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Heart Failure

My middle-aged patient was both confused and concerned.  “I don’t know what the deal is; I can barely make it the hundred yards to my mailbox and back without huffing and puffing and stopping to rest.  And I’ve never been a smoker, so what’s the deal?”

As it turned out, after a full work-up, the deal was heart failure.  Simply put, heart failure is when the pumping ability of the heart weakens to where it can’t readily keep up with the demands of the body.  It affects nearly 6 million Americans of all ages and is responsible for more hospitalizations than all forms of cancer combined.   In fact it is the number one cause of hospitalization for patients 65 years and up.  Nearly 50% of heart failure patients will die within 5 years of their diagnosis.

What causes heart failure?  There is quite a list of factors that can contribute: everything from blocked coronary arteries, diabetes, high blood pressure, heart valve abnormalities, infections and inflammations, toxins (such as excess alcohol) and certain genetic tendencies.  Often a heart which has been weakened a bit by one or more of these factors is pushed into symptomatic failure by excess salt intake, uncontrolled high blood pressure, a new heart rhythm disturbance such as atrial fibrillation, a heart attack or some serious infection.

Initially heart failure may show no symptoms at all.  However eventually a person may experience a long list of symptoms including shortness of breath with minor exertion or with laying down flat, rapid heart rate, tiredness, puffy ankles, chest pain or heart palpitations.

If you were to experience some of these symptoms and present to your doctor, several things could be done to help diagnose whether you had the beginnings of heart failure.  Of course a thorough description of the course of your symptoms including what makes them better or worse would be undertaken.  Likewise a physical exam (with particular focus on the heart, lungs, and blood vessels), blood tests, an EKG and tests such as a chest x-ray and echocardiogram would likely be ordered to assess the heart’s function.

What if in the end you did indeed have the beginning of heart failure?  You would then be given an idea of how advanced your heart failure was and a treatment plan would be put in place.  Certain lifestyle recommendations such as a low salt diet, quitting smoking or excess alcohol, avoiding certain meds such as NSAIDs (ibuprofen, naproxen), and aiming toward an ideal body weight and modest exercise would be discussed.  Likewise, there are a few meds that have been shown to be beneficial in certain types of heart failure and these would likely be started.  Risk factors such as high blood pressure, high cholesterol and diabetes would need to be carefully controlled.

Of course to pursue a healthy lifestyle to avoid the factors that lead to heart failure would be best of all.  But if in spite of that you or someone you love start showing symptoms of possible early heart failure, have it checked out; the earlier you start treating it with both lifestyle and appropriate meds the better your precious heart is likely to do.

Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville.  Contact him at 982-0835






Living and Dying By What We Eat

           “Let food be thy medicine and medicine be thy food.”  This was the advice of one of history’s best known physicians, Hippocrates, who lived around the 4th century B.C.  He must have had an okay idea of things as he apparently lived to around 90 years old when many were dying quite young.  At the same time, our diet isn’t the only determinant of disease and wellness.  Genetics, exercise, toxic habits, chronic stress, accidents, infections and many other factors play into it.

            A recently released study did a statistical analysis of the relationship between certain dietary habits and early death from heart disease, diabetes and stroke.  Ten particular dietary habits were connected with these bad outcomes.  A bit surprisingly, excess intake of salt had the biggest negative impact.  Here you want to be eating non-processed whole foods as much as possible, while avoiding fast foods and, unfortunately, going very carefully with any restaurant food as well.  Most of the salt is already in the food even if you don’t add any at the table.  Read labels, but almost anything in a box, bag, jar or can already has a good bit of salt in it.  Shooting for less than 2 grams (2000 mg.)of sodium per day is a good goal.

            Next in line for increasing early deaths was having too low of an intake of seeds and nuts.  Who knew squirrels were so smart? So, munch on those almonds, but don’t get the super salty variety.  High processed meat intake came in third in negative impact, so try to minimize cold cuts, hot dogs and sausages.  And since low seafood intake (with its healthy omega-3 fats) was another cause of increased early deaths, replace them with tuna or salmon a couple times a week.

            Here we come to no surprise as numbers five and six were too low an intake of vegetables and fruits.  The goal of about four servings of each per day is ambitious but pays off.  And while you’re eating all those fruits and veggies, take a pass on the sugar-sweetened drinks.  The sweet teas, Mountain Dews, full-sugar sports drinks and other sugary drinks drive us toward obesity, diabetes, and earlier death.  Of course water is best.  The non-calorie flavored drinks, though not perfect, can be consumed in moderation.  For the most part, “Don’t drink your calories” is a good motto to go by.  Strikingly, higher intake of sugar-sweetened drinks was the factor with the highest impact on early cardiovascular death in the younger (25-64 year old) population, while salt kicked in more in the 65 and older population.

            A final couple of factors that were negatives were too little intake of polyunsaturated fatty acids (think olive oil, salmon, nuts and similar sources of “good fats”) and whole grains.  Excess intake of unprocessed red meat had only a very minimal negative impact – whew!

            None of us is going to eat perfectly, but some attention toward accentuating the good stuff and passing on the bad stuff can help a lot.  This study showed that almost half of early death from stroke, heart disease and diabetes could be attributed to one or more of these dietary habits.  And with a little attention, you really can find a lot of foods that you actually like and are still good for you.  Don’t believe the line, “If it tastes good, spit it out.”

            In the end we’re told in Psalm 90 to “…number our days that we may obtain a heart of wisdom.”  I do believe our days are ultimately set by our Creator, but He generally works by using means in our life, and a healthy diet can be a potent one.  The idea is to enjoy a healthy diet, not to obsess or stress over it.  Dig in!

Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville.  Contact him at 982-0835


Whooping Cough: Still Lurking

The 3 year old girl sat quietly on the exam table as her mom described her symptoms.  “A couple of weeks ago she had what just seemed like a cold.  Then she developed a little cough.  But day by day it’s just gotten worse and worse.  She’ll seem fine in between coughing spells  but when she starts coughing she just goes and goes until she finally has to take a big breath in.  Sometimes she coughs so hard it makes her throw up.  And night-time is terrible; that’s when it really picks up.”

That description is quite typical for whooping cough, also called pertussis, and sure enough the nasal swab we used to test this little one came back the next day positive for pertussis. Whooping cough gets its name from the “whooping” sound that is made when gasping for air after a fit of coughing.  It is sometimes called “the 100 day cough” but it often drags on even longer.  Worldwide there are still an estimated 30-50 million cases of whooping cough yearly with about 300,000 deaths.  Pertussis is particularly prevalent in the many nations where vaccination rates are low.  One study found that, in eight countries where immunization coverage was reduced, incidence rates of pertussis surged to 10 to 100 times the rates in countries where vaccination rates were sustained.

In the U.S., before pertussis immunizations were available, nearly all children developed whooping cough. Between 150,000 and 260,000 cases of pertussis were reported each year, with up to 9,000 pertussis-related deaths.  Since the onset of routine vaccination, pertussis has fallen to about a 10th of that number of cases and last year, for comparison, there were 18 deaths from pertussis.  Case numbers show that children who haven’t received pertussis vaccine are at least 8 times more likely to get pertussis than children who received all 5 recommended doses.

The majority of deaths occur among infants younger than 3 months of age and more than half of infants less than 1 year of age who get pertussis are hospitalized.  That’s why, besides the need to start vaccination of infants promptly at 2 months of age, vaccination of preteens, teens and adults – including pregnant women – is especially important for families with new infants.   Unfortunately, this little 3 year old is from a big family who doesn’t immunize, and the disease is quite infectious.

Here’s the tricky thing about whooping cough: It starts just like a cold, followed a few days later by an increasing cough.  So at first, it really doesn’t seem like anything very serious.  By the time the cough has really shown itself to be something suggesting whooping cough, antibiotics (such as azithromycin and other relatives of erythromycin) only slightly change the course of the illness.  Antibiotics do at least render the person non-infectious which is no small thing given how highly contagious it is.

So, what are the take-home messages?  Old, and potentially deadly, illnesses like whooping cough are still around and can rear their ugly heads, especially when vaccination rates fall.  So be sure and protect yourself, your kids, and your community with timely immunization.  When whooping cough is around, there is no need to panic, but there is certainly a need to be vigilant.  Even minor respiratory symptoms need to be checked out early to stop the progress of this miserable, and potentially dangerous, malady.

Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville.  Contact him at 982-0835


Respiratory Syncytial Virus (RSV)

“He’s really just been moving a little slower than usual and not eating or drinking as much… and he’s kept a fever for a few days.  Oh, and I noticed he seems to be breathing a bit quicker than usual, and just seems tired.  Other than that just cold symptoms with a runny nose and a cough.  Finally I decided to bring him in to be checked.”  Mrs. Clay, a young mom of a cute but tired-looking 3 year old boy, was relating the recent chain of events that had landed her son, Tommy, in our office after 5 days of symptoms.

Tommy looked deceptively OK.  He just sat rather placidly on the exam table waiting for me to check him over.  He didn’t look like he was in any particular distress.  When I listened to his lungs there were no crackles or wheezes, just normal breath sounds.  But those breath sounds were at a rate of almost 60 breaths per minute – two to three times the normal rate for him.  And his oxygen level from the pulse oximeter was an even 90% when a healthy 3 year old should be in the high 90’s.  It was all enough to convince me he needed a chest x-ray.  Sure enough, the x-ray showed pneumonia on both sides.  That made my next decision easier – next stop, Children’s Hospital in Knoxville for what ended up being a two day hospital stay for supportive treatment.

The cause of Tommy’s pneumonia was respiratory syncytial virus (RSV).  During these days when we are seeing schools close due to illnesses, we are seeing flu, strep, flu-like viruses, and yes, RSV.  RSV is the leading cause of lower respiratory tract infections (think pneumonia, and a wheezing condition called bronchiolitis) in infants and young children. In the U.S. each year, 4-5 million children younger than 4 years old acquire an RSV infection, and more than 125,000 are hospitalized.

Symptoms of RSV infection may include fever, cough, rapid breathing, shortness of breath, fatigue, wheezing and other abnormal lung sounds.  In young infants, apnea and cyanosis (turning bluish) may occur.  Of course with any of these symptoms at a significant level it would be wise to have a child examined, their lungs listened to, and their oxygen level checked.  When appropriate, there is a fairly easy in-office test that can be done to confirm or rule out RSV.        When it comes to treatment, it is mainly supportive – keeping them hydrated, making sure they are not getting exhausted with their breathing, being sure they are maintaining a good oxygen level.  Those who have more severe cases are the ones who end up in the hospital on IV fluids and oxygen.  There are also some rather rarely-used meds and preventives used primarily on the very young or those with congenital heart and lung conditions.  Otherwise, bronchodilators help only a few and most of the other treatments such as steroids haven’t really proven themselves in studies.  So all-in-all, treatment is mostly to support the patient while their body fights off this rather miserable virus.

Infants hospitalized for RSV are at higher risk for subsequent wheezing and abnormal pulmonary function and this increased risk may persist for up to 10 years or longer. RSV’s role in causing subsequent reactive airway disease (asthma) remains controversial. By age 3 almost all children have had at least one episode of RSV.  It is primarily in those well under a year of age that the illness can, rarely, be life-threatening. Unfortunately recurrent infection can occur and usually produces illness lasting 7-10 days rather than the typical 3-4 day illness caused by most colds.  Even the elderly can get severe RSV infections and November through February tends to be peak RSV season in Tennessee. So if those respiratory symptoms seem a bit worse or are dragging on longer than expected, best to get them checked out and see if those three letters, RSV, have gotten you.

Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville.  Contact him at 982-0835