CASE STUDY FOR CHAPTER 5 HER STORY With three kids and a full-time job, Teresa was accustomed to feeling tired. Lately, however, she was truly exhausted because she was having trouble breathing, which kept her up at night. Teresa soon developed a cough as well, but she wasn’t overly concerned; she blamed her symptoms on her busy schedule, being overweight, and her lifelong battle with allergies. Finally, after a few months of severe fatigue, breathlessness, and a persistent cough, Teresa consulted her primary care physician. She ordered blood tests to rule out thyroid problems and diabetes, but she was most concerned with Teresa’s blood pressure: it was 160/120 mm Hg. Her doctor became extremely worried and asked me to see Teresa in our cardiology practice later that same day. THE EVALUATION I found out from Teresa’s medical history that her father had died of myocardial infarction when he was 63 and her mother had hypertension for years. During our talk, I could hear that Teresa had dyspnea. On auscultation, I detected abnormal lung sounds. Her feet and ankles clearly had edema, and her blood pressure was much higher than when her physician had checked it just hours earlier. Meanwhile, with a rush on the blood tests that Teresa’s primary care physician had ordered, we were able to rule out diabetes. Although the thyroid test results weren’t available yet, it seemed unlikely that a thyroid disorder was to blame for Teresa’s problems. She did not have other symptoms that characterize hypothyroidism, such as inexplicable weight gain, thinning hair, and constipation. I began to suspect that Teresa had a serious heart problem, so I ordered an electrocardiogram (EKG) and an echocardiogram. These tests revealed that Teresa had tachycardia and cardiomegaly—sure signs that her heart had been damaged. THE DIAGNOSIS The EKG and the echocardiogram results confirmed my suspicion that Teresa was suffering from congestive heart failure, a life-threatening condition in which the heart is unable to pump enough blood throughout body. Heart failure patients tend to get easily fatigued because there is not enough oxygen circulating throughout the body; these circulation problems cause edema, too. More specifically, Teresa appeared to have pulmonary edema, which leads to the difficulties in breathing. While many conditions can lead to heart failure, high blood pressure was the clear culprit in Teresa’s case. Hypertension puts too much pressure on the blood vessels, which forces the heart to pump harder. Without treatment, Teresa’s heart would continue to enlarge and weaken, which could be fatal. THE TREATMENT Because Teresa’s symptoms were so severe, I called an ambulance to take her to the hospital right away. In the hospital, she was given diuretics to remove excess body fluid, including from her lungs. I also prescribed ramipril, an ACE inhibitor that would lower Teresa’s blood pressure and reduce the exertion on her heart. Heart failure is a chronic condition that can’t be cured and must be managed with strategies to improve heart function. Once her condition was stabilized, I added carvedilol, a combination alpha and beta blocker that controls blood pressure and slows heart rate, to her medications. In some people, it improves heart function as well. I also advised Teresa to lose weight and reduce her salt intake since too much sodium would cause fluid to build up in her lungs and extremities. I asked her to undergo a stress test and then to sign up for a medically supervised exercise program at the local hospital. CASE CLOSED When Teresa came back to see me 3 months later, the swelling in her feet had gone down considerably. Her blood pressure was under control, and her fatigue had let up considerably. In addition to her supervised workout, Teresa had started taking a daily walk and returned to work part time. Heart failure can’t be cured, and Teresa is still likely to have a shorter lifespan than someone without it, but taking her medications and following a healthy lifestyle will help her stay well for as long as possible. Discussion Questions 1. Teresa’s blood pressure was 160/120 mm Hg. What do each of these numbers measure? 2. What are tachycardia and cardiomegaly? Give the word parts for these terms. 3. Differentiate between an electrocardiogram and an echocardiogram (see Chapter 15). 4. How do ACE inhibitors work to lower blood pressure?