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Had rheumatic fever. EKG abnormal with inverted twaves, ejection fraction of less than 20%. Advice?

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Cardiologist, Interventional
Practicing since : 1995
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Patient is 66 years old, no prior health problems at all. Had Rheumatic feather when he was a child. Recently had a physical done and the ekg was abnormal with inverted twaves. Patient had an echocardiogram and the docs diagnosis was that the patient had an ejection fraction of less than 20%. What should the dr. advise the patient to do immediately? Please be specific
Posted Tue, 23 Apr 2013 in Hypertension and Heart Disease
 
 
Answered by Dr. (Prof.) Subroto Mandal 17 hours later
Hello,

Thanks for the query.

As per the details provided, most probably doctor will stabilize the patient first with medicine, and after that he may suggest for angiography to see for the reason for low ejection fraction.

Further management will depend on the results of angiography.

Hope I have answered your query. Let me know if you need clarifications.
Take care

SUBROTO
Above answer was peer-reviewed by
 
Follow-up: Had rheumatic fever. EKG abnormal with inverted twaves, ejection fraction of less than 20%. Advice? 43 minutes later
Thanks for the follow up Dr Mandal but I have a few more questions. How serious is an ejection fraction of less than 20%? Is it serious enough that the doctor should take immediate action and follow up with the patient? What would the angiography tell the doctor?
 
 
Answered by Dr. (Prof.) Subroto Mandal 10 minutes later
Hi,

Welcome back.

Ejection fraction below 20% is concerning. In many cases, ejection fraction of less than 20% can make a patient sick and serious. A doctor is needed to act immediately and fast based on the clinical symptoms.

Angiogram is done to understand the blood supply of heart - the coronary arteries. It identifies any blocked artery supplying to heart. A blocked coronary artery is the most common cause for a low ejection fraction.

The block needs to be rectified and corrected to stabilize low ejection fraction. .

Hope I have answered your query. Let me know if you have any other enquiries.

Regards
Above answer was peer-reviewed by
 
Follow-up: Had rheumatic fever. EKG abnormal with inverted twaves, ejection fraction of less than 20%. Advice? 2 days later
When the doctor called the patient to tell him that his diagnosis was that the patient had an ejection fraction of less than 20%, should the doctor have told the patient that he needed to have the Angiogram immediately? or should it have been left up to the patient to casually make an appointment when he had time. The reason for my question is really I need to know the seriousness of an ejection fraction of less than 20%. Is that diagnosis life threatening? Also, if the ejection fraction was caused by a blocked artery and the blockage is cleared, what is the general prognosis going forward? Thank you again for your time and expertise. Looking forward to hearing from you.
 
 
Answered by Dr. (Prof.) Subroto Mandal 3 hours later
Hello and welcome again,

This is not always correct that with less than 20% Ejection, doctor should do angiography.

I want to clear that Angiography ig only a test not the treatment, so if doctor thinks that patient is fit to do angiography, then only he will do angiography.

Secondly angiography is also a risky test with low ejection fraction. This can be done with this situation if patient is well stable.

So, angiography is not the full answer, once we clear the blockage then patient can get benefit.

After clearing of blockage, there are chances to improve the ejection fraction, but it’s not always.

Sometime after clearing of blockage ejection fraction doesn't improve.

So, in this situation, doctor will stabilize the patient first, then angiography and if needed he will perform angioplasty.

I hope answered your query.

Good luck.
Above answer was peer-reviewed by
 
Follow-up: Had rheumatic fever. EKG abnormal with inverted twaves, ejection fraction of less than 20%. Advice? 7 hours later
Doctor,

First please understand that I really appreciate your responses to my questions and I hope you dont mind that I am writing so much. I am try to figure out whether or not my father is getting the proper medical advice and whether or not the doctor should be doing more. I completely understand that an Angiography is a test and not a treatment. Here are the facts again about the patient. 66 year old Non Smoking very fit male who was never sick in his life except for Rheumatic fever when he was 11 years old. Yes he had the common cold once in a while but never sick nor did he ever take medication for anything. Pertinent NEGATIVES include chest pain, dyspnea, orthopnea, palpitations, paroxysmal nocturnal dyspnea and syncope. NO hypertension, diabetes or any family history of heart disease. All of this information was taken right off of his medical records. The patient went to have a routine physical done and during that physical the doctor saw that he had inverted lateral T waves on the EKG. Blood work was also done during the physical and the total cholesterol level was a 298 with the LDL levels at 229. After the physical and cholesterol was complete, the doctor performed an Echocardiagram and his diagnosis was (1.)"Severely Depressed left ventrical systolic function Global" Estimated Ejection Fraction <20%. (2.) Mild Abnormal left ventrical diastolic function: Impared relaxation. (3.)Normal estimated pumonary systolic pressue 25-30mm" (4.)Aortic Valve: Mild Aortic Sclerosis. (5.)Mitral Valve: Trace Mitral Regurgitation. (6.)Tricuspid Valve: Trace Tricuspid Regurgitation. (7.)Chamber Size: Dilated Left Ventrical & Mild Left Ventricular Hypertrophy. If the patient had this diagnosis what should have been done next. Is the diagnosis serious? if so what should the doctor advise next? Should the doctor tell the patient to come in immediately for further tests like an angiography to see if a blockage was causing the low ejection fraction or could the patient make an appointment at his convenience to have further work done? I am trying to figure out the seriousness of the diagnosis. Is it life threatening? If there are any question you have for me please by all means ask me? Thank you so much again for your time and expertise.
 
 
Answered by Dr. (Prof.) Subroto Mandal 4 hours later
Hello,

Thanks for providing detailed information. It makes us understand the clinical picture of the patient better and thus helps us to answer your queries better. Let me answer your queries in this way:

1. The seriousness of ejection fraction depends on the symptoms the patient has. Symptomatic patient with low ejection fraction is more serious than asymptomatic patient with the same ejection fraction.
I am glad to know that your father is not in distress which suggests that he is not in a life threatening situation now.

2. That being said, the situation can change. Therefore since your father is asymptomatic, I think he should be subjected to angiography at the earliest.

3. A cardiologist would be the apt person to treat him. If angiography is not considered yet, I think you may consider a second opinion from a cardiologist.

I hope it is clear to you now. Let me know if you have any questions.

Regards
SUBROTO
Above answer was peer-reviewed by
 
Follow-up: Had rheumatic fever. EKG abnormal with inverted twaves, ejection fraction of less than 20%. Advice? 47 hours later
Doctor,

I am sorry if I was not clear in my previous questions but I think you need to know that my father passed away from a heart attack in January 2011 It was five months after the doctor gave my father the diagnosis of the ejection fraction of <20%. The reason I am asking these questions is because I want to know if the doctor practiced a reasonable standard of care? Yes my father did not have any symptoms but the EKG and the Echocardiagram clearly showed that there was a problem. Should the doctor have followed up with my father and stressed the importance of having the Angiography? After the doctor gave my father his diagnosis he never spoke to my father again and my father died five months later. I had an autopsy done on my father and the Pathologist found that my dad died of Atherosclerotic Cardiovascular Disease. Here is what the pathologist wrote in his report "The major findings in the report included: severe hardening of the arteries (atherosclerosis) involving two major arteries that supply blood to the heart muscle. Also, there was evidence of extensive prior heart muscle damage due to inadequate blood supply (ischemia) that had formed scar tissue". Given the facts that my father had Ejection Fraction of <20%, Rheumatic fever when he was a child and high cholesterol is it not reasonable to think that a Cardiologist would want to get the patient in for further tests as soon as possible? Should he not have followed up with my father diligently until he found out what was wrong?
 
 
Answered by Dr. (Prof.) Subroto Mandal 21 minutes later
Hello,
I have gone through all the details of your father.
In my opinion, physician treating can take the best decision regarding the patient, according to the situation. What opinion I am giving is as per your input.

On many occasions, decision, and plan of management may vary depending on different physicians.

Hope I have answered your query.

SUBROTO
Above answer was peer-reviewed by
 
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