Our case in this poll involves 65-year-old female with nonischemic cardiomyopathy resulting in NYHA III and Stage D heart failure (HF) necessitating an automatic implantable cardioverter-defibrillator (AICD) and left ventricular assist device (LVAD) complicated by recurrent drive line infections; paroxysmal atrial fibrillation; chronic hypoxic respiratory failure from obstructive lung disease; chronic kidney disease; anemia; hypothyroidism; pulmonary coccidioidomycosis, and a recent emergency department visit for COVID-19 pneumonia treated with a short course of steroids and remdesivir, presented to the hospital with a productive cough and increased oxygen requirements from her baseline. The patient was admitted for acute on chronic hypoxic respiratory failure caused by superimposed multifocal bacterial pneumonia. As her respiratory illness was treated, her hospitalization was complicated by an acute gastrointestinal bleed requiring endoscopic intervention, as well as acute renal failure requiring brief hemodialysis. While her conditions eventually stabilized, her course was prolonged by persistent complaints of generalized weakness and fatigue. Daily assessments and comprehensive workups were unremarkable for hemodynamic deterioration, new infections, worsening anemia, metabolic disturbances, or acute neurologic pathology. Routine LVAD interrogations were unrevealing for functional abnormalities or new alarms.

Below are the responses from this poll:

"Ordering repeat blood cultures" was selected by 14% of responders. While the patient is certainly at risk for acquiring additional infections, she remains afebrile and hemodynamically stable, and daily labs and imaging are not suggestive of new infectious processes.

"Obtain thyroid studies" was selected by 11% of responders. Thyroid screening in the inpatient setting should be limited to patients with clinical signs and symptoms that strongly suggest the presence of thyrotoxicosis or myxedema coma, as acute nonthyroidal illnesses have been shown to decrease the specificity of serum thyroid stimulating hormone (TSH) resulting in many false positive results.^1,2 While fatigue and weakness can be associated with thyroid disease, the patient is not exhibiting the classic findings of extreme thyroid states such as cardiovascular instability or altered mentation. One may consider thyroid myopathy as part of the differential; however, this is more often characterized by myalgias and neuromuscular weakness predominantly involving the proximal musculature.³ Hypothyroid associated myopathies can also be accompanied by sensorimotor axonal neuropathies which the patient also lacks.⁴ Finally, there is no mention of abrupt discontinuation of the patient's hormone replacement therapy which is a common risk factor for acute thyroid illnesses.⁵

Most responders chose "Consult rehabilitation services" (71%). There have been multiple studies demonstrating the role that hospitalizations have on the functional decline of older individuals. While the impact of inactivity can result in global organ dysfunction, its adverse effects on skeletal muscle alone are profound and can be explained by changes that occur starting at the molecular level.⁶ Prolonged immobility in the hospitalized patient has been shown to reduce adenosine-5'-triphosphate (ATP) and glycogen concentrations and increase lactic acid formation, all of which can result in increased fatiguability.⁶ Furthermore, extended bed rest can lead to a decrease in the rate of protein synthesis and a concurrent increase in the rate of protein degradation causing muscle fiber atrophy and a subsequent reduction in overall strength with some studies estimating a daily loss from 1.3% to 3.0%, potentially amounting to a 10% loss of strength in just 1 week of bedrest.⁶ The lower extremity musculature has been found to be most susceptible to these changes.⁶ While these effects have been observed in all patient populations, they are most debilitating in older adults, particularly for those individuals who were previously capable of independently performing all activities of daily living.⁶ Furthermore, there is unmistakable evidence of progression of sarcopenia and cardiac cachexia in older patients with advanced heart disease including advanced HF.⁷ LVAD therapy does not reverse the pathophysiology of HF but allows for enhanced symptom management and additional utilization of guideline directed medical therapy for HF. Over several months, patients with a LVAD may reverse sarcopenia and muscular atrophy due to the ability to perform more physical activity as a result of improved cardiac output.⁸ However, in an inpatient setting, particularly with prolonged hospitalizations, the risk factors for disuse muscular atrophy and deconditioning exist for these patients as for any other patient. It is thus critical to recognize and anticipate these effects and initiate rehabilitation specialists as early as possible in the patient's hospitalization.⁹

Approximately 2% of responders chose "Order an electromyographic study". Electrodiagnostic studies are used to evaluate for neuromuscular diseases or degenerative conditions,¹⁰ none of which is historically present in our patient. Furthermore, she is not demonstrating new signs on clinical exam for a focal motor or nerve deficit. Her global weakness is more suggestive of diffuse muscle atrophy, and early rehabilitation should be the next step before nerve conduction studies are considered.

References

1. Bashkin A, Yaakobi E, Nodelman M, Ronen O. Is routine measurement of TSH in hospitalized patients necessary? Endocr Connect 2018;7:567-72.
2. Premawardhana LD. Thyroid testing in acutely ill patients may be an expensive distraction. Biochem Med (Zagreb) 2017;27:300-07.
3. Fariduddin MM, Bansal N. Hypothyroid Myopathy (StatPearls [Internet]). 2022.  Available at: https://www.ncbi.nlm.nih.gov/books/NBK519513/. Accessed 07/15/2022.
4. Brzozowska MM, Banthia S, Thompson S, Narasimhan M, Lee J. Severe hypothyroidism complicated by myopathy and neuropathy with atypical demyelinating features. Case Rep Endocrinol 2021;May 19:[Epub ahead of print].
5. Galindo RJ, Hurtado CR, Pasquel FJ, García Tome R, Peng L, Umpierrez GE. National trends in incidence, mortality, and clinical outcomes of patients hospitalized for thyrotoxicosis with and without thyroid storm in the United States, 2004-2013. Thyroid 2019;29:36-43.
6. Hoenig HM, Rubenstein LZ. Hospital-associated deconditioning and dysfunction. J  Am Geriatr Soc 1991;39:220-22.
7. Lena A, Anker MS, Springer J. Muscle wasting and sarcopenia in heart failure - the current state of science. Int J Mol Sci 2020;21:6549.
8. Vest AR, Wong WW, Chery J, et al. Skeletal muscle mass recovery early after left ventricular assist device implantation in patients with advanced systolic heart failure. Circ Heart Fail 2022;15:e009012.
9. Chen Y, Almirall-Sanchez A, Mockler D, Adrion E, Dominguez-Vivero C, Romero-Ortuno R. Hospital-associated deconditioning: not only physical, but also cognitive. Intl J Geriatr Psychiatry 2022;Feb 2:[Epub ahead of print].
10. Adebayo P, Taiwo F, Owolabi M. EMG indications and findings in a sub-Saharan African neurorehabilitation center. Clin Neurophysiol Pract 2018;3:99-103.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, COVID-19 Hub, Heart Failure and Cardiomyopathies, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Mechanical Circulatory Support, Geriatric Cardiology

Keywords: Activities of Daily Living, Defibrillators, Implantable, Atrial Fibrillation, remdesivir, Blood Culture, COVID-19, Cachexia, Coccidioidomycosis, Heart-Assist Devices, Inpatients, Multiple Organ Failure, Myalgia, Myxedema, Proteolysis, Sarcopenia, Heart Failure, Thyrotropin, Thyrotoxicosis, Hemodynamics, Cardiac Output, Risk Factors, Hormone Replacement Therapy, Lung Diseases, Obstructive, Renal Insufficiency, Chronic, Emergency Service, Hospital, Acute Kidney Injury, Pneumonia, Bacterial, Respiratory Insufficiency, Neural Conduction, Hospitalization, Muscle, Skeletal, Lower Extremity, Cardiomyopathies, Muscle Fibers, Skeletal, Renal Dialysis, Lactic Acid, Adenosine, Glycogen, Hospitals, Steroids, Anemia, Fatigue, Oxygen, Adenosine Triphosphate

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