This site is intended for health professionals only

At the heart of general practice since 1960

Out-of-hours doctor fobbed off breathless patient with antibiotics

Dr Tanvir Jamil explains why it is crucial to look for LVF in patients with breathing difficulties

Dr Tanvir Jamil explains why it is crucial to look for LVF in patients with breathing difficulties

Case History

David is a 65-year-old ex-smoker who had an MI five years ago. He also has COPD. He called the out-of-hours doctor last night for advice on cough and problems breathing. He asked for antibiotics, which often sort out his chest. This morning his wife asks you to 'pop in'. You find David is short of breath, wheezy and a little blue. You diagnose left ventricular failure.

That's the trouble with using an out-of-hours service ­ your patients often suffer.

Let's not be quick to blame the duty doctor. How many times have we all prescribed anti-biotics to an older patient who requests them? Do we always take a full history? Point taken. I haven't seen much LVF in general practice since the paramedics seem to get all the interesting cases.

What are the main features?

The classic symptom is paroxysmal nocturnal dyspnoea caused by redistribution of excess fluid into the lung when recumbent. Other symptoms include fatigue, breathlessness on mild exertion and nocturnal cough. Occasionally patients cough up pink-tinged or brown sputum. Tachycardia is one of the earliest signs.

Others include a laterally displaced apical impulse, basal crepitations and a ventricular or atrial gallop rhythm. Pleural effusions may also occur and these usually accumulate in the right hemithorax first then bilaterally. Excess pulmonary fluid can manifest as bronchospasm and wheezing.

What about the differential diagnosis?

Include all the causes of breathlessness, especially asthma, COPD and obesity. A chest X-ray may be needed to distinguish a severe asthma attack from acute LVF. However, asthmatic patients are usually younger, have a history of atopy and there is often an obvious trigger such as an upper respiratory viral infection. Also their peak flow is low and they usually respond well to salbutamol.

Sounds like David has had acute LVF.

I agree. He has some of the typical features ­ extreme dyspnoea, cyanosis, tachypnoea, restlessness and anxiety with a sense of suffocation. Patients are often pale and sweaty and prefer sitting upright. The pulse is rapid and thready and BP may be low.

Respiration is laboured and crepitations widespread. Hypoxaemia can be severe and carbon dioxide retention is a late ominous sign.

Would you agree the main cause in David is probably an MI or ventricular damage from longstanding ischaemic heart disease?

Yes. Other causes include:· cardiomyopathy· hypertension· valvular heart disease· arrhythmias· infection· pregnancy.After admission, what kind of investigations are the admitting team likely to carry out and why?Most of these investigations should also be done on patients with intermittent LVF who do not require admission:·

  • FBC ­ check for anaemia
  • U&Es ­ renal function as a baseline prior to diuretic and ACE inhibitor therapy
  • thyroid function ­ especially with atrial fibrillation
  • ECG ­ look for infarction, ischaemia, ventricular hypertrophy; LVF is unlikely in the presence of a normal ECG
  • chest X-ray ­ look for upper lobe diversion, diffuse patchy lung shadows, pleural effusions and cardiomegaly
  • peak flow ­ not very reliable in acute situations; PF < 200l/min indicates a probable respiratory cause
  • echocardiography ­ the investigation of choice; some GPs are now able to order an echo without a consultant appointment; an echo will shed light on ejection fraction, valve function, wall motion abnormalities and left ventricular hypertrophy
  • follow-up after discharge may include exercise ECG and coronary angiography.

After discharge what kind of medication is David likely to be on?

  • ACE inhibitors ­ beneficial effects on ventricular remodelling and reduce mortality in patients with significant failure
  • diurectics ­ low-dose spironolactone (25mg daily) has been shown to reduce mortality in some patients on ACE inhibitors and other diuretics
  • statin ­ with his history of MI David should already be on a regular statin.

Other patients may require Digoxin (a positive ionotrope useful in atrial fibrillation), other antiarrhythmics, vasodilators and beta-blockers.

What is my role as David's GP?

You should review him once he has been discharged and ensure he is on optimal therapy and taking it correctly. Arrange regular bloods to assess renal and liver function and lipids, especially if he is on an ACE inhibitor and statins. David will also need advice about exercise, salt, smoking, NSAIDs, fluids and alcohol. Don't be afraid to talk about lifestyle including sexual activity. If a patient can manage two flights of stairs briskly, sex should not be a problem.

What about his outlook?

The prognosis of heart failure is often worse than certain cancers. Almost half of readmissions are due to poor compliance, excessive salt or fluid intake or taking inappropriate medications such as NSAIDs. Other factors include sub-optimal therapy, anaemia, occult thyroid disease, treatment-induced hypotension, excess alcohol consumption and adverse drug effects. Heart transplantation is the only treat-ment that changes the history long-term. Tanvir Jamil is a GP in Burnham, Buckinghamshire

Key points

  • Paroxysmal nocturnal dyspnoea equals left ventricular failure
  • Heart failure patients need regular monitoring to ensure optimal therapy
  • Don't be afraid to bring up sexual health with older patients ­ especially if their partner is well
  • Heart transplantation is the only treatment that changes the natural history of LVF long-term

Rate this article 

Click to rate

  • 1 star out of 5
  • 2 stars out of 5
  • 3 stars out of 5
  • 4 stars out of 5
  • 5 stars out of 5

0 out of 5 stars

Have your say