Congestive heart failure patient needs expert care
Dear Dr. Roach: My husband was diagnosed with congestive heart failure a year ago. His ejection fraction was 15-20. Now it is 25-30, but he’s worse. For the past few months, he has been admitted to the hospital at least once a week. It started with an overload of 13 litres; he came home, and within a few days was unable to keep his blood pressure up and was readmitted for dehydration. They loaded him up on fluids, sent him home a few days later, and he was overloaded again. His kidneys get “insulted” every time he gets dehydrated. How do you find the balance?
D.E. Congestive heart failure is not a single disease; it’s a syndrome of inadequate blood flow from the heart to meet demand. It has many different causes, but the most common are longstanding high blood pressure, heart attacks and dilated cardiomyopathy, which itself often is caused by a virus but can be caused by alcohol or some chemotherapies.
One measurement of heart failure is the ejection fraction, the amount of blood pumped out by the left ventricle with every beat. That’s normally between 50 per cent and 75 per cent or so, but because the heart can dilate (enlarge), an ejection fraction of 15 per cent might cause only mild symptoms or might be incompatible with life. Further, medications that improve the ejection fraction can make symptoms worse in some people.
When the heart is as precarious as your husband’s, it is very difficult to manage fluid. Too little fluid, and the heart can’t provide enough blood for critical organs — in which case, the kidneys frequently are damaged. Too much fluid, and the heart fails and the lungs become congested, as can the abdominal cavity.
Heart failure this severe deserves an expert. General internists such as myself can manage many people with heart failure, but a cardiologist or even a cardiologist with special expertise in heart failure, can make a big difference. Careful management of medications might help him a lot. Unfortunately, some people will require more drastic treatments, such as a left-ventricular-assist device or a heart transplant. Not everyone is a good candidate for these therapies. Dear Dr. Roach: I’m a 63-year-old man in decent health, but with an age-related enlarged prostate. I take finasteride and tamsulosin daily. When I talked to my doctor about this, I got the idea that this medication works by lowering my testosterone, but my daughter says that might not be the case.
I recently joined an exercise program that is supposed to increase my testosterone levels and help me lose some belly fat (I’m maybe 20 pounds overweight). Will this cause me any problems, and will this increase my risk of prostate cancer?
J.K. Tamsulosin (Flomax) works by relaxing muscles in the prostate gland that block urine flow, so it starts working right away. Finasteride (Proscar) works not by blocking testosterone, but by preventing the body from making dihydrotestosterone, which increases prostate size and causes hair loss (maybe your daughter has read up on it). The preponderance of data show that finasteride causes no increase in prostate cancer risk.
Resistance exercise increases testosterone production, but the testosterone does not stay long in circulation. Exercise might reduce the risk of developing prostate cancer in the first place, and is likely to slow progression in people who have early prostate cancer. It’s yet another reason that regular exercise is beneficial. Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth @med.cornell.edu