One of the best things about being a doctor is that you get to meet some amazing people.
I have decided today to include a section in my blog on patient stories. I will discuss stories of patients with health problems, and how they overcame it and how they were treated.
I hope that this category of articles will inform you not only about the medical condition itself, but also about what treatments there are available these days.
Patient Name: Mr NRB
Patient Age: 66 years
Mr NRB came to see me around 2 years ago feeling a little breathless. He told me that he was unable to climb stairs easily, and that his regular walk had become a bit of a task.
In the past, he had suffered a heart attack and had a stent put into one of his arteries as a treatment. He also had high blood pressure and diabetes.
His sleep had become quite disturbed as well. In fact, he was unable to recall when he actually had a good night’s rest. After going to bed, he would wake up a few hours later and feel very breathless.
We commenced him on medical therapy and followed him up regularly. Being the good patient that he was, he kept his follow up appointments.
Around 1.5 years later, he visited me again, but this time he looked different.
He was extremely breathless. He was not even able to speak to me properly.
At home, he was so breathless in the night that he would rush to the bedroom window at 2 am for a breath of fresh air.
In addition to this, he found that he was excessively tired all the time. Walking to the shop to pick up milk had become increasingly difficult.
He came to see me as he was struggling at home and his family (and Mr NRB) were very concerned.
“How are you feeling?”, I asked him. “Dreadful doctor. I can’t do anything I enjoyed previously. My life has become very difficult to lead”, he said.
After examining him, it was evident that his heart was weak and there was fluid in his lungs. His legs were slightly swollen as well.
In order to assess how weak his heart was, we decided to put him through certain tests.
The first test we conducted was an electrocardiogram, or an ECG. This test revealed that the heart was beating regularly, but the electrical conduction through the heart was not right.
In fact, one electrical bundle in the heart was malfunctioning, leading to an ECG change called ‘left bundle branch block’. This change can be seen in patients who have had heart attacks in the past, though there are other conditions that can lead to it as well.
Given this ECG change, we performed a echocardiogram. For those of you who do not know this test, an echo is a painless investigation that helps evaluate the structure and function of the heart muscle. It tells us how strong the heart is.
Mr NRB’s echo showed that his heart function was drastically reduced at 25%. The normal function is around 55% or more.
But that’s not all. There were changes in the echo that showed that certain parts of the heart muscle were not moving well. This indicated to us that the circulation to the heart muscle was poor.
Given his clinical state, we thought it best to admit him.
Once he was admitted, he was closely monitored in the cardiology unit in the hospital. He was treated with medicines to get rid of extra fluid in the lungs. The blood tests showed that he had not had a heart attack, and that his kidneys were functioning normally.
Extra fluid in the body is usually the cause of breathlessness in patients who have a weak heart.
While he was being monitored, we noticed he had a few irregularities in his heart rhythm. The lower chamber of his heart had developed it’s own electrical activity, and was trying to pump blood in an erratic fashion.
Just so you know, the heart beats due to electricity generated within it. I have previously discussed the electrical activity of the heart in detail, which I invite you to read here.
Sometimes, the bottom chamber (the ventricle) starts to beat by itself, becoming a little bit like a villain in a good bollywood film. However, the beating is not strong enough to push blood to all the vital structures in the body.
This weak ‘extra beats’ can sometimes occur back to back, leading to a rhythm called ventricular tachycardia. This can be a life-threatening rhythm if not treated quickly.
Mr NRB had developed ventricular tachycardia when he was being monitored in the hospital. We treated him immediately with intravenous medication and stabilised his rhythm.
But his problems did not end there.
A heart that is weak and that does not beat in a synchronised fashion is a very inefficient heart.
Mr NRB not only had a life-threatening rhythm problem, he also had a weak and inefficient heart.
Something had to be done to improve this.
The Next Decision…
Now, if the heart is weak, there are a few treatments that we can offer to the patient.
Firstly, medical therapy. We prescribe medicines that will not only get rid of extra fluid; they will also help the heart beat a little harder and stronger.
But medicines can only do so much. Furthermore, they cannot correct the abnormal synchrony that Mr NRB had.
The next treatment option we were faced with was a special pacemaker. This pacemaker had the capability of not only controlling the erratic heart rate; it could also re-synchronise the heart and make it more efficient.
The special pacemaker treatment that is currently available is called a CRT, or cardiac re-synchronisation therapy. This pacemaker makes the heart a lot more efficient. It does so by making sure that all the chambers of the heart beat in the way that a normal heart does.
But that is not all that a CRT device does. There are 2 special modes that are available with this device – a pacemaker mode and a defibrillator mode.
The pacemaker mode helps keep the heart rate under control. The device used is called a CRT-P, where ‘P’ stands for pacemaker.
The defibrillator mode helps control the abnormal rhythm. It has the capability of doing so by delivering a small shock to the heart. This is called a ‘CRT-D’ device.
And yes, this shock can be a little uncomfortable. But it saves lives.
We decided based on Mr NRB’s history, to offer him a CRT-D device. The procedure was performed under local anesthesia and completed in around 2 hours.
What Happened After…
We discharged Mr NRB on medication a couple of days later.
On follow up a week later, he was already feeling a little better. He had stopped waking up in the middle of the night due to breathlessness, and was feeling less tired as well.
Fast forward 2 months, and he is now feeling a lot better. His appetite has improved. He is walking 20 minutes a day without feeling breathless. We (and Mr NRB) are extremely pleased with his progress.
Given that I have mentioned CRT-D treatment here, I think it is only fair to tell you about it.
Basically, the device has 3 wires that sit in 3 chambers of the heart. These wires are attached to a generator.
Electrical current is passed through these wires in an orderly manner. This way, the heart starts to beat in an orderly fashion as well.
Here is a video that explains how it is done –
Does It Work?
There are strict criteria that have been laid down by the American Heart Association when it comes to implanting pacemakers. Doctors have to follow these guidelines when considering pacemaker insertions.
From clinical trial evidence, CRT pacemakers work in specific scenarios only. They can significantly improve symptoms and improve quality of life.
But not everyone is a suitable candidate for pacemakers. Every person is different, and a number of criteria have to be met. If these criteria are not met, the pacemakers will not work.
That being said, there is always a small number of patients who do not respond to pacemaker treatments. Prior to putting in a pacemaker, it is impossible to tell if the patient will respond or not. We will only know after the device has been placed and the patient is regularly followed up.
What Other Options Did We Have?
If Mr NRB was not suited for a pacemaker, we were left with very few choices.
While heart transplant is always an option, there are extremely strict criteria for acceptance. Furthermore, the cost of transplant is extremely high. Even if you could afford a transplant, the monthly medical bills will remain at around Rs. 20,000 to Rs 25,000.
Age is a factor as well. Heart transplants are usually reserved for younger patients.
There are newer devices that have now emerged that could improve the function of the heart. Once again though, these are very, very expensive, with some even costing around Rs 5,800,000!!! (Nearly $90,000).
Do you have any questions or would like to know more about this type of treatment? Drop us an email at firstname.lastname@example.org.