Heart failure...a strange presentation.

in #health8 years ago (edited)

Doctors tend to confuse patients when it comes to heart failure.

We say "you HAVE heart failure" and mean one thing or, say "you are IN heart failure" and mean something else entirely. I didn't realize this disparity until I had a heart failure patient whose heart problems were giving him liver ones.

A 62 year old man with known heart failure (a weakened left heart muscle) and diabetes came into the hospital with fairly sudden yellowing of his skin and weakness.

On further evaluation - his lungs were clear, his blood pressure was lower than usual, his legs were swollen and his liver function was worse. The raised levels of bilirubin (which goes along with liver failure) explained his yellow skin.

But why was his liver function worse?!?

He wasn't on any new medications, he wasn't having a fever and his liver ultrasound didn't reveal any acute problems. We were stumped so, we started checking for infections - hepatitis a,b,c,e, EBV, CMV etc - and got a hepatologist consult. As none of the blood tests showed anything, we were planning on doing a liver biopsy.

While all of this was happening patients leg swelling kept getting worse.

You would expect to see bad swelling with complete liver failure but he wasn't there yet. His numbers were bad but it wasn't complete shut down...yet! Since we were stumped anyways we decided to evaluate his heart with an echocardiogram. This was to see if we were dealing with two problems: heart and liver, rather than just liver alone. What we found surprised us; it was his heart causing the problems alright, just a new issue that had come on quietly!

The blood flow from the liver leaves through the hepatic vein and meets up with the inferior vena cava [IVC] and it all ends up in the right heart (drawn on the left side because doctors think backwards...we are thinking of your heart not ours). This side of the heart then sends the blood up to the lungs to get oxygen. This oxygenated blood is then sent back to the left side of the heart which sends it out to the body.

As the heart muscle weakens and someone develops heart failure, the output of the heart decreases. This weakened left heart muscle is equivalent to HAVING heart failure. This decreases the forward movement of the blood and plasma. Classically with this, during moments of stress, the forward flow of the blood and plasma being worse, the plasma backs up into the lungs putting someone INTO heart failure.

So, with this patient we already knew that he HAD heart failure (a weak left heart muscle), but what we didn't realize was that he was also IN heart failure (because there was no fluid in lungs).

The echocardiogram showed us everything. He had NEW failure in his right heart.

Diabetes damages nerves thus, he had probably had a heart attack that he didn't feel and was feeling weak because he was now not getting enough forward flow of the blood/plasma into his lungs. This was causing back up into his liver and causing hepatic congestion. The further decrease in forward flow was also lowering his blood pressure.

We started him on an IV medication to cause the heart to contract more vigorously and unsurprisingly all his blood numbers improved. Happy ending right? Nope, the last I saw him the guy was on a waiting list for a heart transplant.

No cure for a weakened heart muscle.

Once you HAVE heart failure, you have to pray that the heart muscle gets stronger with preventative medications, because we can't fix it. We can only prevent you from ending up IN it but we can never take it away.

At least he got to avoid the liver biopsy! :/

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More please! Very interesting and the drawing is an excellent visual aid.

Thank you! And definitely working on it...please check the blog http://steemit.com/@gmalhotra for the other stories i have already posted!

I thought that in heart failure you tend to want to reduce the stress on the heart, not give an "IV medication to cause the heart to contact [sic] more vigourously". Is this different in R+L heart failure? Can you explain?

Here's the dilemma of heart failure. When you have a mild form we tell you to exercise in the hope of building up the heart muscle with the stress. But, when it's really bad we say "take it easy." Because when it's really bad, the only way to get the heart to pump the blood forward, in the times stress, is to dehydrate you to decrease your pressure so the heart has to work less. This dehydration is done with diuretics. But with both sides having problem or with very very severe left side failure....the patients blood pressure is usually so low that we can't dehydrate patients...it will drop their blood pressure even further. During these times we need to force the heart to work harder with IV meds. Of course this is a gross over simplification....the type of stress (eg arrhythmia vs infection vs renal failure) changes the situation also. But, what i said above usually explains most situations.

Fixed the spelling error ;)

Great post. The problem with CRP is...so now you know that your risk is higher but, as far as I know, theres nothing we can do about the elevated CRP levels...no drugs treat it.

Thanks for the post @gmalhotra! Very informative, I learned a lot about our body.

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