Further Adventures of the Geriatric Doctor-in-Law 5: The Trial of Therapy

Here’s an anecdote to illustrate one of my favorite principles: trial of therapy, not high-tech investigation leading to cookbook care.

Mother-in-law Liz has not been that great lately. Quite confused with no obvious cause, but also complaining of pain. Pain in the shoulders, pain in the forearms, but recently also chest pain. Of course we take chest pain seriously because there are an awful lot of important things in that part of the body. But often you can tell the cause of chest pain just by asking the right questions and listening carefully to the answers. Unfortunately because Liz doesn’t remember very well the answers aren’t always accurate.

The only thing that seemed to worsen the chest pain was exertion, which for Liz means walking more than about 30 seconds with her walker. She certainly has heart disease and the trouble with her aortic valve is not going to get any better. Physically going over her heart and lungs, it was pretty obvious that the ribs where they join the sternum or breastbone were sore, even just to light pressure.

That finding is a welcome one to every emergency room doctor, because it usually means that a complaint of chest pain is coming from the chest wall. That is the bones, muscles, and cartilage forming the exterior box of the chest, not the heart, lungs, esophagus, and big blood vessels inside.  It means we’re dealing with a relatively benign chest pain cause which usually goes away on its own.

But there was still that troublesome complaint of worsening with exertion. And that is usually angina, chest pain coming from heart muscle working under stress without enough blood supply. It can be a late complication of aortic valve disease, but it’s usually the result of hardening of the arteries that supply blood to the heart. And another one of my favorite principles is “the commonest cause of anything in a frail elderly person is multiple causes.” So Liz could have had both chest wall pain and angina.

The tests to diagnose angina range from exercise cardiogram to the dangerous and high-tech imaging of the heart’s arteries themselves. But another far simpler test is just to try angina treatment and see what happens. So I got some nitroglycerin paste (the old-fashioned form of a common angina treatment), rubbed it on Liz’s skin under a little piece of paper, and walked Liz around including up the aluminum ramp at the back of their cabin. Any chest pain? No. Just a little short of breath. I reached a tentative conclusion that we were dealing with angina.

Next morning, getting ready to order the more current nitroglycerin patches, I decided to try one more step to be sure. I got Liz to walk through the same exercise routine including up the ramp, without any nitro paste. No chest pain.

Now it looked as if my chest wall pain theory was right all along, and that worsening with exertion just meant worsening with movement. And by doing my negative trial of therapy I had luckily avoided putting Liz on an unnecessary medication, when she was already on quite a few necessary ones.

Frail old people are oddballs. They don’t necessarily show us textbook signs and symptoms of textbook diseases. And only rarely is it feasible or reasonable to subject them to the gold-standard evaluations that specialists do to prove or disprove common disease states. My name for angina in somebody like Liz is “nitroglycerin-responsive exertional chest pain”. Because that’s what it is. Or more exactly “nitroglycerin-responsive exertional chest pain in Liz Clark”.

This is another example of what I’ve called human health science .  All the randomized controlled trials of surgery and drugs in the world are nothing, where this particular elderly lady is concerned, beside the real-world facts of what works for her and what doesn’t. The Platonic entity “angina” is no more than an artificial construct compared to what’s going on in her life at this particular time, and what if anything we can do about it.

About John Sloan

John Sloan is a senior academic physician in the Department of Family Practice at the University of British Columbia, and has spent most of his 40 years' practice caring for the frail elderly in Vancouver. He is the author of "A Bitter Pill: How the Medical System is Failing the Elderly", published in 2009 by Greystone Books. His innovative primary care practice for the frail elderly has been adopted by Vancouver Coastal Health and is expanding. Dr. Sloan lectures throughout North America on care of the elderly.
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