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• W2073353929 abstract "DR DELBANCO: MR C IS A 75-YEAR-OLD RETIRED FISHERMAN who came to the United States from the West Indies more than 10 years ago. He and his wife live in Boston, Mass, with their daughter, who has been an important source of support for him. He has Medicare and supplemental commercial insurance. In 1988, Mr C developed exertional dyspnea and was diagnosed as having congestive heart failure and chronic obstructive pulmonary disease (COPD), with a forced expiratory volume in 1 second of less than 0.5 L. Chest radiographs showed a large cardiac silhouette, with hyperlucent lung fields and flat diaphragms. Electrocardiogram results showed poor R-wave progression and were consistent with left ventricular hypertrophy and left atrial enlargement. Echocardiogram results showed severe left ventricular dilatation, diffuse hypokinesis, ejection fraction of less than 0.20, and mild right heart dilatation, with 3+ mitral regurgitation and 2+ tricuspid regurgitation. He also had chronic mild renal insufficiency, with a creatinine level of about 221 μmol/L (2.5 mg/dL), and a history of gout, with erosive arthritis, nephrolithiasis, and uric acid stones. There is no known family history of heart disease. Cardiac risk factors include long-standing mild hypertension and 50 pack-years of cigarette smoking, ending in 1988. Mr C was treated initially with captopril, furosemide, digoxin, aspirin, and isosorbide. From 1990 to 1995, he was relatively stable, requiring hospitalization for heart failure once or twice a year. A search for the cause of his dilated cardiomyopathy revealed no history of alcohol abuse and normal serum iron, iron binding capacity, ferritin, and thyroid function test results. There was no history or sign of malnutrition. In 1993, he developed diabetes mellitus and was treated with dietary restrictions and oral hypoglycemic agents. In 1996, Mr C developed episodes of intermittent atrial fibrillation and flutter. While in sinus rhythm, he was noted to have second-degree atrioventricular (AV) block, with a Wenckebach pattern. Echocardiogram results showed increasing biventricular dilatation, with a left atrial size of 5.2 cm. Aspirin was replaced by warfarin. Mr C’s renal insufficiency worsened, hyperkalemia developed, and captopril was discontinued. Therapy with hydralazine hydrochloride and amlodipine was initiated. In the past 3 years, Mr C has been hospitalized every 3 to 4 months. His functional status is significantly limited. He can walk slowly around his apartment but cannot climb stairs. He experiences chest pain a few times per week, while walking or at rest, that usually responds to sublingual nitroglycerin. His dyspnea worsens when his weight increases by more than 0.9 kg. He uses oxygen both at rest and with physical activity. Attentive care by his family members and visiting nurse services makes it possible for him to continue living at home. On physical examination, Mr C appears chronically ill and weak. He does not cough. He is normotensive, with distant heart sounds and a soft left sternal border systolic murmur that radiates to the left axilla. There is no hepatojugular reflux orperipheral edema.Recentelectrocardiogramresults showed a sinus rhythm, with ventricular ectopy. Recent 24-hour cardiac monitoring showed asymptomatic runs of ventricular tachycardia. An arterial blood gas study revealed a partial pressure of oxygen of 69 mm Hg and a partial pressure of carbon dioxide of 51 mm Hg, with venous carbon dioxide of 36 mg/dL. Mr C’s current medications include hydralazine hydrochloride, 100 mg twice daily; amlodipine, 5 mg/d; extendedrelease isosorbide, 90 mg/d; digoxin, 0.125 mg/d; bumetanide, 2 mg twice daily; metolazone, 2.5 mg as needed when his weight increases by more than 0.9 kg; warfarin, 5 mg/d; glyburide, 10 mg/d; colchicine, 0.6 mg/d; allopurinol, 100 mg/d; several bronchodilators that he inhales intermittently; oxygen; and stool softeners. [Editors’ note: The patient spoke little English, and during the interview his daughter spoke for him.]" @default.
• W2073353929 created "2016-06-24" @default.
• W2073353929 creator A5031717153 @default.
• W2073353929 date "1999-06-23" @default.
• W2073353929 modified "2023-09-25" @default.
• W2073353929 title "A 75-Year-Old Man With Congestive Heart Failure" @default.
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• W2073353929 doi "https://doi.org/10.1001/jama.281.24.2321" @default.
• W2073353929 hasPubMedId "https://pubmed.ncbi.nlm.nih.gov/10386557" @default.
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