SEPTEMBER/OCTOBER 2019
.
DISCOVER 25
Back in Mr. Mendez’s room, I said, “The good news is, all tests are
normal.”
My patient beamed.
“So what’s causing this?” the first daughter demanded.
“Still hard to say,” I replied. “It might be wise to admit him to run the
next battery of tests. I’d like to have a cardiologist and a rheumatologist
see him.”
My patient’s face fell. The lead daughter spoke again: “You men-
tioned medications. What about the drugs he’s taking?”
Right. The meds. “Those are widely used drugs with long safety
records,” I stammered.
“But you said many things could cause this.”
“You’re right, I did.”
UNBLOCKING THE BETA-BLOCKERS
The simple fact was that in hot pursuit of the exotic, I’d missed the
commonplace. Atenolol, Mr. Mendez’s beta-blocker, has been around
for decades. A revolution in cardiac care when introduced in the
1960s, beta-blockers are now ubiquitous — to the tune of 70 million
prescriptions each year in the U.S.
Once a heart has been damaged from a heart attack, it’s bad for it
to get too worked up. Beta-blockers act to cloak the receptors in the
heart (called beta-receptors) that respond to fight-or-flight hormones
like adrenaline. Beta-receptors also inhabit blood vessels. When
stimulated, they dilate arteries to increase flow to muscles — handy
when you’re sprinting away from saber-toothed tigers. Block the
beta-receptors, however, and you might get the opposite: Arteries
that constrict too tightly. Familiar as they may be, beta-blockers are
potent medications with real side effects, including depression. My
own mother was on them once, and they turned her sunny disposition
to thoughts of plunging off balconies.
I pulled out my cellphone and tapped the pharmacology app.
All the data it delivered used to come in the form of a Gutenberg
Bible-sized tome — the iconic Physicians’ Desk Reference that door-
stopped many a doctor’s office. I typed in “atenolol,” then “adverse
effects.”
At the bottom of a long list was “Raynaud phenomenon.”
“It’s the atenolol,” I declared. “You were spot on.”
“How do you know?” several daughters asked at once.
“All the tests are negative, he looks good, and the medication was
recently started. I’m pretty sure.”
“So what do we do?” the lead daughter asked.
“His pulse is on the slow side. That’s also probably due to the ateno-
lol. You can’t stop it abruptly, or his blood pressure and heart rate could
shoot up. Give him half a dose until you see your doctor in a day or
two. Then she can substitute something else.”
“Ya le volveran a ser rosados,” I told Mr. Mendez. Pink toes soon.
He nodded solemnly. “Gracias, doctor.”
Two weeks later, I checked in with the daughter. No more blue. And
a good lesson in how the usual suspects never stop being so.
D
Tony Dajer is an emergency physician in New York City. The cases described in
Vital Signs are real, but names and certain details have been changed.
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