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Hidden in plain sight.

5 Apr, 16 | by Toby Hillman

 

Hooded Grasshopper by J.M.Garg – Own work, CC BY 3.0,

Patients do not come with diagnoses attached to their foreheads.  If only they did,  huge numbers of hospital visits and admissions could be avoided.

To overcome the ever increasing number of potential diagnoses, and the rising tide of illness encountered by our ageing populations, we rely ever more heavily on investigations to guide us to the likely diagnosis, and thereafter, management.

But what if the tests don’t tell you what you wanted to hear? what if the clinical picture says one thing, but the tests say another?  Usually this scenario starts a ‘merry’-go-round for the patient concerned.  Oligo-organists (specialists in normal terminology) become increasingly irate with each other, sending a patient on a wild goose chase from clinic to clinic, trying as hard as they can to reassure the poor patient that there is nothing wrong with their X, and it must be the Y-ologists who will hold the key to unlocking their symptoms and making that breakthrough in management.

Heart failure is one of those areas where patients can go for some time before a diagnosis is firmly settled on.  Patients don’t go to their physician complaining of heart failure.  Instead they complain of breathlessness.  It is telling that there are two distinct rating scales for dyspnoea in common usage -(MRC scale if COPD and NHYA class if Heart Failure) – it is a symptom that has become divided by a common language.

Patients with heart failure are not helped by the way in which we as a profession have been guilty of listening to ourselves, and our tests, rather than our patients.  The seemingly contradictory Heart Failure with Preserved Ejection Fraction (HFpEF) is an entity that has been hotly contested, but looks to become the predominant mode of heart failure.  A review recently published online in the PMJ into the pathophysiology and treatment of HFpEF  shows just how far we have come over the last 20-30 years in understanding that such a disease even exists, that it can be characterised using an imaging modality that was once used to cast doubt on a clinical diagnosis of heart failure.  However, despite this increased understanding, we are only just getting to know which treatments might be beneficial, or harmful for a growing cohort of patients.

As I read the review, along with bewilderment at the detail that can be obtained from a non-invasive bedside test, I was struck by the journey that HFpEF has come on in the time that I have been training and practising medicine.

I clearly recall times when I was told that I was plainly wrong when a patient with the clinical syndrome of heart failure was given a clear bill of health by an echocardiogram – causing me to doubt my skills and insight.  And yet now, we discover that by examining the heart with a different mindset, very detailed pictures of the diastolic function of a heart can be estimated, allowing patients to be treated in a more refined manner.

In addition, the review brought home the absurdity of relying solely on a single test to determine the diagnosis of a clinical syndrome.  The review outlines the risk factors for HFpEF – it is a familiar roll call of the diseases of age and lifestyle.  So the test we used to think of as the gold standard to rule out a diagnosis, has been fine-tuned, and gives a more nuanced picture, but despite advancing technology, we return to the need to treat the patient before us, and not the test result.  And in treating the person, we must treat the whole person. This includes their co-morbidities and risk factors, and not just the ones we happen to find interesting.

Perhaps the journey that the diagnosis and management of HFpEF has taken from seemingly outlandish diagnosis to the dominant mode of heart failure also reflects the journey that physicians must go on as they progress through training – from relative ignorance and lack of experience – to specialist knowledge and a narrowing of focus – and back again to a more generalist role, encompassing multi-morbidity and diagnostic uncertainty.

As we face an increasing burden of multi-morbidity, escalating healthcare costs, and increasing patient expectation, I don’t think it will be appropriate in the future to say – no, your lungs are OK, off  you go to see the heart docs. Instead, a more generalist model of care, helping patients to navigate their multiple long term conditions, to reach a balanced solution will be the standard we will aspire to.

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