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Silent ischemia1
The Journal of Emergency Medicine, Vol. 22, No. 4, pp. 423– 424, 2002 Copyright © 0 Elsevier Science Inc. Printed in the USA. All rights reserved 0736-4679/⫺1900 $–see front matter
PII S0736-4679(02)00441-9
Humanities and Medicine
SILENT ISCHEMIA Ijaz A. Khan,
MD, FACP, FACC
Division of Cardiology, Department of Medicine, Creighton University School of Medicine, Omaha, Nebraska, USA Reprint Address: Ijaz A. Khan, MD, FACP, Creighton University Cardiac Center, 3006 Webster Street, Omaha, NE 68131
I saw 94-year-old Mrs. M in an outreach clinic. Mrs. M was being treated for hypertension. She was enjoying a healthy life until 6 months previous when she was diagnosed with hypertension on a routine physical examination. She was told that her blood pressure was mildly elevated. Anti-hypertensive therapy was initiated with a -adrenergic receptor blocking agent. On each of the subsequent visits, a new anti-hypertensive agent was added to her drug regimen, and eventually, to achieve the ideal control of blood pressure, her anti-hypertensive drug regimen consisted of a maximum dose of a -adrenergic receptor blocking agent, a high dose of a calcium-channel blocker, and a high dose of an ␣-adrenergic receptor blocking agent, along with a high dose of a diuretic agent. Mrs. M’s symptomatic life began after initiation of the medications for treatment of high blood pressure. She started feeling weak and dizzy and experienced symptoms of easy fatigability and muscular ache. However, these symptoms were attributed to her advancing age. Mrs. M was a compliant patient, and continued using all of the medications as advised. Meanwhile, her symptom of dizziness continued getting worse and one day, while standing up from a couch after a prolonged period of sitting, she felt severe dizziness and fell down. The fall resulted in fractures of her spine and right hip joint. She underwent multiple orthopedic manipulations, resulting in a 2-week hospitalization. The pain, agony, and suffering she went through were, in her words, “indescribable.” After 2 weeks of hospitalization, she was dis-
charged home in a wheelchair. All of the antihypertensive medications were discontinued, except for a low dose of a -adrenergic receptor blocking agent, and her blood pressure remained near the upper limits of normal. During hospitalization, an electrocardiogram (EKG) was taken. The EKG showed ST-T wave changes, which were diagnosed as silent ischemia. A cardiology consultant told her she possibly would be transferred to a tertiary care center at a 2-h driving distance for a cardiac catheterization. This was the reason for her current visit. The consult request read ‘management of silent ischemia—possible cardiac catheterization.’ After reviewing her chart, I went to see Mrs. M, who was sitting in a wheelchair with a mixture of fear, depression, and agony on her face. After greetings and introducing myself, I asked Mrs. M my usual first question. “What bothers you Mrs. M?” She replied, “Severe pain in my back and right hip. I fell down at my home. I was taking all the medications as was advised for the treatment of high blood pressure. I could not understand why did I fall down, but doctors in the hospital told me it was because of an excessive drop in my blood pressure upon standing up after a prolonged sitting. I think I should have taken it easy and should have stood up slowly rather than abruptly.” She then told me about the EKG that was taken while she was in the hospital for management of fractures. She never experienced chest pain. Unfortunately, that particular EKG was not present in the chart. She insisted that I look at her EKG. She was curious to get another cardiologist’s opinion about it. I
Humanities and Medicine is coordinated by Richard M. Ratzan,
RECEIVED: 2 July 2001; ACCEPTED: 29 October 2001 423
MD,
of West Hartford, Connecticut.
424
went page by page through her two-volume chart but could not find her EKG. The nurse also attempted to locate her EKG from the hospital records but was unsuccessful. Her cardiac evaluation was all within normal limits. Considering her insistence that I look at her EKG, I gave her the option to have a new EKG. This option brought a sense of intense fear on her face. She said, “How will I be transferred from the wheelchair to the couch? I am in severe pain, I cannot lie flat, and just a little bit of movement causes excruciating pain in my back. Well! I will try. I want to know what is wrong with my EKG. I never had any heart problem, I never had any heart symptoms.” Mrs. M was taking three different types of analgesics, including one narcotic analgesic to alleviate pain. In addition, she needed the aid of a sleeping pill at night. Eventually, an EKG was taken. It was abnormal—it
I. A. Khan
had widespread nonspecific ST-T wave changes. I noticed expressions of fear and impatience on her face while I was looking at the EKG. She said, “Did you see silent ischemia on my EKG?” I said, “No, you do not have to be transferred to the tertiary care hospital for cardiac catheterization.” I saw a dramatic change in her facial expression. The expression of fear changed to that of relief. I witnessed a smile on her face—the first time during this visit, and she said, “Thank God! This silent ischemia was killing me. I was worried to death about transfer to another city. I am in so much pain that I cannot even move comfortably from wheelchair to bed.” While driving back home that evening, I was thinking, “what was more important in 94-year-old Mrs. M’s life: an ideal control of blood pressure and management of ‘silent ischemia’— or—preservation of the quality and dignity of life?”
PII S0736-4679(02)00441-9
Humanities and Medicine
SILENT ISCHEMIA Ijaz A. Khan,
MD, FACP, FACC
Division of Cardiology, Department of Medicine, Creighton University School of Medicine, Omaha, Nebraska, USA Reprint Address: Ijaz A. Khan, MD, FACP, Creighton University Cardiac Center, 3006 Webster Street, Omaha, NE 68131
I saw 94-year-old Mrs. M in an outreach clinic. Mrs. M was being treated for hypertension. She was enjoying a healthy life until 6 months previous when she was diagnosed with hypertension on a routine physical examination. She was told that her blood pressure was mildly elevated. Anti-hypertensive therapy was initiated with a -adrenergic receptor blocking agent. On each of the subsequent visits, a new anti-hypertensive agent was added to her drug regimen, and eventually, to achieve the ideal control of blood pressure, her anti-hypertensive drug regimen consisted of a maximum dose of a -adrenergic receptor blocking agent, a high dose of a calcium-channel blocker, and a high dose of an ␣-adrenergic receptor blocking agent, along with a high dose of a diuretic agent. Mrs. M’s symptomatic life began after initiation of the medications for treatment of high blood pressure. She started feeling weak and dizzy and experienced symptoms of easy fatigability and muscular ache. However, these symptoms were attributed to her advancing age. Mrs. M was a compliant patient, and continued using all of the medications as advised. Meanwhile, her symptom of dizziness continued getting worse and one day, while standing up from a couch after a prolonged period of sitting, she felt severe dizziness and fell down. The fall resulted in fractures of her spine and right hip joint. She underwent multiple orthopedic manipulations, resulting in a 2-week hospitalization. The pain, agony, and suffering she went through were, in her words, “indescribable.” After 2 weeks of hospitalization, she was dis-
charged home in a wheelchair. All of the antihypertensive medications were discontinued, except for a low dose of a -adrenergic receptor blocking agent, and her blood pressure remained near the upper limits of normal. During hospitalization, an electrocardiogram (EKG) was taken. The EKG showed ST-T wave changes, which were diagnosed as silent ischemia. A cardiology consultant told her she possibly would be transferred to a tertiary care center at a 2-h driving distance for a cardiac catheterization. This was the reason for her current visit. The consult request read ‘management of silent ischemia—possible cardiac catheterization.’ After reviewing her chart, I went to see Mrs. M, who was sitting in a wheelchair with a mixture of fear, depression, and agony on her face. After greetings and introducing myself, I asked Mrs. M my usual first question. “What bothers you Mrs. M?” She replied, “Severe pain in my back and right hip. I fell down at my home. I was taking all the medications as was advised for the treatment of high blood pressure. I could not understand why did I fall down, but doctors in the hospital told me it was because of an excessive drop in my blood pressure upon standing up after a prolonged sitting. I think I should have taken it easy and should have stood up slowly rather than abruptly.” She then told me about the EKG that was taken while she was in the hospital for management of fractures. She never experienced chest pain. Unfortunately, that particular EKG was not present in the chart. She insisted that I look at her EKG. She was curious to get another cardiologist’s opinion about it. I
Humanities and Medicine is coordinated by Richard M. Ratzan,
RECEIVED: 2 July 2001; ACCEPTED: 29 October 2001 423
MD,
of West Hartford, Connecticut.
424
went page by page through her two-volume chart but could not find her EKG. The nurse also attempted to locate her EKG from the hospital records but was unsuccessful. Her cardiac evaluation was all within normal limits. Considering her insistence that I look at her EKG, I gave her the option to have a new EKG. This option brought a sense of intense fear on her face. She said, “How will I be transferred from the wheelchair to the couch? I am in severe pain, I cannot lie flat, and just a little bit of movement causes excruciating pain in my back. Well! I will try. I want to know what is wrong with my EKG. I never had any heart problem, I never had any heart symptoms.” Mrs. M was taking three different types of analgesics, including one narcotic analgesic to alleviate pain. In addition, she needed the aid of a sleeping pill at night. Eventually, an EKG was taken. It was abnormal—it
I. A. Khan
had widespread nonspecific ST-T wave changes. I noticed expressions of fear and impatience on her face while I was looking at the EKG. She said, “Did you see silent ischemia on my EKG?” I said, “No, you do not have to be transferred to the tertiary care hospital for cardiac catheterization.” I saw a dramatic change in her facial expression. The expression of fear changed to that of relief. I witnessed a smile on her face—the first time during this visit, and she said, “Thank God! This silent ischemia was killing me. I was worried to death about transfer to another city. I am in so much pain that I cannot even move comfortably from wheelchair to bed.” While driving back home that evening, I was thinking, “what was more important in 94-year-old Mrs. M’s life: an ideal control of blood pressure and management of ‘silent ischemia’— or—preservation of the quality and dignity of life?”