IT WAS, I believe, Herophilus who in 300 B.C. said that the best physician is the one who can distinguish between what is possible and what is impossible. Sigerist, Henry E.: “The Great Doctors,” New York, W.W. Norton. 1933, p. 45. In the treatment of congestive heart failure we must realize that only certain things are possible and they are made possible only by medication which is physiologic in nature. If we fail to face that fact our patient will fail to improve.
The treatment of congestive heart failure can be divided into several general divisions and I shall go over them briefly, with the chief object in view of being practical.
The first need is rest. Complete rest is essential. It acts by lessening mental and physical strain and also by lowering the metabolic demands. The cardiac patient usually rests more comfortably sitting up in an erect or almost erect position. The exact reason for this is not clear but I occasionally encounter patients who are lying flat, warned not to move because of the erroneous idea that a change in position might be dangerous. The patient should not sit up by his own effort but can easily be raised not sit up by his own effort but can easily be raised to a sitting position and his breathing will then be much freer.
Complete rest should be prolonged, first, until there are no signs of congestive failure: no leg edema; and then beyond that until, by carefully testing him out, you determine that he can be active without sending the heart rate much above 90 for any length of time. Activities should be resumed very gradually but in the absence of signs and symptoms you are safe in letting the patient do what he may be able to accomplish without accelerating the hart rate above 90. It will do no harm to send the heart rate above this level if it returns to normal within a minute or two. Tachycardia which indicates that this type of patient has attempted too much will usually persist much longer than a few minutes.
The second factor in treatment is diet. A low-calorie diet apparently has some advantages as it tends to lower to basal metabolic rate. In congestion heart failure it tends to be somewhat above normal in many cases. On the other hand, adequate nutrition must be provided in a form permitting assimilation with the minimum of digestive work. For this purpose sugar is desirable, but cane sugar often aggravates digestive disturbances. Lactose is preferable and may be given with fruit juices. The various dextri-maltose foods used for infants are very helpful during the early period of treatment.
Gradually the diet can be enlarged in the direction of a standard bland diet. This eliminates raw foods, foods rich in roughage, salty foods and in general those that tend to produce gas. As the diet is enlarged we must keep in mind the following rules: avoid dilatation of the stomach, take fluids between meals rather than with meals. Take soup in great moderation if at all, and avoid watery dishes such as stewed tomatoes, squash, etc. The intake of fluids must be controlled to prevent gastric dilatation but there is a more important reason which we shall now consider.
Then diet must include the prophylactic treatment of edema. The patient accumulates edema because he takes in more water than he excretes. We get rid of water in three ways: by the water vapor in respiration, by evaporation from the skin, and by the kidneys. The kidneys eliminate approximately 75 per cent of the fluid output. As they are the chief factor, we cannot safely restrict fluids until we are certain that he kidneys are competent.
A simple concentration test will answer the question as far as the kidneys are concerned. The two-hour renal test is cumbersome and tedious and I have used a much simpler one described originally by Fishberg. 2 Fishberg, Arthur M.: “Hypertension and Nephritis,” Phila., Lea & Febiger, 1930, p.45. The patient is given a dry protein dinner in the evening with six ounces of fluid and nothing further to ear or drink until the following morning. The first morning specimen collected under these circumstances should reach a specific gravity of 1.022 or higher.
It is does, the kidney can concentrate well and fluids may be safely restricted. If the specific gravity is lower, confirmed by repeating the test, the kidney concentrating power is probably impaired and the practical conclusion is twofold: determine the blood urea nitrogen and meanwhile permit two quarts of fluid as uremia is worse for the patient than edema.
Thus we can check up on kidney concentrating power by a simple clinical test which does not require technical laboratory assistance and then we must decide how much fluid to give per day. We can restrict fluids absolutely to 1,000 cc. or possibly to 800 cc., which is the maximum reduction you can usually make for a week or ten days at a time. On the long run you usually have to permit a liter or a quart a day. Another method of determining the amount of fluid that is desirable in chronic cases has the advantage of playing a game with the patient.
He may be told that he can have as much no drink as he has put in ounces of urine the day before. If he has voided thirty ounces of urine he has also eliminated ten or twelve ounces more by respiration and perspiration. If the amount taken in is equivalent to the urine output be will therefore bail himself out to the extent of 25 per cent more than he is given. In limiting fluids it is important to count liquids in other foods. Fruit should be counted as 50 per cent liquid and it is wise to avoid watery vegetables as already noted.
In the prevention of edema it is important to reduce the salt intake. An absolutely salt-free diet cannot be attained and it would have the disadvantage of producing a complete loss of appetite. Unless edema is increasing, food many be cooked with the ordinary amount of slat but none should be added when served. In general I am not in favor of the substitutes for salt which contain sodium mallate or the like.
These cannot be cooked, as they decompose in cooking and the taste is not satisfactory. Moreover, as far as we know it is the sodium ion which tends to hold fluid and not the chlorine ion, so that other salts of sodium are equally undesirable.3Loeb: “Medicine,” vol. 2,p. 171, 1923. For other references see Fishberg, Arthur M.: “Hypertension and Nephritis,” Phila., Lea & Febiger, 1930, p.45. p.85.
With the patient at complete rest on a low-calorie diet made upon food that is easily assimilated, with care to limit the fluid and salt intake, a certain degree of improvement will follow. Medication must do the rest.
As a typical case, I shall consider the patient with auricular fibrillation, as the onset of this arrythmia is responsible for the occurrences of chronic congestive failure in many cases. The mainstay of drug treatment here is digitalis.
The clinical pharmacology of digitalis may be explained by a very homely comparison, which is not strictly true but which is near enough to the truth to serve as a practical guide. If we desire a therapeutic effect from digitalis we must bring about a certain degree of saturation of the myocardium. The art of administering digitalis in these cases consists in producing a useful degree of saturation without exceeding it.
The comparison which I have referred to is this: let us suppose we have a quart pail with a small hole in the bottom of it. We shall assume for the same of argument that the hole permits one ounce of fluid to leak out daily. Let us suppose further that we put an ounce of water in the pail each day.
At the end of the first day the ounce of fluid has leaked out and at the second day the second ounce out and at the end of the second day the second ounce of fluid has leaked out and if you go on putting an ounce a day into this pail, it will remain empty at the end of each day. This corresponds to the physician who gives his patient five drops of the tincture of digitalis three times a day. He will not reach any useful degree of saturation and may conclude that the drug is ineffective.
To return to our comparison, let us suppose that we now put in the pail two ounces a day. At the end of the first day one ounce will have leaked out but one ounce is left in it; at the end of the second day another ounce has leaked out but a second ounce remains and thus at the end of thirty-two days, the thirty-two-ounce pail will be full. If now on the thirty-third day we add two ounces, the pail will run over. This corresponds again to the physician who was given his patient thirty to forty minims of digitalis twice a day.
He observes the patient improve steadily until the second, third or fourth week, and then sudrabbits suffering from some type of endocrine imbalance which prevents them from reacting to the test. She believes that steinization looked for, as it is possible for certain non pregnant conditions to give haemorrhagic follicle formation within the heart and thereafter give a daily maintenance dose to maintain the useful degree of drug effect.
