When 43-year-old Barbara Harris found herself panting as she climbed the steps to her front door, she knew something was wrong. She was overweight and had high blood pressure, but she’d never been sick like this. In the hospital, she was shocked when her doctors told her she was suffering from mild congestive heart failure. Because her high blood pressure had gone untreated for years, her heart muscle had been damaged and was now unable to pump enough blood for her body’s needs. Blood returning to the heart was backing up, resulting in fluid buildup in her lungs and making her short of breath.
She also had a mild heart murmur, probably a remnant of a childhood bout with rheumatic fever. An echocardiogram (an ultrasound of the heart) confirmed that her mitral valve was slightly leaky, allowing blood back into the atrium and forcing her heart to work harder to pump it out. Harris was treated for two days and went home with medication to lower her blood pressure and decrease the buildup of fluid.
Two weeks later, on a cold February evening, she was back in the hospital.
“It was OK at first when I went home,” she told us from her hospital bed. I was working that month on the inpatient wards as an attending physician, along with a resident and a medical student. Harris adjusted the prongs of the oxygen tubing in her nostrils. “But it started again pretty quickly. I didn’t even want to walk anymore; it got too hard. I’m out of breath. And my ankles are killing me.” I pressed one of her ankles, leaving a little dent in the warm flesh, and asked her to rotate her feet. Wincing, she moved them a tiny bit. Ankle swelling could be a sign of heart failure, but mild cases do not usually cause pain. It was probably a red herring.
Once a patient has congestive heart failure, treatment is a delicate balancing act that includes nuanced adjustment of medication, a low-salt diet, and frequent weight checks. In some people this is easy; in others, missed medications or too much salt can cause the symptoms of uncontrolled congestive heart failure to return. But Harris had been avoiding salty food, and she hadn’t missed any pills. She was so compliant, in fact, that her blood pressure and leaky heart valve probably could not explain the relapse at hand.
It was time to rethink. We sat in the doctors’ station and talked about what might have triggered her symptoms. A heart attack was a possibility; we would get better information from a stress test. Alcohol could do it, although Harris told us she didn’t drink. So could a condition affecting the heart valves (she did have the heart murmur, but it was mild) or bacterial endocarditis, a potentially life-threatening infection of a valve.
Over the next two days, we kept her busy. We cultured her blood for bacteria, which, if present, would increase the likelihood of bacterial endocarditis. We also sent her for various heart tests. But none of this told us anything new. Her blood was clear of infection and her heart was pumping well enough to rule out a heart attack. What had knocked her heart out of control?
On her third day in the hospital, there was a seismic shift in Harris’s condition. Her nurse beckoned to us from down the hall, where we were examining another patient. When we came into her room, she was sweating and massaging her knees. The nurse said her temperature was 102 degrees.
“Look at this,” Harris panted, pulling her sheet aside so we could see her legs. “My ankles are fine now, but I’m hurting in my wrists—I can barely move my hands. And my knees, look how puffy!”
Dan, the resident, listened to her heart, his brow furrowed in concentration. “Her heart sounds different,” he said. “It’s weird. She has a bunch of new murmurs.” Before, the lub-dub of her heart had been clear; now, all I could hear were loud whooshing sounds.
I was stunned. Dan and I were thinking the same thing: It had to be bacterial endocarditis. In endocarditis, small masses of bacteria form on the surface of a heart valve, and these little infected clumps—septic emboli—can slip off into the bloodstream. Depending on where they settle, they can cause major problems: abscesses, strokes, kidney disease, blood clots, and, by interfering with a heart valve’s normal function, congestive heart failure.
I asked the student to draw some more blood to culture again for bacteria and to order another echocardiogram, which would show whether bacteria had built up on a valve.
We were flabbergasted when the echocardiogram results came in that afternoon. It looked like another patient’s heart, and a really bad heart at that. The mitral valve no longer leaked a small amount; now a jet of blood regurgitated backward into the left atrium with each beat. And it wasn’t only the mitral valve. The aortic valve also spewed blood in the wrong direction. The valves were damaged, but the echocardiogram showed no bacterial clumps. This didn’t seem to be bacterial endocarditis. So why were Harris’s heart valves worsening before our very eyes?
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%20confirmed%20that%20her%20mitral%20valve%20was%20slightly%20leaky,%20allowing%20blood%20back%20into%20the%20atrium%20and%20forcing%20her%20heart%20to%20work%20harder%20to%20pump%20it%20out.%20Harris%20was%20treated%20for%20two%20days%20and%20went%20home%20with%20medication%20to%20lower%20her%20blood%20pressure%20and%20decrease%20the%20buildup%20of%20fluid.</p>%20%20<p>Two%20weeks%20later,%20on%20a%20cold%20February%20evening,%20she%20was%20back%20in%20the%20hospital.</p>%20%20<p>%E2%80%9CIt%20was%20OK%20at%20first%20when%20I%20went%20home,%E2%80%9D%20she%20told%20us%20from%20her%20hospital%20bed.%20I%20was%20working%20that%20month%20on%20the%20inpatient%20wards%20as%20an%20attending%20physician,%20along%20with%20a%20resident%20and%20a%20medical%20student.%20Harris%20adjusted%20the%20prongs%20of%20the%20oxygen%20tubing%20in%20her%20nostrils.%20%E2%80%9CBut%20it%20started%20again%20pretty%20quickly.%20I%20didn%E2%80%99t%20even%20want%20to%20walk%20anymore;%20it%20got%20too%20hard.%20I%E2%80%99m%20out%20of%20breath.%20And%20my%20ankles%20are%20killing%20me.%E2%80%9D%20I%20pressed%20one%20of%20her%20ankles,%20leaving%20a%20little%20dent%20in%20the%20warm%20flesh,%20and%20asked%20her%20to%20rotate%20her%20feet.%20Wincing,%20she%20moved%20them%20a%20tiny%20bit.%20Ankle%20swelling%20could%20be%20a%20sign%20of%20heart%20failure,%20but%20mild%20cases%20do%20not%20usually%20cause%20pain.%20It%20was%20probably%20a%20red%20herring.</p>%20%20<p>Once%20a%20patient%20has%20congestive%20heart%20failure,%20treatment%20is%20a%20delicate%20balancing%20act%20that%20includes%20nuanced%20adjustment%20of%20medication,%20a%20low-salt%20diet,%20and%20frequent%20weight%20checks.%20In%20some%20people%20this%20is%20easy;%20in%20others,%20missed%20medications%20or%20too%20much%20salt%20can%20cause%20the%20symptoms%20of%20uncontrolled%20congestive%20heart%20failure%20to%20return.%20But%20Harris%20had%20been%20avoiding%20salty%20food,%20and%20she%20hadn%E2%80%99t%20missed%20any%20pills.%20She%20was%20so%20compliant,%20in%20fact,%20that%20her%20blood%20pressure%20and%20leaky%20heart%20valve%20probably%20could%20not%20explain%20the%20relapse%20at%20hand.</p>%20%20<p>It%20was%20time%20to%20rethink...</p>%20%20<p><i>Image:%20iStockphoto.</i></p>){kind=link}