Friday, November 15, 2013

Case History : Dilated Cardiomyopathy

In my clinical practice I do 'collect' one to two cases of congestive dilated cardiomyopathy  a month, not that rare, but my statistic is skewed because as a cardiologist, this kind of problem do land up on my 'table' .

Notable amongst them is a Malay male,  lorry driver, 45 year old who saw me some 13 years ago with a big ,globular heart on chest x-ray, coming to my outpatient clinic with complaint of shortness of breath on mild exertion. Echocardiogram examination revealed reduced heart pumping action [ contraction, LVEF ] of about 25 %  [ normal LVEF  is between 55 to 80 % ]. He is now 55, has three daughters who are now doctors, one of them in a specialist training program at the UITM hospital in Selayang. Every time I see him in my clinic, I tell him that he is the 'most successful lorry driver in the whole wide world !' His LVEF has climbed up to a decent 48%. Eddy Warman, that is his real name. With success, one do not need to use a pseudonym.
" Would you like me to refer you to Sungai Buluh ,Eddy, because there is nothing spectacular with your medications. All simple and all freely available for free in the government hospital ?"
"...Biarlah doktor. Disini ada barakah. Saya boleh bayar.. "
This 'biarlah doktor' has been going on for 13 years.
It is simple people like Eddy that keep me going all these years.

Which reminded me of a  patient I saw yesterday. And this is a digression from the subject. Not my patient actually. He came in for an 'executive profile' full examination and a stress test by me was one of the 'profile'. I was busy upstairs with my regular patients. I was late for 20 minutes.
" Doc, You guys treat us like animals!!....blah blah blah blah blah blah ", he stood on the threadmill  with arms akimbo, ready to fight. I read him well.
" I am very sorry Mr Ding, this is  totally unavoidable" , I am sorry.. ". 
We do  meet such characters in our daily practice once in a few years.
After nearly 33 years of practice, I thought of giving such young punk just a tight slap on the face , but he was lucky , I have a bad cold and was in no mood for confrontation.
They are usually lawyers. The lawyer-doctor alchemy is a bad alchemy I must say.
Lawyers somehow feel life is always confrontational.

Three ladies with congestive cardiomyopathy on my follow-up over the last 5 years did extremely well. One is an insurance banker, in her mid 40's, who came shortly after losing her baby at delivery and presented with heart failure [ peripartum congestive cardiomyopathy; cardiomyopathy realted with pregnancy ]. To make matters worst and cloud the issue further, she had dengue fever near delivery with platelet level around 12 thousand !

LVEF 12 % ! I had to ask a nurse to follow her whenever she went to the  loo. At 12 %, you can get cardiac arrest anytime or a bad fall in the toilet. Two months down the lane, she was fully active in her job and follow up echo six month later, was normal. Al hamdullillah!

The other two ladies in their 40's had 'tachycardia -induced' [ untreated fast heart beat ] dilated cardiomyopathy. The diagnosis was not apparent initially but much  later in their clinic follow up they came back with fast rythm [ supraventricular tachycardia ]which clinched the diagnosis. I referred both of them to my junior colleauge who did a 'radiofrequency ablation' of accessory pathways in their hearts. In layman's term these two ladies have an extra 'electrical circuits' in their hearts 'electrical cable system' that get  'switched on' for long period of time.
They are doing very well now and their LVEF are low normal.

...and there are young deaths as well. Mr Rodrigo, presented at age 41, a long haul tour bus driver plying Penang KL route, with a heart as big as a football, LVEF 18 %. Lasted for a long 5 years. Miraculously driving until his sudden premature demise at home from a cardiac arrest two months ago. In the UK I would be duty bound to have his license taken off by informing DLVC but in the UK they have good social security as safety net. I knew what was coming, thus advised him early on to co-opt his son to start taking over the business from him.

What is the role of heart transplantation in dilated cardiomyopathy, one may ask? It has a definite role and IJN is the place for it but one or two heart a year with a few hundred or thousands on the waiting list does not make a programme....Cadavaric heart donor is still a rarity in Malaysia.
So in my group of patients I prepare them  and their families early for possible premature demise, and do not put false hope in the horizon.

My 'champion' of course is  Mr LK Lee,a 40 year old dog-trainer, a bachelor, who spent 8 years of his life training dogs for the Saudi Police. I saw him 10 years back, walking into my outpatient clinic with bloated abdomen plus plus and bloated arms and bloated legs due to fluid retention. The bloated legs were so bad , that I could see fluid oozing out from its pores! His LVEF was in single digit and his heart was bloated and hardly pumping as seen on the echocardiogram.

Just last week I saw him on his three monthly follow up visit, looking very good.
"Lee, I did not tell you this but when I saw you 10 years back, I mentally gave you only a  month at the most to live.....", myself ,trying hard to bring the question of mortality on the table...
"Doc, this Tuhan-Allah has been kind to me . I am still able to train some dogs for a living, otherwise how I can pay your bill? "...[ Lee is still 'in this world' and not ready just yet, I thought to myself ]
" My God..Lee, you make me feel guilty. Your drugs cost peanuts compared to those guys who  had stents and angioplasty.."....
For Lee, 10 years is a long long time. Perhaps it is time I address his other 'heart' but political correctness and medical decorum does not allow me that leeway. And he is obviously not ready yet.

This is the 'stuff' that keeps me awake at night pondering, whether I have done enough.
Political correctness versus 'marhabah' for a fellow man.
It is not easy. You feel you have the alchemy and the secret to happiness in this life and the hereafter but you are not willing to share the secret  with the rest.
It is a responsibility we Muslims have to answer.

Nik Howk

ps : 
26/ 12/2013 [ one day post christmass ]

 just saw lee this morning at clinic
" kai fahal Lee? " [ how are you?]
" insyaallah doctor, alhamdullillah "
still the cheerful lee that i come to know 10 years back when he was just 47
he is 57 now, still training his german shepherds for some friends
" bila mahu masuk islam Lee,arab sudah pandai", i said half jokingly, half serious
"..belum ready, doc.."
i have a feeling of 'marhabah' for Lee after all these years
he is my favourite patient and why not: a 'left ventricular ejection fraction of only 8 %
and still around after 10 long years....a world record of sort!!!!

Other articles in the blog :

Purification of the Heart : " Matharat al Qulub'

1 comment:

komal singh said...

Very nice post, impressive. its quite different from other posts. Thanks for sharing.