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Saturday, December 05, 2009

Chief Is Okay For No Reason

Technically, this is all unexplained. But the Chief is fine. I got him out of the hospital last night. His resting blood pressure had never come down but was at least hanging in the 150-160/80 levels, and his pulse had slowed.

The hospital tried to sneak in the Imdur, but luckily I was there when they tried (they didn't even tell him what they were giving him). I said no, thereby mightily pissing off a really superb cardio nurse. SuperDoc and I were calling back and forth all day - I'd get the Chief's readings and retail them over the phone.

By the afternoon, based on the Chief's response to nitro, SuperDoc had told me that Imdur could well kill the Chief. SuperDoc's exact words were "You'll get him home and he'll go out right before your eyes."

Anyway, SuperDoc called in a prescription for a vasodilator that he thought would be a heck of a lot safer, although he didn't want me to use even that unless I absolutely had to.

So here's the SuperDociness of it all: I did not give the Chief any meds last night at all, based on my guidelines from SuperDoc even though the Chief's low reading was hanging in the 80s and the high didn't want to go down from the low 150s. By 5:30 AM the Chief's BP was 93/53, pulse 66. SuperDoc wins again. The highest so far today is 128/68. At SuperDoc's office it was 120/70.

All the heart tests have come back fine. The echocardiogram yesterday was great. The highest occlusion he's got is 40% (this keeps dropping). The hospital cardiologist had not even reviewed the Chief's records when ordering the Imdur, but did after I refused the Imdur on SuperDoc's orders. Cardiologist's final conclusion was that the pain has nothing to do with his heart. That's fine, but the Chief's sudden escalations of blood pressure and pulse are due to some sort of stress. He shows no fever still.

So SuperDoc told me just to sit on the Chief, and call him any time all weekend if something whacks out again. On Tuesday SuperDoc had told me that the next step was to check gall bladder and esophagus, but he didn't want to do esophagus until the Chief is stable.

The Chief normally does not have high blood pressure. However the pain is associated with these fits of high blood pressure. That much I have confirmed. Whether this is angina or whether the blood pressure is causative or a side effect of a cause is in question. Because the Chief is eating so carefully he may not have noticed other symptoms of gall bladder disease. In severe cases, the duct can become so blocked that the gall bladder becomes infected. If there is a sudden release of infected matter into the intestines, some interesting misery can result as the intestinal tract spasms, and of course a gall stone that's traveling through the duct is going may cause havoc.

So if the Chief stays stable over the weekend SuperDoc will refer him for gall bladder testing although he says he cannot let him be sedated right now for an intubation.

In any case, thanks for the kind wishes, tips and prayers. The Chief is very happy to be home; the bulldog is even happier than the Chief. She rode shotgun with us to the doctor's office this morning.

Right now the Chief is on Plavix, Toprol (metoprolol) and lovastatin.

The Chief's chest pain did not remit in the hospital this time even with nitro.

Anyway, for the Anon commenter and those who are wondering about my concern with blood pressure: The Chief does not have sustained high blood pressure. As far as we can tell, his blood pressure is both rising and dropping abnormally for him. Also the Chief's blood pressure has normally been in regular ranges. The cardiologist at the specialty hospital decided this was angina, but it may not be.

Sudden drops in blood pressure can be a symptom of staph infections in the gall bladder or of the biliary duct, which connects the liver, gall bladder and pancreas to the intestine. A gall stone can travel through and block the duct below the pancreas, causing transient pancreatitis. If the gall bladder is infected (especially with staph), you can have a nasty situation develop:

Although the last blood test (Monday) did not show an elevated WBC, the later (not the initial) test in the hospital in SGA did. It is possible that the Chief is experiencing intermittent gall bladder attacks and has a mild infection in there somewhere that is sometimes draining. The Chief has a bang-up immune system which normally does a great job of suppressing infections; he may have a walled off infection.

I am also supposed to check the Chief's blood sugar this weekend just in case anything odd is happening there. So far nothing odd has shown up on the tests, but if his blood sugar is fluctuating oddly it might be time to head down to that duct. Even transient inflammation of the common duct could cause spasms.

Since this appears to have been going on for just about two months, sitting and waiting for it to pass is no longer an option.

PS: Chief's last BP at 12:30 was 108/53, so you can see why I am sending up prayers of gratitude for SuperDoc's deferred retirement. An extended release vasodilator is not what the Chief needs.

MoM, I'm happy that things have stabilized, at least a little.

The systems of the human body are interconnected to an amazing degree, sometimes to clear purpose, sometimes to no clear purpose. The linkage between the immune system and glucose regulation is an example of the latter (they re-use signalling cytokines). I've just run into an example of the former: I was put on sitagliptin back in March. After several weeks I started to get severe irritation and then abscesses at the lower end of the digestive tract. Turns out the sitagliptin was not just disinhibiting the beta cells; it was disinhibiting the whole pancreas (though not to such a degree). It's such an effective med that I'm back on it at 25mg (they start at 100) but even that may have to get cut back. Effective? Amazing. It actually appears to be reversing the "beta cell burnout."
Thank God the Chief is doing better! I wish SuperDoc lived around my area. I keep picturing him looking like Hugh Laurie + 20 years.
Glad you have arrested the decline. Try to avoid shoveling any snow for a couple weeks.....
CF - It IS snowing. But the Chief is still stable, so I don't think I will have to make a hospital run tonight.

The Chief just volunteered for his next BP reading, explaining that he would characterize this as a "rational experimentation protocol".
Wacky Hermit - well, I dragged the Chief about 1000 miles to the snow to get him to SuperDoc, but I'd say it's worth it. There should be a SuperDoc lurking somewhere in your area if it is not too rural - the trick is finding him or her!

Anon - it is amazing the drugs we have. The downside is that combinations and individual reactions become ever more problematic so you need to be exceedingly careful with them. I just can't get over the stuff that's available these days. They've even got one that controls Philadelphia CML. I was astounded to read about Gleevac. The age of miracle drugs.
Glad to hear the Chief is better. Hope you have a quiet and restful remainder of the weekend.
Its good to hear that the Chief is more stable; it helps to have such good 24/7 nursing care.
Great news that the Chief is stable!

I'm guessing that the gall bladder may be the culprit. Can cause weird symptoms that mimic heart problems. Nitro usually causes the pain to decrease but does nothing to remedy the underlying problem. Since nitro did not help, it is probably something beyond just stones, as you said.

Your posts have about the Chief and your medical problems have been a huge argument against the dem healthcare plans. It appears to me that, under their plans, we will not have nearly as much flexibility to diagnose and treat our maladies. The medical bureaucrat is going to be the third party in every medical encounter. And they will drive super Docs out of the business.

Thanks for all the detail and keep us informed. It will be good to know how this is resolved.
I am glad to hear the news! and "sneaking" drugs past a caregiver because the "professional" knows better is not uncommon.
OK, sadly I need more info but I think I know enough to give you the following thoughts to help frame the issues as a physicians might.

As I read your posting, there are several independent but related themes. The two biggest are:

A. Chest pain (CP)
B. Hypertension (HTN)

Some questions I would consider asking:

1. "Why does he have chest pain?"
2. "Why is his blood pressure elevated?"
3. "Are the two related?"
4. "If so, in which direction does the relationship flow?"
5. "If, not then what is going on?"
5. "Are either a problem today?"
6. "Are either a problem tomorrow?"

HTN is a leading cause of renal failure, stroke, coronary artery disease, congestive heart failure, etc... e.g HTN is a major killer, so do not think what I am about to say is belittling the problem. I am truly to give you some context.

But HTN is also a silent killer- e.g. most people do not feel when their blood pressure is elevated, which is why it is such a killer.

HTN kills people in much the way water creates the Grand Canyon. Take a garden hose and spray it against a rock wall for a week- no big deal. Do the same for 1 million years and you have the Grand Canyon.

HTN causes changes to the body's blood vessels over long periods of time that lead to all the problems I alluded to (and more)

Here is my point: IT TAKES TIME.

How long has he had blood pressure issues for?

Then remember that when someone's blood pressure is elevated, it does not usually cause pain.

The reason you see doctors get concerned about blood pressure in chest pain is that IF one is having an acute coronary syndrome or a dissecting thoracic aortic aneurysm, then the elevated blood pressure will make these conditions much worse. But if they are not, then elevated blood pressure in the setting of chest pain has an entirely different- less worrisome- meaning... caveat: unless you have another reason to to worry about the elevated blood pressure.
Anything that causes an elevation in your adrenaline will cause an elevation in your blood pressure.

Therefore pain causes elevations of blood pressure: take a hammer to your thumb and you can verify if you want. ;-)

Which means you should consider (I only say consider) anxiety as statistically, the most common cause of chest pain and elevated BP is anxiety.

Please do not misunderstand me, what is statistically true over large populations is not necessarily true in any one individual... But you should consider it.

AND people who check their BP often usually check it because they are worried. Anxiety effects EVERYONE, even those who tolerate severe physical pain quite well. We all get anxious at times.

Perhaps the following will help:

Obesity is also a major killer in America. Most people however, do not worry about seeing 50 additional pounds when they step on the bathroom scale. Intuitively they understand it is a problem, but it does not cause them immediate anxiety- e.g. they have time.

BP elevations usually have a similar urgency to them in most instances as being 50 lbs over weight, but most people do not have as much experience dealing with elevated BP as they do with obesity. Hence they worry more.

Enough on that

The next question to ask yourself is:

Has he ever had a heart attack?

If not, did he have chest pain and then a coronary cath and the cath showed 40% coronary stenosis?

If so, did the doctors think the chest pain was from this stenotic segment (what we call unstable angina)?

Or did they think the chest pain unrelated to the heart?

Or were they really unsure?

40% stenosis is tough they don't cause angina at 40% narrowing but they can become unstable lesions- sometimes the cardiologists can tell this from looking at the surface contour of the stenotic segment on the cath tapes. Sometimes they cannot.

If I read you correctly, it sounds like they have never diagnosed him with HTN nor do they think his chest pain is from his heart, is this correct?

If so, stop worrying about his blood pressure so much unless there is some other reason to worry. Focus on why he is having chest pain.

Again, I am not saying ignore it, but frequent checks are not helpful.

And again, to be absolutely clear, if he has had a heart attack, or he has congestive heart failure, or a thoracic aneurysm, or another reason to worry about his blood pressure (there are others), then you should worry (within limits). Yet even then over frequent BP checks can be counter productive.

Biliary disease is a cause of chest pain, but there are many many others.

Here is a list of the typical differential diagnoses for chest pain.

I hope this helps and good luck
Excellent news. I hope for a quick return to complete normality soon.
Compliments and respect to SuperDoc too. We need lots more of the kind.
So glad the Chief is better. Prayers have not ceased. Try, try, to be kind to yourself, too.
Michael Adams
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