Sintomas e insatisfação. O contexto na qualidade de vida do portador de diferença valvar
Instituto do Coração do Hospital das Clínicas – FMUSP - São Paulo, SP
"...os objetivos não podem ser medidos através do balanço dos bancos. Eles só podem ser medidos através da qualidade de vida que proporcionam às pessoas..."
(Lyndon Baines Johnson (1908-1973), 37° presidente dos EUA, quem empregou pela primeira vez a expressão qualidade de vida, em 1964)
"...para o homem, há três acontecimentos apenas: nascer, viver e morrer. Ele não sente o nascer, sofre ao morrer e esquece-se de viver..."
(Jean de La Bruyère (1645-1696), moralista francês)
Os pacientes são categóricos: a presença de valvopatia faz diferença na qualidade de vida.
Os cardiologistas são incisivos: a qualidade de vida do portador de valvopatia faz diferença na aplicação de conduta.
A bioética induz: preserve-se e restaure-se a qualidade de vida do portador de valvopatia com a beneficência da Cardiologia, a não-maleficência do
Em clínica de valvopatia,
Num Brasil pluriétnico, a diferença valvar impacta de modo heterogêneo sobre aspectos pessoais, familiares, profissionais e econômicos, cada atendimento é uma situação biopsicossocial peculiar.
É pelas queixas do paciente sob influência da diferença valvar, na ambientação do seu contexto de vida6, que o cardiologista decide quais recomendações técnicas7 devem, quando, como e onde ser aplicadas.
O cardiologista, na missão de ser humano perante o ser humano doente, conecta-se com queixas expostas com a clareza que esperamos do paciente para nosso norte; mas, o que a desaconselha como o termo, razão dos vários estágios da anamnese, há a temerária obscuridade das mal reveladas, desafio ao zelo e à prudência na conduta.
Hipocondríacos, hipossensíveis, poliqueixosos e oligoqueixosos contumazes perturbam a lógica alopática e alvoroçam a responsabilidade antinegligência e antiimprudência.
Havendo incertezas, dificulta-se decodificar a multipolaridade da qualidade de vida e bem distinguir quais os componentes exigentes do compromisso ético com o "máximo de zelo e o melhor da nossa capacidade profissional... art. 2º do Código de Ética Médica".
No universo das insatisfações do paciente com a diferença valvar, privilegiamos
Em clínica de valvopatia,
...o conceito de qualidade de vida está sujeito a várias interpretações1,5;
..."boa" qualidade de vida não é o equivalente a capacidade funcional classe I/II;
... capacidade funcional classe III/IV é um dos aspectos indicativos de "má" qualidade de vida associada à presença de diferença valvar;
... há nítida distinção entre a incapacidade funcional para subir um lance de escadas que sinaliza valor clínico para a tomada de conduta e a captação do descontentamento com obrigações com rotinas de exame e aderências à periodicidade da profilaxia com penicilina benzatina, que soam como momentos estritos ao paciente;
...pacientes fazem adaptações espontâneas e entendem terem preservado a "boa" qualidade de vida; por exemplo, a autolimitação de um devagar lance por lance subindo escada, só comunicada ao médico, por ocasião de maior agravamento, meses depois no pronto-socorro;
...a força para levantar a cancela da ponte entre "má" qualidade de vida e "boa" qualidade de vida, pavimentada pelo acervo tecnocientífico da Cardiologia, emana do mérito da relação risco-benefício sobre o que possa vir, de fato, ser do alcance da Cardiologia;
...é o excesso de risco de intervenções que, habitualmente, reprova iniciativas de benefício sobre certas insatisfações com a morbidade da diferença valvar; por exemplo, para a mulher em classe funcional I que não deseja arriscar intercorrências gestacionais perante estenose mitral;
...
Propõe-se evitar a utilização do termo
Sugere-se desdobrar o conceito de qualidade de vida em a) INSATISFAÇÃO DO PACIENTE PELA DIFERENÇA VALVAR, para considerações amplas sobre o infinito universo biopsicossocial; b) SINTOMAS/CLASSE FUNCIONAL PELA DIFERENÇA VALVAR, para considerações específicas sobre os itens de interesse para a Cardiologia.
A clássica vigilância dos sintomas/classe funcional no portador de diferença valvar tem hierarquia superior do que o maniqueísmo da boa ou má qualidade de vida para precisar a beneficência/não-maleficência dos métodos disponibilizados pela Cardiologia.
Em clínica de valvopatia, o uso propedêutico – e corriqueiro – da expressão
Uma forte razão é que as bases decisórias exigem filtrar os aspectos da complexa qualificação de vida, segundo poros de pragmatismo profissional.
A distinção dos componentes
Em clínica de valvopatia,
Sintoma, portanto, é matéria-prima para diretrizes. E é justamente
Em contrapartida,
As palavras-chaves para decisões sobre conduta para o portador de valvopatia são, pois,
Qualidade do nascer, qualidade do viver e qualidade do morrer são objeto de atenção pela bioética11.
A expressão
Recorde-se que
Desequilíbrios entre ambos são comuns e a presença de doença exerce influência na condução de plenitudes idealizadas; mudanças, quer no sentido da valorização de bens quer no sentido de apreciações filosóficas, podem ser catalisadas pelo estado clínico do paciente.
Se aplicarmos ao portador de valvopatia o WHOQOL-100 da Organização Mundial de Saúde12, que objetiva avaliar a qualidade de vida das duas últimas semanas, haverá muitas respostas
Pesquisa efetuada no ambulatório da Unidade Clínica de Valvopatias do InCor identificou 59% dos entrevistados entendendo que a valvopatia havia tornado suas vidas uma guerra contra a doença.
A vida real do cardiologista não lhe permite, comumente, um envolvimento marcado pela preocupação com aspectos carentes de conotação técnico-utilitarista.
Por uma questão de disponibilidade de tempo e percepção da sua missão, ele vale-se da calosidade do conformismo profissional e passa ao largo de aspirações do portador de valvopatia
"Sucessos terapêuticos" (óptica da Cardiologia) costumam co-habitar com "insucessos de vida" (óptica do portador de valvopatia). A anticoagulação oral pelo implante de prótese metálica coleciona vários casos.
Projeções dos próprios valores induzem o seu espontâneo profissional a considerar e a deliberar que, afinal, "o melhor é assim". É o caso de certas apreciações sobre risco-benefício de intervenções sobre a valvopatia perante capacidade funcional classe II.
Um automático "não há outra maneira de evitar manifestações clínicas ou de beneficiar o prognóstico" dá justificativa a "sofrimentos menores" do portador de valvopatia, talvez não tão pequenos na auto-avaliação de qualidade de vida pelo portador da diferença valvar. É o caso do jovem esportista de sucesso, que é desaconselhado, pelo cardiologista, a praticar esporte competitivo, até que ele volte a preencher critérios da Cardiologia, num futuro incerto.
Em clínica de valvopatia, é desejável que a equipe de saúde encontre um equilíbrio entre o manter-se tecnicamente solidário e a indiferença a insatisfações do paciente que não comportam iniciativas de conduta.
A captação do horizonte biopsicossocial da diferença valvar exige uma angular multidisciplinar; a soma de
Enxergar o
Assim, a ampla potencialidade de interferências da doença sobre a vida marca a história natural da diferença valvar, mas a exigüidade da penetração usual em Cardiologia impede que a qualidade de vida seja um marcador de momentos estratégicos.
O marcador para usufruto da beneficência/não-maleficência de métodos terapêuticos é a xipofagia de sintomas/classe funcional.
Em clínica de valvopatia, cabe bem a conjugação da classe funcional de I a IV com a avaliação objetiva nomeada de A a D, como recomendada pelo comitê da última atualização da New York Heart Association8; um portador de insuficiência aórtica grave, porventura, sem dispnéia, cansaço, palpitação ou angina do peito às atividades habituais é considerado capacidade funcional classe I e avaliação objetiva D; e sem nenhuma alteração de variáveis como ausculta do sopro e bulhas, diâmetros e função ventricular esquerda entre o
O que fala mais alto, literalmente, é o sintoma, a queixa do portador de valvopatia14,15. É a matéria-prima que o paciente nos disponibiliza; após a nossa adequada lapidação, ela resulta ajustada ao encaixe
Assim, mais do que a unilateralidade de apreciação determinada pelo estetoscópio ou pelo transdutor, é pela bilateralidade da comunicação verbal que, em clínica de valvopatia, fazem-se as ponderações sobre a relação temporal de risco-benefício das intervenções propedêuticas e terapêuticas.
Do valor da nitidez da imagem mentalizada a partir de palavras do paciente resulta uma obviedade ao agrado da bioética16: a anamnese é elo robusto na cadeia de beneficência/não-maleficência aplicável ao portador de diferença valvar.
Ela é o ritual da memória, a raiz etimológica de anamnese, praticado junto com o culto do prontuário, um nosso alter ego profissional.
Esse rito secular compõe a prática do sacerdócio, que ainda nos cobram, intermediação entre os deuses deste século XXI, transmutados em evidências científicas e os doentes que acreditam na honestidade, no sigilo e na eficiência, as bênçãos para restauro de sua qualidade de vida.
O corolário de interesse da bioética é que o mérito da anamnese para a condução clínica da diferença valvar valoriza a participação ativa do paciente nos processos de decisão. É a versão bioética da expressão "o coração saindo pela boca".
Em clínica de valvopatia, a informação anamnésica ora tem conotação de objetividade inconteste do relato de uma síncope ora de subjetividade da manifestação de dispnéia ao esforço.
A queixa pode impactar o cardiologista de maneira variável e gerar contraditórios com sinais físicos ou de imagem – mais habitual perante valvopatia mitral17; exames não rotineiros podem, então, ser acionados, como o teste cardiopulmonar e o ecocardiograma com estresse farmacológico18,19. Suas informações objetivas sobre capacidade funcional ganham poder de antinegligência ou de antiimprudência para decisões "valvares", nesses casos de contraposições.
A indicação desses complementos para fundamentar terapêutica deve ficar adstrita a casos selecionados e não se superpõe à finalidade de autorização para prática de atividade física.
Em clínica de valvopatia entendemos que um alerta ético soa toda vez que um teste funcional é instado a falar em nome do paciente; a reflexão impõe-se pela tendência do predomínio da razão segundo a objetividade médica.
Dentro da bipolaridade Cardiologia à disposição do paciente–paciente à disposição da Cardiologia, ampliar a realização de testes funcionais seria pretender do consumo máximo de oxigênio, do limiar anaeróbio ventilatório e do nível de gradiente transvalvar a determinada freqüência cardíaca, inspetores da percepção do paciente sobre si mesmo; correr-se-ia o risco de substituir o calor humano da anamnese pela frieza científica do laboratório. Seria o caso da realização de teste funcional no portador de 1 cm2 de área mitral, "que se diz" oligossintomático, em ritmo sinusal, sem sinais de hipertensão arterial pulmonar desproporcional, sem história de tromboembolismo; pela nossa preocupação antinegligência, ele poderia passar a ser "desmentido" pelo comportamento reativo a uma condição hemodinâmica ausente no seu cotidiano. Nenhuma evidência comprova que estaríamos, dessa maneira, beneficiando o seu prognóstico de vida.
Explicações "razoáveis" para contestação da ausência de verbalização de sintomas significariam trabalhar nos pantanosos terrenos do equívoco de percepção, sedentarismo e ocultação de informação pelo paciente temeroso das conseqüências da exposição.
Partir de um difuso teórico, suposto hipoteticamente para 1 cm2 de área mitral, da fisiopatologia para o sintoma, e não o inverso, traz a possibilidade de sentimentos de desrespeito, além de, não necessariamente, contribuir para o consentimento do paciente para discutíveis mudanças de conduta.
A paráfrase ao princípio Ana Karenina – Leon Tolstoi (1828-1910) – parece-nos pertinente:
A reflexão é válida: o quanto de paternalista deve ser o cardiologista quando, supostamente, o paciente não demonstra intenção de modificar a sua qualidade de vida? Esforços de diálogo, à parte, em busca de uma "verdade, nada mais do que a verdade", será que deveríamos algemá-lo às realidades bioestatísticas da Cardiologia e, assim, nos consideramos zelosos? Ou será que deveríamos tolerar, entendendo que o
Opiniões variam em razão da valoração sobre as duas faces da moeda, já comentado, e subsidiam a análise crítica de certas recomendações de conduta no portador assintomático de diferença valvar.
Uma delas é a do Working Group on Valvular Heart Disease20, anglo-franco-espanhol, que pressupõe que o sedentarismo ou certas limitações de atividade podem comprometer a classificação do paciente como assintomático; o artigo recomenda que "antes de considerar se o paciente é
No Brasil de tantas febres reumáticas, entendemos que o fluxo espirométrico provocado que passa pela boca não deve "calar" a palavra que sai espontânea.
Acentuar o valor do exercício em laboratório, para maximizar objetividade para correlações com medidas da gravidade morfológica do portador de estenose mitral, equivaleria a mudar o fundamento do atual binômio terapêutico observação clínica da evolução-intervenção valvar. De sintoma/anamnese, ele tenderia para grau de lesão valvar/exame funcional.
Ademais, corre-se o risco da imprudência da antecipação determinar uma desastrosa travessia na contramão pela ponte acima referida, ou seja, do extremo "boa" qualidade de vida para o da "má" qualidade de vida. Em outras palavras, sujeitar, desnecessariamente, o risco a se tornar evento, em função de uma visão difusa de benefício.
Lembremos-nos das coleções de casos – não tão freqüentes numa estatística, mas trágicos numa vida – como os de insuficiência mitral surgidos após valvoplastia mitral por cateter-balão, antecipação não somente na indicação "pelo baixo risco", ou, talvez, pelo excesso de entusiasmo de uma curva de aprendizado, como também no subseqüente e imediato implante de uma prótese valvar.
A análise da recomendação para estenose mitral
A subdivisão de qualidade de vida em
Aproveitar o acesso cirúrgico para corrigir uma valvopatia sem indicação se fosse doença isolada, escolher o tipo de prótese de acordo com o perfil psicossocial do paciente, promover a plástica valvar significam figurar o marcador sintoma/classe funcional como possuidor de duas faces.
A primeira é a voltada para o passado e determinante da transformação da história natural em história pós-operatória, um efeito do sintoma que o conjunto de insatisfações do paciente com a diferença valvar não provocara; a segunda é a voltada para o futuro, pelo efeito de prevenir ou de reduzir insatisfações, um objetivo além da reversão dos sintomas.
O cardiologista assim se comportando como agente plural da Cardiologia apresenta-se como guardião do leque de opções da especialidade bem aberto, vai além da atuação "burocrática".
Certos aspectos da qualidade de vida futura não-beneficiados por rotinas institucionais tecnicamente corretas poderiam ter sido, caso tivesse havido a disposição para providências individualizadas.
Por isso, é desejável que os pontos de referência do tratamento/prognóstico não fiquem confinados ao resgate da "boa" qualidade de vida como equivalência à capacidade funcional classe I/II; que eles considerem as influências individuais sobre as insatisfações com a diferença valvar.
Da conjunção do método ético aristoteliano21 com a subdivisão da qualidade vida resulta um efeito pedagógico útil para a beira do leito de clínica de valvopatia.
O 1º estágio é a definição do conflito desencadeado pela diferença valvar como sintoma sim/classe funcional I/II ou III/IV; o 2º estágio é esquematizar os componentes diagnósticos, incluindo as insatisfações em geral; o 3º estágio, é entender o porquê das manifestações objetivas e subjetivas, à luz biopsicossocial, e selecionar as condutas ao alcance, ajustáveis ao melhor benefício dos dois considerados enfoques da qualidade de vida.
O quadro 1 ilustra decomposições da qualificação do impacto biopsicossocial sobre a vida do portador de valvopatia, segundo ângulos distintos de apreciação.
SINTOMA/CLASSE FUNCIONAL PELA DIFERENÇA VALVAR: assintomático-CFI/II.
INSATISFAÇÃO DO PACIENTE PELA DIFERENÇA VALVAR: Insatisfeito com a aproximação da época estimada para troca da prótese, que lhe provoca irritabilidade e baixa concentração de trabalho; a perspectiva lhe traz à memória os 15 dias de permanência pós-operatória na UTI, 10 dos quais semiconsciente e intubado.
SEU CARDIOLOGISTA: "boa" qualidade de vida.
DIRETRIZ ACC/AHA 2006: Retroca a ser determinada por sintomas ou intercorrências.
COMENTÁRIO: O paciente foi mantido sob observação, com recomendação de ficar atento a eventuais sintomas; revisão clínica, laboratorial (hemólise intravascular) e de imagem consideradas úteis para documentação, mas com baixo potencial de determinar o momento ideal da retroca; privilegiou-se a discussão com o paciente sobre os prós e contra das próteses, em razão da insatisfação pela reoperação.
SINTOMA/CLASSE FUNCIONAL PELA DIFERENÇA VALVAR: dispnéia quando se excede em certas atividades não rotineiras, palpitações ocasionais--CFI/II.
INSATISFAÇÃO DO PACIENTE PELA DIFERENÇA VALVAR: Insatisfeito com o ritual fármaco-laboratorial de anticoagulação oral e com o desaconselhamento a operar uma hérnia inguinal que há muito lhe incomoda; insatisfeito com o desconforto da injeção de penicilina benzatina, fica dois a três meses sem a aplicação, desconsiderando os dois episódios de atividade reumática aos 12 e aos 15 anos de idade.
SEU CARDIOLOGISTA: "boa" qualidade de vida.
DIRETRIZ ACC/AHA 2006: Considerar valvoplastia mitral por cateter-balão caso haja morfologia mitral favorável (nível classeI); em caso negativo, considerar intervenção cirúrgica, perante pressão arterial sistólica pulmonar>60 mmHg (nível classe IIa).
COMENTÁRIO: A rotina do Serviço não inclui a intervenção valvar em portador oligossintomático de estenose mitral, mesmo com escore ecocardiográfico favorável, embora admita discussão caso a caso em circunstâncias especiais. O paciente foi mantido sob tratamento clínico, em primeiro lugar porque qualquer intervenção não determinaria mudança na necessidade de anticoagulação oral, e, em segundo, porque a relação do risco da intervenção sobre a mitral para o benefício da herniorrafia foi considerada inadequada.
SINTOMA/CLASSE FUNCIONAL PELA DIFERENÇA VALVAR: assintomático--CFI/II.
INSATISFAÇÃO DO PACIENTE PELA DIFERENÇA VALVAR: Insatisfeito com a perspectiva de síncope a qualquer momento, desde quando foi atrás da segunda opinião da internet.
SEU CARDIOLOGISTA: "boa" qualidade de vida.
DIRETRIZ ACC/AHA 2006: Em ausência de sintomas e de rebaixamento da função ventricular esquerda, a presença de calcificação valvar como marcador de intervenção cirúrgica seria classe IIb.
COMENTÁRIO: O cardiologista explicou ao paciente que não desconsidera o potencial de síncope quando lhe recomenda conduta expectante; ponderou que apesar do impacto emocional, não havia conveniência "preventiva" do implante de prótese valvar aórtica. Nem sempre as análises do risco-benefício pelo médico e pelo paciente são superponíveis; conflitos podem acontecer em função de visões distintas sobre o implante de prótese: a da antiimprudência por parte do médico, que privilegia a morbidade imediata do trans-operatória e tardia do substituto valvar e a da antinegligência, por parte do paciente, com sua angústia quanto à síncope.
SINTOMA/CLASSE FUNCIONAL PELA DIFERENÇA VALVAR: manifestação cíclica de dor precordial e palpitações taquicárdicas que a incapacitam por horas, sentidas especialmente ao repouso, cada vez mais freqüentes – CFIII/IV.
INSATISFAÇÃO DO PACIENTE PELA DIFERENÇA VALVAR: Insatisfeita com o pânico quanto ao inesperado da manifestação de sintomas, acha que o diagnóstico prejudicou a sua vida familiar. Os sintomas desencadeiam um pressentimento de morte iminente.
SEU CARDIOLOGISTA: "boa" qualidade de vida.
DIRETRIZ ACC/AHA 2006: Considerar atuar sobre diagnósticos não cardiológicos, estimular mudanças de hábito de vida e uso de betabloqueadores.
COMENTÁRIO: A valorização da relação médico-paciente é essencial para minimizar insatisfações com o prolapso da valva mitral. Do diálogo, alguns fatos resultaram revelados: a) a paciente debruçou-se na internet e leu "tudo", valendo-se, inclusive, da sua fluência em inglês, francês e alemão; b) o pai falecera subitamente, poucos dias após ter sido cumprimentado pelo médico, ela presente, pela excelência dos resultados de uma série de exames realizados em função de um mal-estar precordial que incluía sintomas "parecidos"; c) lera sobre o relato de um caso de morte súbita em portador de prolapso da valva mitral, o que lhe trouxe um verdadeiro efeito nocebo pelo testemunho com alta representação afetiva do acontecido com o pai.
SINTOMA/CLASSE FUNCIONAL PELA DIFERENÇA VALVAR: assintomático--CFI/II.
INSATISFAÇÃO DO PACIENTE PELA DIFERENÇA VALVAR: Insatisfeito com a dependência
SEU CARDIOLOGISTA: "boa" qualidade de vida.
DIRETRIZ ACC/AHA 2006: Manter INR 2,5-3,5.
COMENTÁRIO: O outro lado da moeda em relação ao caso ABC.
SINTOMA/CLASSE FUNCIONAL PELA DIFERENÇA VALVAR: Dispnéia aos pequenos esforços, sempre acompanhada de sensação que o coração vai sair pela boca--CFIII/IV e, por vezes de tontura e dor precordial.
INSATISFAÇÃO DO PACIENTE PELA DIFERENÇA VALVAR: Insatisfeito com a progressão rápida dos sintomas, ainda reluta em aceitar a intervenção cirúrgica que recusa desde quando era assintomático, indicada pela aortopatia. Os sintomas, é verdade, reduziram a sua convicção antiintervenção; mas foi a realização "urgente" de um exame de imagem no dia em que a dor precordial foi mais acentuada, negativo para dissecção aórtica, que lhe aproximou da aceitação da operação; ele se sente "quase" dando o consentimento, apesar de ter ficado confortável com o tratamento farmacológico da insuficiência cardíaca.
SEU CARDIOLOGISTA: "má" qualidade de vida.
DIRETRIZ ACC/AHA 2006: Reconstrução da aorta e troca da valva aórtica indicada com qualquer grau de insuficiência aórtica em presença de diâmetro da aorta ou de sua raiz>5 cm.
COMENTÁRIO: Sintoma incapacitante sim, sintoma incapacitante não, é a dualidade que costuma dar concordância inequívoca sobre conduta cirúrgica, tanto para o médico quanto para o paciente. Os algoritmos do ACC/AHA 2006 utilizam sintoma como único dado subjetivo. As realidades estatísticas associadas à aortopatia da doença de Marfan representam um item de exceção à interdependência de sintoma incapacitante-classe III/IV ao tratamento cirúrgico da insuficiência aórtica crônica.
SINTOMA/CLASSE FUNCIONAL PELA DIFERENÇA VALVAR: Cansa-se um pouco mais de vez em quando, mas repousa uns 30 minutos e logo passa--CFI/II. Nega limitar-se no cotidiano.
INSATISFAÇÃO DO PACIENTE PELA DIFERENÇA VALVAR: Aparentemente satisfeito com uma boa convivência com a cardiopatia, manifesta boa adesão às recomendações; não verbaliza dificuldades de sua vida pessoal e profissional pela presença da diferença valvar.
SEU CARDIOLOGISTA: "boa" ou "má" qualidade de vida? Solicita reavaliação de imagem e teste cardiopulmonar.
DIRETRIZ ACC/AHA 2006: Havendo dúvidas quanto a sintomas, considerar teste de esforço; se ele resultar sintoma(+), a troca da valva aórtica é recomendação nível classe I; se, ao contrário, for sintoma (-) e associado à função ventricular esquerda normal, conduta clínica.
COMENTÁRIO: Definir subjetividades no cotidiano do paciente por meio da objetividade de exames no laboratório é ponto polêmico, pois poderia suscitar uma rotina de testes "em substituição à anamnese".
O cardiologista sentiu dubiedade sobre o relato da anamnese; resolveu valer-se da consecução dos recursos da Cardiologia como base de referência para concluir sobre a real dimensão dos sintomas. A imprecisão sobre qualidade de vida como "boa" ou como "má", trouxe-lhe um conflito e, pela responsabilidade profissional ante antinegligência e antiimprudência de uma recomendação cirúrgica, sentiu a necessidade de obter informações adicionais da sua esfera de conhecimento técnico.
Os valores obtidos pela espirometria associada ao teste ergométrico "tranqüilizaram" o cardiologista. Uma vez que concluíra que o paciente tinha "boa" qualidade de vida, manteve a conduta expectante.
Quando a anamnese provoca incertezas, o cuidadoso esculpir do equilíbrio clínico-cirúrgico tanto poderá pender para uma atitude de pragmatismo antinegligente determinante de antecipação de indicação cirúrgica, quanto para um passar do ponto idealizado, por meio de uma presunçosa hierarquização antiimprudência. E nesse aspecto, as imprecisões da transposição da subjetividade do paciente para a objetividade do médico superpõem-se às zonas cinzentas entre as classes funcionais.
SINTOMA/CLASSE FUNCIONAL PELA DIFERENÇA VALVAR: Assintomática--CFI/II
INSATISFAÇÃO DO PACIENTE PELA DIFERENÇA VALVAR: Após a surpresa do episódio de edema agudo de pulmão a boa convivência com a cardiopatia foi substituída por enorme apreensão com a valvopatia; manifesta importante grau de insegurança com a eficiência do antiarrítmico; culpa-se por ter suspenso a aplicação de penicilina benzatina desde que ficou grávida, voltou a utilizá-la a cada 21 dias; já realizou três consultas para "segunda opinião".
SEU CARDIOLOGISTA: "boa" qualidade de vida.
DIRETRIZ ACC/AHA 2006: É controverso se a valvoplastia mitral por cateter-balão deve ser realizada em portador de estenose mitral moderada ou importante, com fibrilação atrial de origem recente, que seja assintomático por demais pontos de vista.
COMENTÁRIO: A interpretação fisiopatológica da mudança abrupta da classe funcional define a conduta no portador de valvopatia. Ter ultrapassado um limiar obstrutivo da área efetiva de vazão pela mitral tem significado distinto do "teste funcional" aprontado pela resposta ventricular rápida à fibrilação atrial aguda.
No iminente perigo à vida, a óptica da insatisfação com a diferença valvar é superponível nos três componentes da tríade paciente, cardiologista e Cardiologia. O privilégio é pela relação do presente (manifestação clínica de edema agudo de pulmão) com o passado (estenose mitral); a relação do presente com o futuro (prevenção de novo episódio) fica em segundo plano.
O impacto do mais alto grau de desconforto possível pela valvopatia determinou seqüelas "não exatamente cardíacas"; a seqüência foi insegurança com o futuro mórbido.
Apesar do extremo da gravidade clínica atingida, exigente de medidas de emergência, a oscilação pendular das conseqüências da diferença valvar não impôs iniciativas de redefinições sobre beneficência/não-maleficência da rotina terapêutica, por parte do cardiologista.
Apesar do trauma do edema agudo sobre o viver da paciente, persistiu a rotulação como "boa" qualidade de vida, nas consultas subseqüentes; portanto, sem critério acadêmico para intervenção sobre a causa primária.
Considerar uma intervenção valvar soaria imprudência, pois, pela linha de conduta em Clínica de valvopatia, análises de risco-benefício privilegiam as conseqüências clínicas, mais do que a diferença primordial, razão da habitual longa manutenção da história natural.
O episódio representou para HIJ mais um capítulo da insatisfação com a diferença que se integrou a sua vida, a partir da atividade reumática na adolescência; embora transitório, o agravo, foi suficiente para elevar o nível basal de insatisfação com a sua condição de diferente.
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15. Tarasoutchi F, Grinberg M, Spina GS, Sampaio RO, Cardoso LF, Rossi EG, et al. Ten-year clinical laboratory follow-up after application of a symptom-based therapeutic strategy to patients with severe chronic aortic regurgitation of predominant rheumatic etiology. J Am Coll Cardiol. 2003; 41: 1316-24.
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19. Reis G, Motta Ms, Barbosa MM, Esteves WA, Souza SF, Bocchi EA, et al. Dobutamine stress echocardiography for noninvasive assessment and risk stratification of patients with rheumatic mitral stenosis. J Am Coll Cardiol. 2004; 43: 393-401.
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Max Grinberg Rua Manoel Antonio Pinto, 4 / 21 - A 05663-020 – São Paulo, SP E-mail:
Artigo recebido em 06/08/06; revisado recebido em 06/08/06; aceito em 17/08/06.
Symptoms and dissatisfaction. Context in the quality of life of patients with valve difference
Instituto do Coração do Hospital das Clínicas – InCor - São Paulo, SP
"Goals cannot be measured by the size of our bank account. They can only be measured in the quality of lives that our people lead." Lyndon Baines Johnson (1908-1973), 37th President of the USA, the first to employ the expression quality of life, in 1964.
"Man has but three events in his life: to be born, to live, and to die. He is not conscious of his birth, he suffers at his death and he forgets to live." Jean de La Bruyère (1645-1696), French moralist.
Patients are categorical: valvopathy makes a difference in their quality of life.
Cardiologists are authoritative: the quality of life of patients with valvopathy makes a difference in the treatment employed.
Bioethics induces the preservation and restoration of the quality of life of patients with valvopathy with the beneficence of Cardiology, the non-maleficence of the cardiologist’s expertise and the right of physicians and patients to autonomy.
As regards the clinical approach to valvopathy, quality of life, an expression that has only recently been incorporated to Cardiology, is worthy of critical scrutiny.
Quality of life is employed as a synthesis1-5. However, the expression usually fails to take into consideration certain values and perceptions of patients. It remains in the margin of Cardiology’s strict point of view, and may be subject to interpretation biases. Patients who fail the pre-employment health assessment due to a heart murmur, and who have to "run" every day to try to find a job, would not agree if their quality of life were described as "good" in their medical records just because he or she is asymptomatic.
Brazil is a multiethnic society and the "valve difference" impacts people in a different manner with respect to personal, family, professional and economic aspects. Each patient enjoys a unique biopsychosocial situation.
It is in view of the patient’s complaints, under the influence of his/her valve difference, and of his context of life6, that cardiologists decide which technical recommendations7 he should make and when, how and where he should apply them.
Cardiologists, human beings who have a mission towards suffering human beings, relate to the complaints presented as clearly by patients as expected, and these complaints will guide them. But this is not always so, this being the reason why the anamnesis comprises several stages. There is the risky obscurity of things which are barely unveiled, thus posing challenges to prudence and zeal in the treatment.
Contumacioushypochondriac and hyposensitive patients and those with few or multiple complaints disturb allopathic logic and stir up anti-negligence and anti-imprudence responsibility.
When there is uncertainty, it can be difficult to decode the multiple aspects of quality of life and distinguish which elements require the ethical commitment to the"... maximum care and the best of our professional ability..." article 2 of the Medical Code of Ethics".
In the context of patients’ dissatisfaction with their valve difference, we focus on symptom/functional class and tend to overlook other reasons for dissatisfaction which negatively impact patients’ lives.
In the clinical practice of valvopathies, quality of life does not replace functional class8 or dissatisfaction with differences9, and the expression is therefore not appropriate to harmonize the specifics of each patient with the diffuse availability of Cardiology.
...The concept of quality of life is subject to several interpretations1,5;
..."Good" quality of life is not equivalent to functional capacity class I/II ;
...Functional capacity class III/IV is one of the aspects indicative of "poor" quality of life associated with valve difference;
...There is a clear distinction between the functional inability to climb up a flight of stairs which has clinical value as regards making a treatment decision and understanding the patient’s discontentment with obligations such as adhering to test routines and to periodical prophylaxis with benzathine penicillin, which sound strict to the patients’ ears;
...Patients make spontaneous adaptations and think that they have preserved their "good" quality of life. For instance, the self-imposed limitation of climbing each flight of stairs slowly which is only reported to the physician after the worsening of his condition, months later, at the emergency room;
...The strength required to lift the gate of the bridge between "poor" quality of life and "good" quality of life stems from the merit of the risk-benefit ratio of what is within the scope of Cardiology,and that this bridge is paved by the technical and scientific resources of Cardiology; ;
...It is the excessive risk of interventions that usually causes the rejection of beneficial initiatives relative to certain dissatisfactions with the morbidity of valve-related differences. For instance, for those women in functional class I who do not want to run the risk of gestational events in view of mitral stenosis;
...Incapacitating symptoms/functional class III/IV are the fundamentals, according to universal consensus, for the decision to lift the gate and move across the bridge towards "good" quality of life10;
We propose to avoid using the expression Quality of Life as the major criterion for the adoption of therapy in valvopathies.
We propose that the concept of Quality of Life be defined twofold a) PATIENT'S DISSATISFACTION WITH HIS VALVE-RELATED DIFFERENCE, for broad considerations about his biopsychosocial infinite universe; b) SYMPTOMS/FUNCTIONAL CLASS DUE TO VALVE DIFFERENCE, for specific considerations on items which are of interest to Cardiology.
The classical surveillance of symptoms/functional class in patients with a valve difference prevails over the Manichaeism underlying good or poor quality of life to specify the establishment of the beneficence/non-maleficence of the methods made available by Cardiology.
In the clinical management of valvopathy, the propedeutical – and frequent - use of the expression quality of life by cardiologists with therapeutic purposes should there fore be reviewed.
A strong reason for this is that decision-making factors require the filtering out of aspects relating to the complex qualification of life, according to professional pragmatism.
The patients’ elements of dissatisfaction with his valve difference should be seen as arising from his valve difference and from the symptom/functional class. This contributes to strengthen the concept of complementarity embodied in the two faces of the same coin: tails, the majesty of Cardiology, science and discipline that has to be employed, and heads, the face of the patients with valvopathy, human beings who are the possessor of rights and the object of duties committed to knowledge, training and attitude.
In the clinical practice of valvopathy, a symptom is the variable that has the power to provoke a domino effect of simplistic Manichaeism. Symptoms succeed each other, functional capacity class I/II, functional capacity class III/IV; tests succeed each other; drug therapies succeed each other, events too; good and poor prognoses are made. No to valve intervention. Yes to valve intervention.
Symptoms are the raw material of guidelines. The ACC/AHA 2006 Guidelines for the Management of Patients with Valvular Heart Disease10 have an argument against the use of the expression Quality of Life in the good bedside practices in valvopathy management. The expression quality of life appears only twice in its almost 150 pages: on page e-40 "Because the goal of therapy is to improve the quality of life rather than longevity, symptoms are the most important guide for determining whether or not AVR should be performed" in aged patients with aortic stenosis; page e-80 "Surgery is indicated in patients with life-threatening congestive heart failure or cardiogenic shock due to surgically treatable valvular heart disease with or without proven infective endocarditis if the patient has reasonable prospects of recovery with satisfactory quality of life after the operation." Additionally, none of the articles that compose the fantastic set of more than 1,000 references has the expression "quality of life" in its title.
The words symptom/asymptomatic, however, appear around 600 times, and the expression functional class appears approximately 60 times, of which a reasonable percentage is in association with symptom/asymptomatic.
The key words for decision making in the management of patients with valvopathies are therefore symptom and functional class, preferably in connection with each other.
Bioethics addresses quality of life, birth and death11.
The expression quality of life is an essentially human social representation of life that goes beyond physical well being. Each time period, culture, social stratum has its own scale of values. When adapting to the real conditions of the development of societies, idealized standards tend to emphasize concepts relating to comfort and well being as seen by the upper classes.
We should bear in mind that Quality of Life includes not only concrete quantitative and qualitative factors, but subjective factors alike, such as feelings and virtues5.
Unbalances between these factors are common and disease influences the conduction of idealized plenitudes. Changes towards the valuing of goods, or towards philosophical considerations may be catalyzed by the clinical condition of patients.
If we apply the WHOQOL-100 issued by the World Health Organization12, designed to assess the quality of life to patients with valvopathy and ask them to consider the last two weeks, we will obtain many answers such as very or extremely worried, dissatisfied or very dissatisfied, little or very little able to those questions relating to enjoying life, feeling optimistic towards the future, being bothered by difficulties in doing everyday activities, depending on medication or medical assistance, having access to good quality medical care, ability to carry out daily activities.
Research carried out in the outpatient facility of Incor’s Valvopathy Clinic found that 59% of the interviewees considered that valvopathy had turned their life into a war against the disease.
The real life of cardiologists does not allow them to focus on those aspects devoid of technical and utilitarian connotation.
Because of their limited availability of time and their perception of their mission, they resort to a hardened professional conformism and overlook the aspirations of patients with valvopathy.
"Therapeutic successes" (Cardiology’s point of view) are usually found side by side with "unsuccesses in life" (point of view of patients with valvopathy). Oral anticoagulation because of metal prosthesis implantation provides many of such cases.
Projections of their own values lead professionals to ponder and decide that after all, "this is the best way". This is the case of some assessments on the risk-benefit of interventions on functional capacity class II valvopathy.
An automatic "there is no other way to prevent clinical manifestations or to improve the prognosis" justifies "minor distress" suffered by patients with valvopathy, although such distress may be rated as "not minor" in the patients’ self-assessment of quality of life. This is the case of the young successful sportsman, who is advised by his cardiologist not to practice competitive sport until he meets the criteria established by Cardiology at some uncertain time in the future.
In clinical practice, the healthcare team should strive to find a balance between being technically solidary and indifferent to the patients’ dissatisfaction which do not comprise management initiatives.
Understanding the biopsychosocial scenario of valve differences requires a multidisciplinary approach and expertise from different fields to broaden the understanding of the patient’s real life and contribute to fill in the gaps which are inherent to the relationship between physicians and patients.
Looking at the "heart surrounded by feelings" expands the patients dialog with Cardiology and contributes to a better assessment of the risk-benefit of communication. With a greater perception about points that need clarification, messages become more therapeutic and less etiopathogenic. This is the case of CDE (chart 1), a patient who, though "asymptomatic for heart disease" feels a paralyzing anguish due to the imminence of syncope after researching on the Internet. It is the case of EFG, a patient who, although also asymptomatic, hates to be sentenced to perpetual oral anticoagulation therapy. Many of these complaints are not directly verbalized to the cardiologist who only learns about them through psychologists and social assistants, which then provides an opportunity for adjustment in the patient-physician communication.
Therefore, the large potential interference of disease on life marks the natural history of valve differences, but its little penetration in the realm of Cardiology prevents the use of quality of life as a marker of strategic moments.
The marker for fruition of the beneficence/non-maleficence of therapeutic methods is the binomial symptoms/functional class.
In the clinical practice of valve disease, cardiologists should make the clinical condition fit into the four functional capacity classes. This allows the identification of treatment based on the diffuse biostatistics provided by Cardiology.
However, the functional class is often times established under a light that sometimes dazzles and favors illusions amidst the shadows. The blurred limits established by the four categories of the New York Heart Association (9 reviews from 1928 to 1994, with the NYHA incorporated to the AHA)8 determined a Manichaeist reduction: two categories, functional capacity class I/II and functional capacity class III/IV, have become the rule.
For those who prefer to use the expression poor quality of life as a criterion in the clinical practice of valve disease, functional capacity class III/IV would suffice, thus dismissing other dissatisfactions, but the continuum of functional capacity class I/II is not synonymous with good quality of life.
Even under the point of view of cardiology alone, functional capacity class II is pseudo-homogeneous, in view of the decline of the ability to adapt to valve difference13. Different clinical views are required between the first stage, that we could call post-class I and the final stage, pre-class III. In the latter, the first stages of the worrying symptoms bring together the patients’ dissatisfactions with their quality of life due to their valve disease and the beneficence of Cardiology.
There is lack of organized criteria in the pre-III stage of functional class II that would allow the stethoscope to sound the alarm and make the scalpel work. The efficiency of the alarm depends on a long term alliance between physician and patient, based on sound communication between them that would allow a long-term view on the impact of valve disease on patient’s life.
Readiness is not linked to the core of professional practice, which includes the murmur auscultated that allows the diagnosis of valve disease, and includes other data of physical examination which allow the identification of consequences and comorbidities, or the additional tests that document the condition and complement the information.
In most cases, none of them allow us to assert to what extent the condition impacts the lives of patients with valvopathy. This is why physicians should avoid the technical and utilitarian compulsion of extending the signs identified upon examining patients for symptoms, as if objectivity and subjectivity were totally intertwined.
In the clinical practice of valvopathy, functional classes from I to IV should be combined with the objective assessment from A to D, as recommended by the committee of the last review of the New York Heart Association8. A patient with severe aortic insufficiency, without dyspnea, fatigue, palpitation or anginal pain during ordinary activities fits into functional capacity class I, and objective assessment D. And with no alteration of variables such as auscultation of murmur and heart sounds, left ventricular diameter and function between the "day before" and the "day after", the management approach should be eventually changed. What would be the factor that would trigger such a change? The manifestation of symptoms that compromise life!
It is the symptom that literally speaks louder, it is the complaint of a patient with valvopathy14,15. This is the raw material that patients provide us with; after we work on it, it fits into the functional class framework, which is a real "receptor" of treatment.
Thus,more than a unilateral assessment determined by the stethoscope or by the transducer, it is the bilateral verbal communication between patient and physician that, in clinical practice, allows pondering on the temporal risk-benefit relationship of propedeutical and therapeutical interventions.
The value of the sharp mental image that emerges from the words of patients is in agreement with bioethics16: the anamnesis is a robust link in the chain of beneficence/non-maleficence applicable to patients with valve difference.
The anamnesis is the ritual of memory. The word actually comes from "memory", which takes us to the patient’s record, our professional alter ego.
This century-old ritual is part of our mission, is what is expected from us, the intermediation between the gods of the 21st century, embodied in scientific evidence, and the patients who believe in honesty, confidentiality, and efficiency, the blessings that can restore their quality of life.
The corollary of interest to bioethics is that the merit of the anamnesis as regards the management of valve disease is that it values the active participation of patients in the decision making process. This is the version of bioethics of the expression "to have one’s heart in one’s mouth".
In the clinical practice of valvopathy, the information obtained during the anamnesis is sometimes regarded as indisputably objective information about the report of a syncope and sometimes as subjective information on distress during exertion.
The complaint may impact cardiologists in different manners and generate contradictions in view of physical signs or images – very frequent in cases of mitral valve disease17. Non-routine tests can be performed such as the cardiopulmonary test and pharmacologic stress echocardiogram18,19. The objective information they provide is invaluable to ensure that decisions regarding valves are neither negligent nor imprudent when there is contradictory information.
The indication of these complementary tests to endorse therapy decisions should be restricted to selected cases, and should not overlap the purpose of authorizing the practice of physical activity.
In the clinical practice of valvopathy, we believe that an ethical alarm sounds whenever a functional test speaks for the patient. Careful consideration is the rule due to the tendency to let reason prevail according to medical objectivity.
Within the bipolarity of Cardiology, where Cardiology is available to patients and patients are available to Cardiology, increasing the number of functional tests performed would turn maximum oxygen consumption, ventilatory anaerobic threshold and transvalvular gradient level at a certain heart rate into inspectors of the patient’s perception about himself. We would run the risk of replacing the human warmth of anamnesis for the scientific coldness of the laboratories. This would be so in the case of functional tests performed with patients with 1 cm2 of mitral area, who "reports" to be oligosymptomatic, and has a sinus rhythm, with no sign of disproportionate pulmonary arterial hypertension, no history of thromboembolism, and that, because of our anti-negligence zeal could be "contradicted" by a behavior that is reactive to a hemodynamic condition that is not part of his everyday life. There is no evidence to prove that acting this way would be beneficial to his life prognosis.
"Reasonable" explanations for contesting the fact that the patients do not verbalize their symptoms would mean entering the marshy realm of misperception, sedentary lifestyle, and hiding of information on the part of the patient due to fear of the consequences of exposing such information.
Departing from a theoretical premise, hypothetically assumed for 1 cm2 of mitral area, i.e. from physiopathology to symptom, instead of going the other way around, brings out the possibility of feelings of disrespect, and does not necessarily contribute to obtain the patient’s consent to disputable changes in treatment.
It is pertinent to paraphrase the opening sentence of Anna Karenina by Leon Tolstoy (1828-1910): patients with valvopathies are all alike; but each one is symptomatic in his own way.
The consideration is valid. How paternalistic should cardiologists be when patients do not show any intention of changing their quality of life? Let’s set aside the efforts towards establishing a dialogue in pursuit of the "truth, and nothing but the truth". Should we tie patients to Cardiology’s biostatistical realities and consider ourselves to be careful because of this? Or should we tolerate his attitude and understand that the copy-paste of anamnesis was simply unable to change his script?
Opinions vary depending on the values of the two sides of the coin we mentioned above, and inform the critical analysis of certain recommendations of treatment for asymptomatic patients with valve disease.
One of these recommendations is from the Working Group on Valvular Heart Disease20, a British-French-Spanish workgroup that assumes that sedentary lifestyle or certain limitations of activity can compromise the classification of patients as asymptomatic. The article recommends that before considering whether the patients is truly (our bold print) asymptomatic, it is frequently (our bold print) useful to perform a functional assessment. In other words, in the dictionary of the study’s authors, asymptomatic translates into absence of symptoms after the induction of tachycardia (80% of the predicted heart rate).
In Brazil, where there is so much rheumatic fever, we believe that the provoked spirometric flow that comes out of the patient’s mouth should not silence his spontaneous words.
Increasing the value of exercise in laboratory conditions to maximize objectivity and correlate the measurements so obtained with measurements of morphological severity of patients with mitral stenosis would imply changing the pillar of the current therapeutic binomial -- clinical observation of progression of valve disease versus intervention. It would tend to shift from symptom/anamnesis to degree of valve lesion/functional test.
We would also run the risk of imprudently pushing forward a disastrous trip in the wrong way across the bridge mentioned above, that is, from the "good quality of life" side to the "poor quality of life" side. In other words, we would cause the risk to unnecessarily turn into an event due to a diffuse view of what would be beneficial to the patient.
Let us remember the sets of cases – not so frequently found in statistics, but that are nonetheless tragic for the lives of those who suffered from mitral insufficiency manifested after mitral valvoplasty with a balloon catheter. The intervention may have been pushed forward not only due to its "low risk" but maybe due to excessive enthusiasm in a learning curve, and in the subsequent and immediate implantation of a valve prosthesis.
The analysis of the recommendation for mitral valve stenosis of the ACC/AHA 2006 Guidelines for the Management of Patients with Valvular Heart Disease brings to mind a concern: if the anamnesis of a patient with mitral valve area >1.5 cm2 should raise doubts about a greater probability of functional capacity class II, and if exercise in the hemodynamics laboratory should identify more intense repercussions (pulmonary arterial systolic pressure >60 mmHg, pulmonary capillary pressure > 25 mmHg and transvalvular mitral gradient >15 mmHg), the decision of performing an intervention will fall on the morphology favorable to mitral valvopathy with a balloon catheter. If it is considered, it’s under level of recommendation IIb, evidence C, that is to say, beneficence is not clear in view of the risks. To strengthen our position, we would say that there is risk of imprudence because the risk-benefit relationship at the moment is unfavorable.
The subdivision of quality of life into symptoms/functional class and dissatisfaction with valve difference is useful to foster initiatives focusing on careful consideration and prudence with respect to the future. Many such initiatives are expressed in guidelines.
Some choices such as surgically repairing a valve that would have no indication for surgical repair if it were an insolated disease just because the patient is being operated, or choosing the type of prosthesis according to the psychosocial profile of the patient, or promoting valvoplasty are decisions that cause the symptom/functional class marker to have two faces.
The first face looks backwards, to the past, and determines the transformation of the natural history of valvopathy into its postoperative history, an effect of the symptom that the set of dissatisfactions of the patient with the valve difference had not brought about. The second face looks forward, to the future, by the effect of preventing or reducing dissatisfactions, an objective that goes beyond the reversal of symptoms.
Cardiologists therefore behave as the plural agents of Cardiology, the guardians of a wide open range of options of the specialty, acting beyond bureaucratic actions.
Certain aspects of future quality of life which do not benefit from technically correct institutional routines could have been implemented if personalized decisions had been considered.
This is the reason why it is desirable that the points of reference for treatment/prognosis should not be restricted to restoring "good" quality of life in terms of equivalence to functional capacity class I/II. They should take into account individual influences on dissatisfactions with valve difference.
The combination of the Aristotelian ethical method21 with the subdivision of quality of life gives rise to a pedagogical effect which is useful for bedside behavior in valve disease clinical practice.
The first stage is the definition of the conflict triggered by the valve difference in terms of symptom yes/functional class I/II or III/IV. The second stage includes schematizing the components of diagnosis, including dissatisfactions in general. The third stage implies understanding the reasons for objective and subjective manifestations from a biopsychosocial point of view, and selecting the treatment available, adjusting it to obtain the best benefit between the two considered as the focus of quality of life.
Chart 1 illustrates a breakdown of the qualification of the biopsychosocial impact on the life of patients with valvopathy under different angles of assessment.
SYMPTOM/FUNCTIONAL CLASS DUE TO VALVE DIFFERENCE: Asymptomatic-FC I/II.
DISSATISFACTION OF PATIENT DUE TO VALVE DIFFERENCE: Dissatisfied with the approaching of the estimated date of valve replacement. The patient feels irritable and finds it difficult to concentrate at work. The idea brings to his mind the 15 days spent in the ICU postoperatively, of which the patient remained intubated and semiconscious for 10.
HIS CARDIOLOGIST: "Good" quality of life.
ACC/AHA 2006 GUIDELINES: Replacement to be determined by symptoms or events.
COMMENT: The patient was kept under observation, and was told to pay attention to any symptoms. Clinical, laboratory (intravascular hemolysis) and imaging reassessment was deemed useful for documentation purposes, but had a low potential for determining the ideal time of replacement. The physician preferred to discuss the pros and cons of prosthesis with the patient, in view of his dissatisfaction with the reoperation.
SYMPTOM/FUNCTIONAL CLASS DUE TO VALVE DIFFERENCE: Dyspnea when he overengages in certain non-routine activities, occasional palpitation--FCI/II.
DISSATISFACTION OF PATIENT DUE TO VALVE DIFFERENCE: Dissatisfied with the oral anticoagulation ritual, with its medicines and laboratory routine. He had also been advised against the operation of an inguinal hernia that has bothered him for a long time. He is also dissatisfied with the benzathine penicillin injection, which brings discomfort, and goes without it for 2 or 3 months, ignoring the two episodes of rheumatic fever suffered at 12 and 15 years of age.
HIS CARDIOLOGIST: "Good" quality of life.
ACC/AHA 2006 GUIDELINES: Consider mitral valvoplasty with a balloon catheter if the mitral morphology is favorable (class level I). If not, consider surgical intervention if pulmonary sistolic arterial pressure is >60 mmHg (class level IIa).
COMMENT: The facility where the patient was served does not include valve intervention in oligosymptomatic patients with mitral stenosis, even when the echocardiographic score is favorable to the intervention, although in special circumstances individual cases may be discussed. The patient was maintained under clinical treatment, firstly because an intervention would not determine any change in the need for oral anticoagulation therapy, and secondly because the ratio between the risk of mitral intervention and the benefit of herniorraphy was deemed inadequate.
SYMPTOM/FUNCTIONAL CLASS DUE TO VALVE DIFFERENCE: Asymptomatic--FCI/II.
DISSATISFACTION OF PATIENT DUE TO VALVE DIFFERENCE: Dissatisfied with the prospect of suffering a syncope at any time since he looked for a second opinion on the Internet.
HIS CARDIOLOGIST: "Good" quality of life.
ACC/AHA 2006 GUIDELINES: In the absence of symptoms and with lower left ventricular function, the presence of valve calcification as a marker of surgical intervention would be class IIb.
COMMENT: The cardiologist explained to the patient that he does not ignore the potential syncope when he recommends that the patient have an expectant attitude. He pondered that, despite the emotional impact, the "preventive" implant of an aortic valve prosthesis was not convenient. Risk-benefit analysis carried out by the physician and the patient not always match. Conflicts may arise due to different viewpoints on the implant of prosthesis: the physician’s anti-imprudence approach, that directs his focus to transoperative immediate morbidity and late morbidity of the valve replacement and the patient’s anti-negligence approach, due to his anguish concerning syncope.
SYMPTOM/FUNCTIONAL CLASS DUE TO VALVE DIFFERENCE: cyclic manifestation of precordial pain and tachycardic palpitation that incapacitate her for hours. They’re felt especially at rest and have become increasingly frequent—FCIII/IV.
DISSATISFACTION OF PATIENT DUE TO VALVE DIFFERENCE: Dissatisfied with the panic she feels due to the unexpected manifestation of symptoms. She believes the diagnosis has impaired her family life. The symptoms trigger a presentiment of imminent death.
HER CARDIOLOGIST: "Good" quality of life.
ACC/AHA 2006 GUIDELINES: Consider acting on non-cardiological diagnosis, fostering change in lifestyle and using beta-blocker.
COMMENT: Valuing the relationship between physician and patient is key to minimizing dissatisfaction of mitral valve prolapse. During their conversation, some facts came up: a) the patient had researched the Internet and read "all" about her condition in English, French and German; b) her father had died suddenly, few days after his doctor had congratulated him in her presence for his excellent results in a series of tests performed as a result of precordial distress that included "similar" symptoms to hers; c) she had read a report on a case of sudden death of a patient with mitral valve prolapse, which caused a nocebo effect, since the report reflected to a high degree what had happened to her father, which deeply affected her.
SYMPTOM/FUNCTIONAL CLASS DUE TO VALVE DIFFERENCE: Asymptomatic--FCI/II.
DISSATISFACTION OF PATIENT DUE TO VALVE DIFFERENCE: Dissatisfied with his ad eternum dependence on the anticoagulation ritual that includes medicines and laboratory routines. He feels that the tablet is his "life insurance", and is frightened by the thought of needing yet another "heparin bridge", which he had undergone twice: when he underwent cholecystectomy and rhinoseptoplasty.
HIS CARDIOLOGIST: "Good" quality of life.
ACC/AHA 2006 GUIDELINES: Maintain INR between 2.5-3.5.
COMMENT: The other face of the coin when compared with the case of ABC.
SYMPTOM/FUNCTIONAL CLASS DUE TO VALVE DIFFERENCE: Dyspnea on minor exertion, always accompanied by the feeling that his heart would go out through his mouth--FCIII/IV and, sometimes dizziness and precordial pain.
DISSATISFACTION OF PATIENT DUE TO VALVE DIFFERENCE: Dissatisfied with the fast progression of the symptoms, he still refuses to accept the surgical intervention, which he has refused since he was asymptomatic. The intervention had been indicated because of his aortopathy. The symptoms actually reduced his anti-intervention conviction. But it was an image test performed with urgency on the day the precordial pain had worsened, which resulted negative for aortic dissection, that made him feel close to consenting to the intervention, although he felt comfortable with the pharmacological treatment of heart failure.
HIS CARDIOLOGIST: "Poor" quality of life.
ACC/AHA 2006 GUIDELINES: Reconstruction of the aorta and aortic valve replacement indicated for any degree of aortic insufficiency in the presence of aortic diameter or aortic root diameter >5 cm.
COMMENT: Incapacitating symptom yes, incapacitating symptom no. This is the duality that usually allows unequivocal agreement on surgical treatment as much for the physician as for the patient. ACC/AHA 2006 algorithms use symptoms as the only subjective data. Statistical realities associated with the aortopathy of Marfan’s disease represent an item of exception to the interdependence of incapacitating symptoms-class III/IV to the surgical treatment of chronic aortic insufficiency.
SYMPTOM/FUNCTIONAL CLASS DUE TO VALVE DIFFERENCE: Every once in a while he gets tired a little more, but this symptom disappears after a 30 minute rest--FCI/II. He refuses to impose limitations to his everyday activities.
DISSATISFACTION OF PATIENT DUE TO VALVE DIFFERENCE: He is apparently satisfied, and lives well with his cardiopathy. He adheres well to the recommendations. He does not verbalize difficulties in his personal and professional life because of his valve difference.
HIS CARDIOLOGIST: "Good" or "poor" quality of life? He requests reassessment of imaging and cardiopulmonary test
ACC/AHA 2006 GUIDELINES: When there is doubt regarding symptoms, consider performing exercise testing. If the result is symptom(+),valve replacement is a recommendation class level I. If, on the other hand, he is symptom (-) and associated with normal left ventricular function, clinical management is advised.
COMMENT: Defining subjectivities in the patient’s everyday life by using the objectivity of laboratory tests is controversial as it might cause a routine of tests to "replace the anamnesis".
The cardiologist felt uncertain about the report of the anamnesis and decided to avail himself of the resources of Cardiology as a reference to draw conclusions about the real dimension of symptoms. The imprecision about whether the quality of life was "good" or "poor", created a conflict and, because of his professional responsibility vis a vis the anti-negligence and anti-imprudence approach of a recommendation for surgery, he felt the need to obtain additional information from his area of technical knowledge.
The values obtained by spirometry associated with exercise testing reassured the cardiologist. Once he had concluded that the patient had a "good" quality of life, he adopted an expectant treatment approach.
When the anamnesis causes uncertainties, the crafting of the balance between clinical-surgical approach may either tend to a pragmatic anti-negligent attitude, that determines the anticipation of the indication for surgery or to going beyond the ideal point, by a presumptious hierarchization of anti-imprudence. In this regard, the imprecision of the translation of the patient’s subjectivity into the physician’s objectivity overlap the blurry boundaries between functional classes.
SYMPTOM/FUNCTIONAL CLASS DUE TO VALVE DIFFERENCE: Asymptomatic--fCi/ii
DISSATISFACTION OF PATIENT DUE TO VALVE DIFFERENCE: After being taken aback by the episode of acute pulmonary edema, the patient, who lived well with her cardiopathy, became very apprehensive with her valvopathy. She feels very insecure about the efficiency of the anti-arrhythmia medication. She feels guilty for having suspended the application of benzathine penicillin since she became pregnant, and she started to use it again every 21 days. She has looked for three "second opinions".
HER CARDIOLOGIST: "Good" quality of life.
ACC/AHA 2006 GUIDELINES: Mitral valvoplasty with balloon catheter in patients with moderate or severe mitral stenosis, with recent atrial fibrillation, is controversial if the patient is asymptomatic from other points of view.
COMMENT: The physiopathological interpretation of the sudden change in Functional Class determines the approach in patients with valvopathy. Crossing an obstructive threshold of the effective flow through the mitral orifice has a different meaning with respect to the "functional test" indicated by the fast ventricular response to acute atrial fibrillation.
When there is imminent risk to life, the perspective of dissatisfaction with the patient’s valve difference overlaps the triad composed by patient, cardiologist and Cardiology. Focus must be given to the relationship between present (clinical manifestation of acute pulmonary edema) and past (mitral stenosis). The relation between present and future (prevention of a new episode) remains in the background.
The impact of the highest possible degree of discomfort due to valvopathy led to sequelae which were "not exactly cardiac". The continuation was uncertainty with a morbid future.
Although the patient reached an extreme level of clinical severity , which required emergency measures, the oscillation of the consequences of the valve difference did not impose initiatives to redefine beneficence/non-maleficence of the therapeutic routine on the part of the cardiologist.
Although the patient felt the trauma of having had an acute pulmonary edema in her everyday life, the label "good" quality of life persisted in subsequent visits, and therefore there was no academic criterion for intervention on the primary cause.
Toconsider a valve intervention would sound imprudent, since according to the line of management in the clinical practice of valvopathy, risk-benefit analysis focus on clinical consequences rather than of the fundamental difference, this being the reason for the usually long maintenance of the natural history.
The episode represented, for HIJ, yet another chapter of her dissatisfaction with the difference which became part of her life since the rheumatic episode in her adolescence. Although transient, the aggravation was sufficient to elevate the baseline level of dissatisfaction with her condition.
No potential conflict of interest relevant to this article was reported.
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Max Ginberg Rua Manoel Antonio Pinto, 04 ap. 21 A 05663-020 São Paulo, SP E-mail:
Manuscript received August 06, 2006; revised manuscript received August 06, 2006; accepted August 17, 2006.