Prognosis

Disturbances of the Heart
by Oliver T. Osborne, M.D.

(Page 5 of 21)

Janeway sums up his conclusions by stating that "from the time of the development of symptoms indicative of cardiovascular or renal disease, four years will witness the death of half the men and five years of half the women. By the tenth year half the remainder will have died, leaving one fourth both of the men and the women who have lived beyond ten years." The causes of death he would place in the following order: gradual cardiac failure; uremia; apoplexy; some complicating acute infection; angina pectoris; accidental causes; acute edema of the lungs and cachexia. An early occurrence of myocardial weakness shows a 50 percent probability that death will be caused by cardiac insufficiency. Heart pains comprise another important indicator of future cardiac death, perhaps not an angina. Nocturnal polyuria would indicate a uremic death in about 50 percent of the patients, and typical headache or cerebral symptoms show the probability of uremic death in more than 50 percent, and death from apoplexy in a large number of the other 50 percent As just stated, rapid loss of weight is a bad symptom.

Janeway has previously reported seven patients with hypertension who had diabetes. Diabetes generally, on the other hand, causes a low blood pressure. Patients with this trouble and with hypertension, and without nephritis, probably have an increased secretion from the suprarenals.

We may sum up the prognosis in hypertension as follows: Hypertension alone is not of unfavorable omen; if it is not readily reduced by ordinary means, it is more serious. If associated with kidney, heart or liver defect, it is most serious. If there are such serious conditions as edema, ascites, lung congestion, cyanosis and great dyspnea, the prognosis is dire.

Obesity being a cause of high blood pressure, it should be treated more or less energetically, even if the individual does not continue to add weight.

Stone believes that the higher the diastolic pressure the greater danger there is of cerebral death, while a patient with a very high systolic, but a diastolic pressure of 100 or lower, is in more danger of cardiac death. He urges a greater consideration of the pressure pulse in determining the load of the heart and the great danger from a sustained diastolic pressure of over 105 as sooner or later bound to cause myocardial symptoms. This load of the heart is also shown by an increased pulse rate and increased respiratory efforts. In cardiac failure, as the systolic pressure falls the diastolic is likely to be increased, and the pressure pulse thus diminishing, allows insufficient blood to go to the medullary centers, and death soon occurs. Therefore, in acute illnesses a sustained pressure pulse gives a better prognosis than a diminishing pressure pulse. The strenuous measures that should he used to lower a high diastolic pressure are contraindicated when the diastolic pressure is already low, even if the systolic pressure 1s high. If a high systolic pressure begins to fall more or less rapidly the heart shows fatigue, and should be stimulated by digitalis or strophanthin.

Rowan finds that a diastolic reading of 100 mm. or more usually means that there is a narrowing of the lumen of the vessels, owing to stimulation of the vasoconstrictors, although it may mean the existence of a true arterial fibrosis. While a real atheroma generally causes a reduction in diastolic blood pressure, or at least but slight increase, he has found in syphilitic cases with arteriosclerosis a high diastolic pressure. If the blood pressure cannot be reduced by ordinary measures, arteriosclerosis is probably present. Several blood pressure examinations must be made, while the patient is being treated, to establish the diagnosis.

Rowan finds the reading of the pulse pressure to be of great importance, as this will indicate, sometimes before any other symptom is present, that the patient is either improving or doing badly, and it also aids in indicating the proper medicinal treatment.

In arteriosclerosis the systolic pressure may be high while the diastolic is low; hence there is a large pressure pulse. If the heart becomes weak the systolic pressure will drop, and any improvement caused, especially in aortic regurgitation, is by an increase of the systolic pressure.

Rowan finds, as has long been recognized, that a conclusion as to whether or not cerebral hemorrhage will occur cannot be made from the condition of the radial arteries, as patients with soft radials may suffer from cerebral hemorrhage, while those "with hard, sclerosed, pipestem-like arteries may live to a great age and die of anything rather than apoplexy."

Swan, has studied the blood pressure in fifty cases of disturbed thyroid, and finds that functional myocardial tests show that the myocardium is nearly always disturbed in these patients.

Before taking up the subject of treatment of high blood pressure, it may be suggested that a high diastolic pressure with a falling systolic pressure may require vasodilators on the one hand or cardiac tonics on the other, and sometimes the decision can be made only by proper tests. In other words, if the diastolic pressure is lowered the heart will be relieved. On the other hand, if the diastolic is being raised by an increased venous pressure from a failing heart, digitalis, strychnin and caffein may be of benefit in lowering the diastolic as well as raising the systolic. However, if there is a high systolic and a low diastolic pressure, vasodilators are often contraindicated.