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Unexplained shortness of breath should be investigated urgently.

Sunset in Drumheller. (Dr. Noorali Bharwani)
Sunset in Drumheller. (Dr. Noorali Bharwani)

Recently, a relative of mine died. She had shortness of breath. She went to ER and was admitted to a hospital. She was investigated. After a week of investigations, she underwent coronary angioplasty for a narrow coronary artery. Two days later she was discharged. She went home and within an hour she fainted and died. That was sudden and tragic.

Statistics show one in 20 patients with unexplained shortness of breath in the primary care setting will have heart failure as its cause.

Statistics also show 38 per cent of patients with unexplained shortness of breath do not receive a definitive diagnosis within six months post-referral.

When a person presents with shortness of breath, the clinician has to determine whether it is due to cardiac (heart failure) or pulmonary cause.

Heart failure – also known as congestive heart failure – occurs when the heart muscle doesn’t pump blood as well as it should. When this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath.

What causes heart failure?

Common causes of heart failure are coronary artery disease, heart valve disease, high blood pressure and cardiomyopathy. If you’ve been diagnosed with one of these conditions, it’s critical that you manage it carefully to help prevent the onset of heart failure.

How would you know you are in heart failure?

Swelling of the feet and ankles, shortness of breath, fatigue, abdominal fullness due to swelling and distention of the liver are early manifestation of heart failure.

If you have these symptoms, you should see your doctor immediately. The doctor will order investigations which will include: blood tests, chest x-ray, echocardiogram, stress test, CT scan, MRI, coronary angiogram etc.

Some doctors rely mostly on NT-proBNP testing to monitor patients with heart failure. You do not need to fast or do anything to prepare for the test. Levels go up when heart failure develops or gets worse, and levels go down when heart failure is stable. In most cases, BNP and NT-proBNP levels are higher in patients with heart failure than people who have normal heart function.

The result helps your doctor determine if you have heart failure, if worsening fatigue or shortness of breath are due to heart failure or another problem or if heart failure has progressed toward end-of-life. It is important to note that this test is only one method your doctor uses to monitor your condition. Based on your results, your doctor can choose the best treatment plan for you.

Sixty-seven per cent of patients with unexplained shortness of breath did not need further diagnostic work-up after taking NT-proBNP test. A very useful test for patients with chronic unexplained shortness of breath.

The Canadian Cardiovascular Society recommends NT-proBNP screening to help confirm or rule out heart failure in patients with shortness of breath when clinical diagnosis remains uncertain. This can aid in decision-making and accelerate the pathway to appropriate referral.

In Alberta, Laboratory Services has offered B-type natriuretic peptide (BNP) or N-terminal proBNP (NT-proBNP) testing in hospital laboratories across the province since 2012. Emergency Department physicians and cardiologists are able to order these tests to assist with diagnosing and treating heart failure. This test has improved quality of referrals to cardiologists and has reduced diagnostic delays.

Treatment for heart failure:

For most people, heart failure is a long-term condition that can’t be cured. But treatment can help keep the symptoms under control, possibly for many years.

The main treatments are: healthy lifestyle changes, medications, devices implanted in your chest to control your heart rhythm, and surgery. Treatment will usually need to continue for the rest of your life.

The life expectancy for congestive heart failure depends on the cause of heart failure, its severity, and other underlying medical conditions. In general, about half of all people diagnosed with congestive heart failure will survive five years. About 30 per cent will survive for 10 years.

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Outpatient Treatment for COVID-19 Infection

Saskatoon Farm, Foothills County, Alberta. (Dr. Noorali Bharwani)
Saskatoon Farm, Foothills County, Alberta. (Dr. Noorali Bharwani)

According to Reuters, global COVID-19 cases have surpassed 500 million, as the highly contagious BA.2 sub-variant of Omicron surges in many countries in Europe and Asia and North America.

Recent surge across Canada has been driven by the Omicron variant and its BA.2 subvariant.

In Alberta and rest of Canada, COVID-19 numbers are going up as we relax on our need to wear a mask, avoid crowded gatherings and get fully vaccinated. Wearing a mask is strongly recommended by Canada’s Chief Medical Officer of Health.

In order to prevent hospital overcrowding with COVID-19 infected patients, Health Canada has approved out-patient use of medications for certain group of venerable individuals who are infected. Since these medications are currently in short supply, Health Canada has advised provinces to prioritise patients as follows:

  1. Individuals who have the highest likelihood of severe illness including those who are immunocompromised regardless of vaccination status;
  2. Individuals over the age of 80 whose vaccinations are not up to date; and
  3. Canadians aged 60 or older who live in underserved rural or remote communities, long-term care homes, who are from First Nations, Inuit, and Metis communities, or whose vaccinations are not up to date.

Alberta Health Services and Alberta Health are rolling out the administration of outpatient treatments like Paxlovid™ and Remdesivir, COVID-19 medications recently approved by Health Canada that are shown to prevent COVID-19 from progressing in high-risk patients with mild to moderate symptoms if taken within five days of symptom onset (seven days for Remdesivir), says Alberta Health website.

Patient will be first assessed by a healthcare professional before Paxlovid or Remdesivir will be available to the patient.

Paxlovid is taken orally in pill form. One dose is a combination of two nirmatrelvir (pink) tablets and one ritonavir (white) tablet, taken twice a day for five days. Patients with a reduced kidney function may have their dose reduced to two pills twice a day for five days.

Remdesivir is given intravenously by a qualified health professional. The medicine is given over 30 minutes. You will be watched closely for another 15 to 30 minutes after getting the treatment. You can expect the appointment to last about 1.5 hours, including setup time.

In Alberta, Who Is Eligible for Paxlovid and Remdesivir?

Treatments are available for patients who have a lab-confirmed COVID-19 infection if they can receive the treatment within five days of symptom onset for Paxlovid or seven days for Remdesivir and they are:

  1. Unvaccinated or have received one dose of a COVID-19 vaccine and are: age 55 and older or Indigenous, and age 45 or older or age 18 and older with a pre-existing health condition including diabetes (taking medication for treatment), obesity (BMI >30), chronic kidney disease (estimated glomerular filtration rate, <60 ml per minute per 1.73 m2 of body-surface area), congestive heart failure (New York Heart Association class II, III, or IV), chronic obstructive pulmonary disease, and moderate-to-severe asthma, pregnant OR
  2. Immunocompromised (vaccinated or unvaccinated), due to reasons including but not limited to: have received a transplant, is an oncology patient who has received a dose of any intravenous or oral chemotherapy or other immunosuppressive treatment since December 2020, has an inflammatory condition (e.g., rheumatoid arthritis, lupus, inflammatory bowel disease) receiving a dose of any systemic immunosuppressive treatment since December 2020 OR
  3. Living in long-term care or designated supportive living, regardless of age or vaccine status.

How do you access Paxlovid or Remdesivir?

If you have tested positive for COVID-19 and your symptoms began less than four days ago and you believe you meet the eligibility criteria (above), please call the dedicated Health Link line at 1-844-343-0971 to find out if you qualify to receive treatment. Do not call 811, says Alberta Health website (Outpatient Treatment for COVID-19). The website also has more information.

Remember 10 words: Wear a mask, avoid crowded gatherings and get fully vaccinated.

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Bruce Willis and the Long-term Effects of Aphasia

View from Saskatoon Farm, Foothills County, Alberta. (Dr. Noorali Bharwani)
View from Saskatoon Farm, Foothills County, Alberta. (Dr. Noorali Bharwani)

Recently, Bruce Willis’ family announced that he will be taking a step back from his career of almost 45 years and more than 100 movies due to an aphasia diagnosis. Aphasia is a medical condition that leaves patients struggling to verbally communicate. It affects speech and the ability to read or write.

As of 2022, films featuring Willis have grossed over US$5 billion worldwide, making him one of the highest-grossing actors in the world.

About five years ago I wrote about this subject as one of my relatives was diagnosed with primary progressive aphasia. There are many types of aphasic conditions.

According to the Aphasia Institute, there are over 100,000 Canadians living with aphasia today and one in three stroke survivors are diagnosed with aphasia. As the population ages the incidence of aphasia is expected to increase.

An aphasic person cannot express himself or herself when speaking, has trouble understanding speech, and has difficulty with reading and writing or finding words.

Brain damage causes aphasia. This quite often happens after a stroke or head injury. It can happen if a person has a brain tumour or Alzheimer’s disease. It is important to remember primary progressive aphasia is not Alzheimer’s disease. In primary progressive aphasia the problem is a disorder of language with preservation of other mental functions of daily living for at least two years. Symptoms may get worse after that.

The effects of aphasia differ from person to person and can sometimes be eased by speech therapy. Most people affected by this condition can maintain ability to take care of themselves and pursue hobbies. In some instances, a person can remain employed.

Primary progressive aphasia may present in a number of different ways but it commonly appears initially as a disorder of speech, progressing to a nearly total inability to speak in its most severe stage, while comprehension remains relatively preserved.

Symptoms begin gradually, often before age 65, and worsen over time. People with primary progressive aphasia have a difficult road ahead. They are fighting against a condition in which they will continue to lose their ability to speak, read, write, and/or understand what they hear. The illness progresses slowly.

Medically speaking, primary progressive aphasia is caused by a shrinking of the frontal, temporal or parietal lobes in the brain, primarily on the left side. The condition affects the language centers in the brain.

Who is at a higher risk of being affected by primary progressive aphasia?  A person having learning disabilities and a person who has certain gene mutations – that is it may run in the family.

An individual who has aphasia should carry an identification card and obtain materials available from the National Aphasia Association. This helps in communicating about the person’s condition to others.

Unfortunately, people with primary progressive aphasia eventually lose the ability to speak and write, and to understand written and spoken language. As the disease progresses, other mental skills, such as memory, can become impaired. Some people develop other neurological conditions. With these complications, the affected person eventually will need help with day-to-day care.

People with primary progressive aphasia can also develop behavioral or social problems as the disease progresses, such as anxiety or irritability. Other problems might include blunted emotions, poor judgment or inappropriate social behavior.

The diagnosis of the condition is based on history of worsening communication skills, changes in thinking and behaviour over one to two years. Besides physical examination a doctor will order several tests including blood tests, speech and language tests, genetic tests, MRI, etc.

Unfortunately, primary progressive aphasia cannot be cured, and there are no medications to treat it. The good news is, some therapies, like speech and language therapy, may help improve or maintain your ability to communicate and manage your condition.

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Long term use of alcohol will shrink your brain.

Celebrating Africa Day in Calgary, Alberta. (Dr. Noorali Bharwani)
Celebrating Africa Day in Calgary, Alberta. (Dr. Noorali Bharwani)

A recent article in Natural Communications (March 4, 2022) titled “Associations between alcohol consumption and gray and white matter volumes in the UK Biobank”, says there is evidence to show even moderate drinking is associated with changes in brain volume in middle-aged and older adults.

We know heavy alcohol consumption has been associated with brain shrinkage. The new study shows even moderate drinking will shrink your brain. The study was done in the UK. The researchers used multimodal imaging (MRI) data from 36,678 generally healthy middle-aged and older adults from the UK Biobank.

The study shows the negative associations between alcohol intake and brain shrinking are already apparent in individuals consuming an average of only one to two daily alcohol units, and shrinkage increases as alcohol intake increases.

Alcohol use and abuse is a worldwide problem. There is a significant healthcare and economic cost. Alcohol use disorder is one of the most prevalent mental health conditions worldwide with harmful effects on physical, cognitive, and social function. It contributes to cardiovascular disease, liver disease, nutritional deficiency, cancer and accelerated aging.

How do we define chronic heavy alcohol consumption?

Three or more drinks for women and four or more drinks for men on any day is considered heavy drinking. These individuals have lower gray matter volume of the brain. Chronic alcohol drinking also shrinks the white matter of the brain. The article says, “Further, research suggests that the effects of alcohol consumption on brain volume interact with the effects of aging.”

The researchers found individuals who consumed moderate-to-high amounts of alcohol (14 or more alcohol units per week) showed brain atrophy.

The article concludes by saying this study provides additional evidence for a negative association between alcohol intake and brain structure in a general population sample of middle-aged and older adults.

This finding suggests the general recommendation that it is OK for women to have one drink a day and two for men is not valid anymore. Research showed that a daily drink seems to age the brain by two years compared to the brains of those who do not consume alcohol. And if you take two drinks a day your brain will look 10 years older than that of a teetotaller.

What is Canada’s low-risk alcohol drinking guideline?

Health Canada (2012) guideline says you can reduce your long-term health risks by drinking no more than10 drinks a week for women, with no more than two drinks a day most days and 15 drinks a week for men, with no more than three drinks a day most days. You should plan non-drinking days every week to avoid developing a habit.

Is this recommendation valid anymore?

An article in Lancet (No level of alcohol consumption improves health – August 23, 2018) also rejected the notion that any amount of drinking can be healthy. With the new study findings, should Health Canada change its guideline?

In the last two years, due to stress and loneliness imposed by COVID-19 pandemic there has been huge increase in drug and alcohol consumption in Canada and elsewhere. And the effects of alcohol use on health care, crime and lost productivity were estimated at $14.6 billion – more than tobacco and all other psychoactive substances combined.

Statistics Canada reported alcohol-induced deaths increased in 2020, especially among those under age 65. It is simple. The more you drink, the worse it is for your health. Especially, your brain health. Maintenance of brain health is central to health and wellbeing across the lifespan. Those who are lifetime alcohol abstainers report the highest level of mental well-being and quitting alcohol improves mental well-being.

Finally, we should be careful in recommending moderate drinking that can improve health-related quality of life. Instead of having a drink have an apple. An apple a day keeps the doctor away!

Don’t let your brain shrink. Take care of your gray and white matter. Be safe.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!