A 70-year old gentleman presented at the Emergency Department with a history of slowly progressive breathlessness and swelling of feet for the previous year-and-half. His problems got aggravated to such an extent that he was frequently awakened from sleep by attacks of breathlessness. The documents provided to us by his relatives showed that he had had multiple admissions in the District Hospital, and received one dose of DC shock for a cardiac irregularity known as ventricular tachycardia. This is a potentially dangerous heart rhythm that may require prompt correction.
At the time of admission, he was breathless even at rest, and could not lie down. His urine output had fallen during the past two days. His pulse rate was 120/minute, regular. His blood pressure was 160/70 mmHg. The clinical examination showed features of ankle swelling, and an enlarged heart with poor contractile function. There were signs of congestion in the lungs, and fluid accumulation in his abdomen.
The ECG showed sinus rhythm with left bundle branch block; the QRS duration was 160 millisec. Echocardiography showed dilatation of all the 4 chambers of the heart; the ejection fraction was 22%. Based on these findings, we made a diagnosis of Dilated Cardiomyopathy.
He was receiving various medicines prescribed by the doctor at the District Hospital that gave him partial relief.
We admitted him in the Intensive Care Unit and put him on salt-restricted diet. Oxygen inhalation was promptly instituted, and an intravenous infusion of frusemide was set up. This restored the urine output, and reduced the congestion in the lungs, and ankle swelling.
We decided to change his medicines. We started a new drug (sacubitril-valsartan) which causes unloading of his diseased left ventricle. In the next few days, we started administering metoprolol succinate and digoxin, which reduced the heart rate to some extent.
We released him from the hospital but strongly advised him not to move out of Kolkata so that we were able to tackle any new emergencies.
We saw him at the out patients’ department at approximately ten days’ intervals for the next six weeks. We discovered that he had iron deficiency, and therefore treated him with one dose of intravenous iron. We introduced two other medicines to improve his cardiac function, viz., ivabradine, and eplerenone. They caused further improvement in his clinical status, but we felt that he should improve further.
We then explained the situation to his relatives and re-admitted him in the hospital to implant a Cardiac Resynchronization Therapy-Defibrillator (CRT-D) device.
We have, thereafter, followed him up at the outpatients’ department for more than fifteen months. At present, he is much less symptomatic, and his ejection fraction has increased to 36%. His ankle swelling has disappeared, and there is no fluid accumulation in his abdominal cavity. He can lie down comfortably to enjoy his night’s sleep, and is no longer troubled by the spells of nocturnal breathlessness. He is able to walk about for nearly twenty five minutes in a nearby park, with intermittent rest.
The clinical history of the gentleman (name withheld, to respect his confidentiality) is typical of a condition known as Dilated Cardiomyopathy. Till the late 1980s, the treatment that was available did not permit survival for more than a few months in most of the patients. The introduction of the ACE (Angiotensin Converting Enzyme) inhibitors in the early 1990s relieved the symptoms, and increased the survival. In fact, the use of an ACE inhibitor by the doctor at the District Hospital caused some reduction of the symptoms of our patient.
Two novel modalities of treatment have been recently approved by the guidelines. These were successfully applied by us in this patient.One is a new drug known as sacubitril-valsartan, which is far superior to the conventional medicines like ACE inhibitors or ARBs (Angiotensin Receptor Blockers). Large scale clinical trials in Europe have shown that it saves lives, and is a better choice than some of the existing medicines.
The other is an implantable device known as the CRT-D. The left and right ventricles of a patient of dilated cardiomyopathy often contract in an un-coordinated, asynchronous manner, thus resulting in inefficient cardiac function. This device synchronizes the contraction of the left and right ventricles, and increases the efficiency of the heart. It is also capable of delivering a small shock which can bring back ventricular tachycardia to normal (sinus) rhythm. Incidentally, our patient had a documented episode of ventricular tachycardia in the District Hospital, which was treated with an external machine that gave a DC shock. It is clearly impracticable to get the patient to carry the heavy weight external machine to wherever he goes. The CRT-D is a small device which is implanted in the patient’s chest, and can give a DC shock whenever it is needed. This device saves many lives.
Both these modalities have been shown to relieve the symptoms, and prolong the lives of patients of Dilated Cardiomyopathy.
This article is posted in the internet in order to create awareness amongst members of the public regarding some forms of heart disease. It is not intended to be a substitute for expert medical opinion. For all forms of treatment, no matter whether it is preventive or curative, whether it is by drug treatment or life style modification, please consult your heath care giver.