APPLICATION OF BOGER’S APPROACH IN A CASE OF VENTRICULAR ARRYTHMIA
Bipin S. Jain MD (Hom), MBA (Education Management)1, Shalini M. Sharma, BHMS 2*, Sujit S. Swami, MD (Hom)3
1Principal, Professor and Head, Department of Materia Medica, Dr M. L. Dhawale Memorial Homoeopathic Institute (MLDMHI)
2PG Student, Dept of Medicine, Dr M. L. Dhawale Memorial Homoeopathic Institute (MLDMHI)
3 Medical Officer, Dr M. L. Dhawale Memorial Trust’s (MLDT) Bhopoli Tribal Hospital
*Address correspondence to: Dr Shalini Sharma Email: dr.shalinisharma2111@gmail.com
How to cite this article:
Jain BS, Sharma SM, Swami SS. Application of Boger’s approach in a case of ventricular arrythmia. Journal of Integrated Standardized Homoeopathy (JISH) 2019; 02(01)
Received on: January 28, 2019
Accepted for Publication: March 27, 2019
Abstract:
This case report provides the clinical presentation of a 45-year-old woman with chest pain and palpitation along with ECG changes. She visited the casualty at Dr M. L. Dhawale Trust’s Bhopoli Tribal Cottage Hospital. This case demonstrates the importance of concept of concomitants and the application of Boger’s concept in clinical practice. It also illustrates how the sphere of action of a medicine and location of symptoms, when correctly applied, can lead to wonderful results with Homoeopathic medicines.
Case Record:
Name:Mrs. S M P
Age/ Sex: 45 yrs/ female
Date: 29/07/2018
HIMS Number: HIMS BHO 7231
Chief complaint: A 45-year-old woman, with no known major illness, presented alone to Dr M. L. Dhawale Memorial Trust’s (MLDT) Bhopoli Tribal Cottage Hospital with left sided chest pain radiating to the left arm since 2-3 days with palpitation and headache. No nausea, vomiting, or perspiration.
Situation:
Cardiac complaints usually induce anxiety in the treating physician, especially, when we encounter a cardiac case in a primary care cottage hospital located in a remote tribal area, with no advanced setup. She could not afford to go to any other higher medical institution nor to our bigger Rural Homoeopathic Hospital (RHH), Palghar, which is about 20 km away and is well equipped to handle such cases. An ECG was taken immediately, which demonstrated ventricular premature contractions (VPCs) in lead V6.
What are VPCs?
VPCs are the most common ventricular arrhythmia (irregular heartbeat). It may be perceived as a skipped beat or felt as palpitations in the chest in some patients. Most VPCs are asymptomatic, but may result in troubling palpitations in some patients (1).
Due to the emergency nature of the complaints, a physician’s opinion was taken on the phone. They advised immediate administration of a beta blocker (metoprolol 25 mg) and advised that the patient be transferred to our secondary care hospital at Palghar for observation in the Special Care Unit. However, the patient refused to travel to Palghar. Therefore, the physician advised to keep her for observation at our Bhopoli Tribal Cottage Hospital and to repeat the ECG in the evening.
Understanding the Clinical State:
The ECG demonstrated VPCs, which enabled us to correlate our patient’s complaints, chest pain and palpitations:
- VPCs i.e. ventricular premature contractions may be isolated or occur in groups. They may be present with or without structural heart disease.
If left untreated, VPCs may induce cardiomyopathy, in which the heart muscle becomes less effective and symptoms of heart failure may develop. Sudden cardiac death may occur as well.
- Generally, assessment and treatment of VPCs is challenging and complex, and is highly dependent on the clinical context. The prognostic significance of VPCs is variable and is best interpreted in the context of the underlying cardiac condition (2).
- Asymptomatic patients usually require no therapy. Most patients with symptomatic VPCs in absence of structural heart disease can be managed with beta blockers. However, if structural heart disease is present, evaluation and treatment is essential.
- Standard management of cardiac arrythmia includes hospitalization with continuous ECG monitoring, administration of anti-arrythmia drugs and beta blockers.
In our case, VPCs were present along with chest pain. Therefore, after assessing the clinical state, we were ready to send patient to our RHH, Palghar, but she refused. This situation posed a significant challenge to us, as it was a risk to manage such a patient in the Tribal Primary care cottage Hospital at Bhopoli.
However, with the patient’s deep confidence in us and the physician’s support, we decided to manage the patient in our set up. The patient’s vitals were continuously monitored.
General examination:
Temp: Afebrile
Pulse: 74/min
Blood pressure: 160/90 mm Hg
Respiratory rate: 18/min.
Systemic examination:
RS: AEBE, clear
CVS: S1, S2 heard
CNS: conscious, oriented
Figure 1. Morning ECG. VPCs in lead V6
Per the physician’s advice, 1 dose of metoprolol 25 mg was administered to the patient. Her vitals were constantly being monitored.
Metoprolol is a 2nd generation cardioselective beta blocker that binds to the beta receptors and blocks the binding of epinephrine and norepinephrine. This inhibits normal sympathetic effects. The drug decreases the contractility, conduction velocity, and rate of the heart. The drug has a mean elimination half-life of approximately 3-4 hours. The recommended dose for adults is up to 100 mg/day. However, its relative selectivity is lost at higher doses (3).
Unfortunately, even after administration of metoprolol, the patient reported persistent palpitation and headache. Her BP was 160/90 mm Hg.
The ECG was repeated at 5:30 pm in the evening. This ECG was suggestive of VPC in leads I and II. The morning ECG had demonstrated VPC in a single lead (V6), whereas the evening ECG showed VPCs in two leads. Increase in frequency of VPCs was prognostically not a good sign. The patient’s chest pain and palpitations had reduced to 60% of the original, while her headache persisted.
Figure 2. Evening ECG. VPC – Lead I
Figure 3. Evening ECG. VPC – Lead II
The result of the evening ECG was communicated to the physician, who advised another dose of beta blocker.
As the patient still had symptoms, including headache, chest pain, and palpitations, we decided to manage the patient Homoeopathically.
The evening dose of beta blocker was not administered. This was a conscious decision taken by us as a team because the morning dose of beta blocker had not resulted in significant improvement in the patient’s complaints and ECG.
The totality of the case was taken:
| Location | Sensation | Modalities | Concomitants |
| Cardiovascular
System Heart Onset – sudden since 2-3 days D-5-10 mins F- on &off
|
pain+
radiating to left arm palpitation+ no nausea no vomiting no perspiration BP -160/90 mmHg ECG – VPCs |
>Rest + | Headache
B/L Temporal region Pulsating pain ++ Extending to face >closed eyes++ <noise++ <sunlight++ |
The only characteristic symptom in this case was the Concomitant (headache) symptom that had presented with the chief complaints (chest pain & palpitation). Onset of the complaints was sudden. Other characteristic aspects were pathology (irregular heart beat), location & characteristic modalities. On this basis, Boger’s approach was followed.
Totality:
TIME: Sudden onset
LOCATION: Heart
LOCATION: Head – temporal region
SENSATION: Palpitation
SENSATION: Pulsating headache
PATHOLOGY: Arrythmia – Irregular heart beat
CONCOMITANTS: Headache along with heart complaints
MODALITIES:
> Closing eyes
< Sunlight
<Noise
Repertorization of the Symptoms:
Understanding of the remedy:
There are many Homoeopathic remedies that can be employed when treating patients with cardiac complaints. It is the individualizing characteristics of the patient that lead to the best Homoeopathic remedy for each patient.
In this case, along with palpitation, headache was the prominent accompanying symptom. After repertorizing the symptoms, the two closest remedies were Belladonna and Spigelia. Both remedies act on the heart, head, and nerves. If the sphere of action is considered, Belladonna acts mainly on the blood vessels and CNS; whereas Spigelia predominantly acts on the heart, nerves, and head. Spigelia covers violent palpitations, irregular heartbeats, headache as a concomitant, and pulsating type of pain. Belladonna is a right-sided remedy whereas Spigelia covers left sided affections. Thus, Spigelia was the choice of medicine (4,5).
Final Action Taken: Spigelia Anthelmia 200 C
Repetition: Two hourly.
Follow Up:
| Date/ time | Symptoms | Action taken |
| 29/07/2018
8:15 pm |
Pulsating headache at the temporal region
Occasional palpitation BP: 160/90 mmHg |
Spigelia 200 – 1st dose |
|
10:00 pm |
Headache 40% better. No palpitation BP: 160/90 mmHg |
Spigelia 200 – 2nd dose given. |
|
11:00 pm
|
Headache better 70% better. No palpitation. BP: SQ Patient slept well. |
Spigelia 200 continued 2 hourly |
| 30/07/2018
10:00 am |
Patient feeling better. No headache. No palpitation.
BP: 140/90 mmHg. ECG: Sinus rhythm in all leads |
Spigelia was repeated every 2 hours. The patient slept well overnight. The ECG was repeated in the morning around 10:30 am. This ECG was absolutely normal and did not show any VPCs in any of the leads.
Figure 4 (A). Morning ECG
Figure 4 B. Morning ECG
Figure 4 C. Morning ECG
Figure 4 D. Morning ECG
Figure 4 E. Morning ECG
Result: The morning ECG showed sinus rhythm i.e. normal and regular beats. Not only were the VPCs gone, but the patient’s headache was significantly better. The blood pressure had returned to normal.
Learning
This case teaches us the following points:
- How to perceive totality using the characteristic symptoms and location in acute conditions.
- Importance of knowledge of Materia Medica and the sphere of action of medicines.
- Boger’s concept and its application in clinical practice.
- Importance of concomitant symptoms and their application in clinical practice. For example, in this case, palpitation (arrhythmia) was present with the headache.
- This case also demonstrates the efficacy of Homoeopathy in emergency cases.
- The correct perception of the Homoeopathic philosophy, clinicopathological correlations, and grasp of Homoeopathic totality allows a Homoeopathic physician to handle cases that otherwise would have needed referral to a higher centre or transfer of the case to a modern medicine facility.
- Such cases also help to develop the confidence and faith in students of Homeopathy and help dispel doubts in their minds about the efficacy of Homoeopathy.
- The case also teaches us that patience, self-reflection, self-perception, and self-confidence are cultivated when we practice our science wholeheartedly.
References:
- Masood Akhtar LBB. In edition 2, editor. Cecil’s textbook of medicine.: saunders company; 2000. p. 865.
- Kasper Dennis S. FAS,LDLBEHS. Principle & Practice of Internal medicine. 17th ed.: McGraw Hill Publication.
- KD T. Essentials of Medical Pharmacology. 5th ed. Tripathi M, Editor. New Delhi: Jaypee brothers; 2003.
- Boericke W. Pocket Manual of Homoeopathic Materia Medica and Repertory: B. Jain publishers; 1998 reprint.
- Boger CM. A Synoptic Key of the Materia Medica. 1st ed.: B. Jain publishers; 2002
