This is another powerful example of how modern precision medicine can be more beneficial than ever. When I first went into practice, the diagnosis of congestive heart failure was a death sentence. Even today, 57% of patients with this diagnosis are dead within five years because they don’t get optimal medical therapy before or after diagnosis. In older people, this is a very common problem. One out of 5 people 85 years old or older have congestive heart failure. It is important to all of us because patients with a heart failure diagnosis generate one third of all Medicare spending.
When I arrived at a small southern town to practice 40 years ago there were only 62 beds in the hospital. I was the first full time internal medicine doctor. The closest ICU was over an hour away and half the people in the town were dying of heart disease and strokes. I worked with some nurses to get a six-bed ICU going and not a minute too soon. I was medical director of the ICU for 8 years and treated many of the critically ill patients there. At any given time, I had three patients with heart failure in a six-bed ICU. Most of them were intubated and on breathing machines. When a person with heart failure gets too much salt, they retain water and that water backs up into their lungs. That leads to shortness of breath and it is a medical emergency. They can literally drown in their own fluid. A breathing tube with some extra oxygen and positive pressure can drive the water out of their lungs until we can use powerful fluid pills to get rid of enough water so they can breathe.
One single experience stands out in my work with heart failure. One of my patients was a tiny and delightful lady who was having frequent heart failure admissions despite our best efforts with powerful diuretics and the other treatments available at the time. I was at her bedside constantly this time because she was not responding to our usual interventions, and it was beginning to look like she would die this time. One of the problems was her blood pressure. It was 200/100 and that was increasing the work on her heart.
I can date this episode very precisely because it was only a few days after a new disease modifying drug named captopril was approved by the FDA in April of 1981. That was over forty years ago. I had read that captopril could be very helpful in heart failure. There was no drug in the captopril class at the time. Medications like captopril interfere with the effects of a hormone that is involved in causing increased blood pressure and congestive heart failure. That hormone level is always increased in heart failure. I asked the nurse to find some captopril. None of the pharmacies in our small town had it but we did find it in Savannah which was about an hour away. At that time, the South Carolina highway patrol would make a run to obtain something that was emergently needed to save a life. A South Carolina highway patrolman was part of saving this woman’s life.
I had also read that the blood pressure could fall like a rock in a patient who was fluid depleted and received this medication. We were giving this lady massive doses of Lasix, a powerful fluid pill to help her breathe. It was very likely she was fluid depleted. The captopril arrived and it was a 25mg tablet. We had an IV in place so that we could quickly give fluids if needed. I have always had this philosophy about powerful medicines. You can always give more medicine. Once you have given it, you can’t get it back. So, we took the recommended beginning dose of 25mg and cut it into quarters. Then we crushed it, mixed it with some liquid, and flushed it through a tube she already had in place that went to her stomach.
What happened then was one of the most dramatic things I have ever witnessed in decades of taking care of patients with cardiovascular and related diseases. Her blood pressure dropped very rapidly to about 100 on the top number. Her blood pressure fell 100 points in a matter of minutes. We were prepared. I told the nurses to give her the IV fluids at a wide open or maximum rate and we quickly stabilized her blood pressure. Most importantly, her breathing problems quickly improved, and we were able to get her off the breathing machine. We gradually increased her captopril and backed off on her diuretics. She was able to be more active and she was in the hospital less often.
Drugs like captopril and the newer lisinopril and losartan are precision medicines. They all precisely interfere with one of the hormones that causes high blood pressure and heart failure. Most heart failure is caused by heart attack or high blood pressure. The hormone that captopril interferes with kills heart muscle cells and promotes inflammation and scar tissue growth. It causes the heart to remodel and get larger. When you treat your blood pressure with lisinopril and losartan, you are not only lowering the blood pressure, you are blocking an important cause of congestive heart failure. In a study of patients with type 2 diabetes and chronic kidney disease, 21 years of follow-up shows a 70% reduction in hospitalizations for heart failure in patients on optimal medical therapy vs those in usual care. That is because other medications in optimal medical therapy for diabetes also lower oxidant production, inflammation, death of heart pumping cells, and promoting scar growth.
The study of patients with type 2 diabetes was not aimed at heart failure, but by impacting the processes that cause heart failure, it produced the most dramatic heart failure hospitalization reductions that have ever been seen. Now there is another medicine for diabetes that has a major impact of reducing heart failure admissions by 30%. As with captopril, the most important impact of Jardiance is to reduce oxidants, inflammation, and activate a master metabolic genetic survival switch that protects every cell and organ in the body. Metformin for type 2 diabetes does exactly the same thing. So does a statin for cholesterol. These effects are not related to risk factor reduction. The “diabetes drug” Jardiance reduces heart failure hospitalizations by 30% whether the patient is diabetic or not.
The retail price of Jardiance is over $700 a month. You can buy lisinopril and metformin at Walmart with no insurance for $4 a month each. You can get atorvastatin at Walmart for $6.62 with a Good Rx coupon you can find on the internet. You can get the medications used in the protocol that reduced heart failure admission by 70% for just under $15 a month. That is the most bang for the buck that I know of in medicine.
One of the most shocking things to me since I started writing is the number of people who believe that diet and exercise alone are as effective as diet, and exercise, plus carefully selected medications in addressing chronic disease. I am relating this experience with a patient to demonstrate the power of medication in the right setting and with the right precautions. Believing is one thing. Evidence, experience, facts and living through these critical issues with hundreds of patients is another. This woman’s dramatic improvement in a life-threatening situation occurred because we gave her a medication that precisely blocked the effects of a hormone that was killing her. That is another reason it is so important to continue some dose of these medications even when the sugar has become normal.
Great article and so informative. Appreciate all this great information.
Interesting happy story. The difference was you were and still are a caring physician intimately involved in your patients' care. Now there are hospitalists in the hospitals who have no idea who you are or what your history is. They are too busy to read your chart or to coordinate complicated medical procedures and pharmaceuticals. Gone are the Days where the good Doctor followed his patients And figured out the very best treatment for that particular patient. I grieve that those days are gone. But from my experience and those of my loved ones it is basically horrifying how anonymous patients are these days. There are of course still very good caring doctors but the system does not allow them to give the proper care or time or attention in my opinion. We all lose.