
- Since heart muscle can never regenerate, Oscar’s left ventricle is nearly useless. In a normal heart, the left ventricle can pump out 55 percent of the blood in its chamber with each beat. Oscar’s left ventricle can only eject 35 percent of the blood. As a result, his body is deprived of the oxygenated blood it needs to survive and the pressure builds up in his left atrium.
- Eventually, Oscars right ventricle started to fail as well. The pressure from his right ventricle began to back up in to his right atrium, into his vena cavae and eventually into all the vessels in his body. The pressure in those vessels cause fluid to leak out into his tissue. Oscar has edema in his legs from the fluid. When it is particularly bad he can push on his shin and leave an indentation.
- Oscar has also been prescribed Lasix. It works on the loop of henle in the kidney to draw the excess fluid out of Oscars blood and into his urine so that he can eliminate it. The only problem is, it makes Oscar have to use the restroom a lot. Several times during the night in fact. Oscar has grown tired of getting up so many times during the night and he has decided to stop taking the medicine.
- It has been three days since Oscar stopped taking his Lasix. Now his lungs are so full of fluid that they appear white, instead of black on an xray. He is so short of breath he can barely speak two words between breaths. He is getting tired from working so hard to breath and his head occasionally bobs. The fluid needs to be removed urgently or Oscar will die. He will literally drown.
- The paramedics treat Oscar with Continuous Positive Airway Pressure, or CPAP. Just a few years ago, they would have treated him with IV Lasix, Nitroglycerin and maybe some Morphine. Now most services have found the value of CPAP. Within minutes the CPAP begins to force the fluid out of the alveoli in Oscars lungs back into the capillary network. He will still need to go to the hospital and probably ICU, but he may not need to be intubated.
- Oscar has a much better chance of returning home to his family if the paramedics can avoid intubating him. Once a patient is intubated their chances of becoming ventilator dependent are fairly high. Patients who are ventilator dependent can take weeks or sometimes months to learn how to breath on their own again.
- The outlook for Ruth and Oscar is not good. One of them will most likely not be alive 5 years from now. Only half of the patients with congestive heart failure who are over 67 will survive for 5 years after diagnosis. About 20% of them will survive longer than 8-10 years. Ruth wants to spend as much time with her grandchildren as she can. Oscar still has some unfinished business with his youngest son who he hasn’t spoken with in years.