Welcome to Dr. Warrick's podcast channel. Warrick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warrick believes educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love. Hi, my name is Dr. Warrick Bishop and I would like to welcome you to my podcast station and of course to the Healthy Heart Network. Today I'd like to talk about Frank, a 72-year-old patient who I knew for years. Frank was an associate who I'd come to know through the small community I live in and Frank is an excellent example of our management of cardiac failure. and where it can occur in certain situations where you may not even expect it. Frank was 72 when he first came to see me with shortness of breath. I can let you know that he'd lived an active life. He played a lot of sport at a very high level, but in his later years, he swam regularly, he spent a lot of time on his stationary bike, and he loved to travel. Some five years earlier, in his mid to late 60s, he'd required a pacemaker because of rhythm disturbance. No problems with that. The pacemaker worked well, and with implantation of the device, he was restored back to normal function pretty quickly. Two years earlier than that, so slow, between his early to mid 60s, he'd had an episode of chest pain, which proved, with investigation, to be a tight... blockage of the artery running down the front of his heart the artery called the left anterior descending the one nearest the chest wall this was addressed by implantation of a stent and again great result everything sorted out we had followed up frank When he presented at 72 years of age with a stress test to see if the shortness of breath may have been a manifestation of lack of blood flow getting to the heart. We know angina as a tightness or a pain that can occur with not enough blood getting to the heart. But one of the syndromes of angina that we sometimes see is shortness of breath without necessarily having the chest pain. Well, I can report that Frank's stress test did not show any lack of blood flow to the heart. We call that no inducible ischemia, no demonstration of lack of blood flow. So there was some reassurance that his stents were working well. At the same time, for evaluation of shortness of breath, we undertook an echocardiogram or ultrasound of the heart to look at how the heart was literally working. The left ventricle, his main pumping chamber, was pumping well. His left atrium, the pre-pump chamber on the left side, was a little bit dilated, but we do see that as people get older and can be a little bit related to elevated blood pressure years earlier. We were managing it closely now because of his history of previous stenting. We did notice that his pulmonary pressures were marginal. He had a measured pulmonary pressure of somewhere around 30 to 35 millimetres of mercury. Now, you don't need to remember the exact numbers for that, but that's a little bit on the high side, not dramatically so. Well, it was high enough for me to think, perhaps, in the absence of lack of blood flow being a problem for Frank, perhaps a little bit of retention of fluid could be a problem. Now, this retention of fluid can sometimes be a really hard thing. demonstrate if someone's got clear-cut significant severe cardiac failure we will see their features of fluid retention from sitting opposite their neck veins will be prominent because fluid extra fluid will be in their circulation their ankles will be swollen they'll have a clear-cut sock line or even the patient will mention that they can't get their feet into their shoes really clear indicators that there's just too much fluid on board. These same people with those clear-cut features will have clear biochemical markers. So if we were to measure indicators of cardiac failure, like brain natriotic peptide levels, they would be at the high end of the range or clearly into the range demonstrating cardiac failure. Well, for some patients, It's just not as clear cut and for some patients with heart failure in the setting of preserved ejection fraction, the signs can be really subtle and quite difficult to pin down. With that being the case, I thought there's a small chance that Frank may have had heart failure with preserved ejection fraction, partly because of his age, partly because of his pre-diabetic status. Partly because of his previous history of elevated blood pressure and partly also because we know he had some ischemia and therefore some wear and tear on the heart and the vasculature. So I elected to give Frank a small trial of diuretic therapy. I said, here's some furosemide. Take one to two tablets for effect. If one tablet makes you pee like a horse, you definitely don't need two tablets. pass urine appreciably more than normal, then you definitely need two tablets so that we know we're getting fluid out of your body. I want you to do that for three days in a row and no more than three days in a seven-day week. Well, Frank took the instructions on board and off he went. The reason I ask patients not to run the fluid tablet, the diuretic therapy for every day of the week is I don't want to dry them out. too much i want to be careful to remove the excess fluid but not push them into dehydration otherwise we run the risk of damaging their kidneys well i booked to see frank some six to eight weeks later and he came waltzing straight through the door and said Warrick you're a bloody magician so i really didn't have to ask if i helped him or not But he was a fantastic example of someone with preserved ejection fraction, some retention of fluid, which was hard to clearly demonstrate, but a diagnostic therapeutic trial of diuretic therapy of fluid tablets clearly made a difference. Armed with that regime, Frank went on for years. We continued following. I did seem to keep a close eye on his cholesterol levels, making sure he was to target. We kept a close eye on his blood pressure. Of course, we interrogated his pacemaker regularly. And of course, we mitigated his risk of diabetes by keeping a close eye on exercise and lifestyle. Although I'm really sad to say that Frank has since passed away, it wasn't until five years after we sorted out his shortness of breath. And it was not from his heart that he was taken from us. I'm pleased to say that he was out travelling and enjoying life to the max when he had an unfortunate accident that took him from us. Frank was a great patient, an appreciative patient and someone who did really well and was able to pursue the things he wanted to do with... management around all the issues regarding his cardiovascular health. I hope you found his story interesting and informative. If you have any queries or questions, as always, please drop us a note at members at drWarrickbishop.online. If you have any suggestions for future podcasts, of course, let us know. And of course, until next time, please don't die from a heart attack. Goodbye. You have been listening to another podcast from Dr. Warrick. Visit his website at drWarrickbishop.com for the latest news on heart disease. If you love this podcast, feel free to leave us a review.
