Decompensated Heart Failure and Alternative Medicine

Today's case involved a 77-year-old man referred to medicine for progressive dyspnea of around one year’s duration.  He experienced orthopnea and increased leg swelling. He is also known for aortic stenosis, a history of congestive heart failure, and hypertension as well as a JAK-2 positive myeloproliferative disorder.  His physical examination was consistent with decompensated heart failure.  Further history was obtained which included some naturopathic remedies consisting of unknown infusions and blood ozonation by some sort of German machine.

Learning points:

-Dyspnea is a common presenting complaint to an emergency department; it is essential to remain open to diagnostic possibilities regarding its etiology – common players include decompensated heart failure, exacerbations of chronic pulmonary diseases, and venous thromboembolic disease.

-Historical points that help you rule in a diagnosis of heart failure are: previous admissions for heart failure, orthopnea, paroxysmal nocturnal dysnpea, leg swelling, dysnpea on exertion, needing several pillows for sleep and/or sleeping in a seated position

-On physical examination, inspiratory crackles, peripheral edema, a positive abdominojugular reflex, an elevated JVP, and an S3 can be helpful findings

-Dealing with people seeking ‘alternative’ medical advice in conjunction with allopathic (our) medicine can be challenging for several reasons:  We are not taught what many of these therapies are.  Our previous mantra that they are unlikely to help but are probably not harmful is likely untrue – many of these therapies present harms and risks to patients.  We sometimes see providers of alternative therapies as taking advantage of desperate people from a financial and hope perspective.  Finally, it seems as though we, as a hospital, are expected to ‘pick up the pieces’ when these therapies fail or cause harm to patients

-Maintaining a degree of composure and openness regarding alternative medicine while providing advice to people is essential to our therapeutic relationships

-Many people are on proton pump inhibitors and other chronic medicatons which do have harms and are rarely ‘debrided’ from their medication list by their usual practitioners

Further Reading:

Srivastava, R. (2012). What's the alternative? The worldwide web of integrative medicine. N Engl J Med, 366(9), 783-785.

Wang, C. S., FitzGerald, J. M., Schulzer, M., Mak, E., & Ayas, N. T. (2005). Does this dyspneic patient in the emergency department have congestive heart failure?. Jama, 294(15), 1944-1956.