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Dr. Andrew Rynne
MD
Dr. Andrew Rynne

Family Physician

Exp 50 years

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Suggest tests to assess the function of heart other than Echo

Answered by
Dr.
Dr. Ilir Sharka

Cardiologist

Practicing since :2001

Answered : 6925 Questions

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Posted on Tue, 7 Jun 2016 in General Health
Question: Dear Dr Iliri,
It is XXXX again, with further questions.

I have calmed down about the protein in urine as GP didn't find any in a new test but I am having greater anxiety about my heart and had a bit of an issue with my medical clearance at work for travel to Cambodia. As I wanted to be honest, I told the medical clearance manager (who is an RN, not an MD) about my history with cardiomyopathy and ablation. I provided my echo report of February 4th of this year. The manager said that for their purposes all tests must have been conducted within 30 days so my echo report will not be adequate. My cardiologist does not agree and says there is no indication for a new echo so soon. It looks as if my only solution will be to find a new dr who will do an echo for my medical clearance.

I am now anxious for several reasons- first because I am afraid that a new doctor will interpret my echo in a way which is below 70 EF and makes me very worried. I once had echoes three times in a month and had EF anywhere from 55 to 70. I am very happy with the 70 EF and terrified it has gone down. That the medical office will not accept my echo of February 7th makes me believe it is possible to have significant changes in that time.

Again, would my perfect EKG, BP, and pulse ox show any indicators of some relapse I could be suffering? I just wish there was some way besides echo to be sure my heart function is ok. I know you've said if I feel ok, I am ok, but as I didn't have severe symptoms even when very sick, I don't trust this. Also, this week I met someone at the gym who is on the transplant list and has an LVAD in a backpack and yet can run 20 miles at high speed on the treadmill! It made me feel like even being able to exercise is no guarantee my heart is ok.

Should I try to explain to the medical office that my 7 week old echo is absolute still valid? I believe their belief is that cardiomyopathy is never curable. Also they are concerned because I have only been off all heart meds for about 4 months.

Last question, dear Dr Iliri- would drinking a liter, quite quickly, cause urinary urgency, in your opinion? I can't stop this compulsion to drink so much in order to make sure I am urinating enough only now my bladder feels overactive after feeling under active for many months. My PCP doesn't think I need to see a urologist. I last saw a urologist for LOW bladder sensation in XXXXXXX last year and he told me I was fin
doctor
Answered by Dr. Ilir Sharka 11 hours later
Brief Answer:
I would explain as follows:

Detailed Answer:
Dear XXXXXXX

I am glad to discuss with you again on HCM!

I understand this new situation, and I would explain that it is normal for legal purposes (especially when they are not specialist of the field), new tests are needed to confirm that you are a healthy person.

This doesn't mean that you are sick. This means just that they are not specialists of cardiac disorders. I agree with your doctor that there is no need of a new echo, as it will result normal, but you need to do it for your clearance manager(according to their rules).

You can do it in every other doctor and I am sure that it will show a normal cardiac function. You should not doubt on this!

So just relax and try another doctor (maybe privately) and show it to your clearance manager.

I know every step in your past medical history and your latest performed tests and would reassure you that you have nothing to worry about.

Regarding the fact that you drink a liter water, I would explain that urinary urgency in this situation is just a physiological reaction to fluid intake. You have nothing to worry about it. Drinking so much is related to a compulsive disorder you have and anxiety. But you should try to avoid yourself from doing this.

If you can not stop yourself from drinking so much, you should accept the fact that you will have urinary urgency as a normal reaction of your body to fluid intake (remember that we are like machines, to remain constant we have to regulate our inputs (food and water) with our outputs (stool, urine, sweating) in order to keep our body balances.

You have no bladder dysfunction! Just a normal healthy bladder.

Hope to have clarified some of your uncertainties.

Best wishes,

Dr. Iliri
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka 29 hours later
Dear Dr Iliri,
I was able to have my regular cardio do an echo today as he understood my anxiety about seeing a new dr for tests. He said everything was fine and normal. This time he put EF as 64. Last time was 70, and 65-70 the time before that. I have attached those three reports including today's. He said absolutely nothing has changes but as I am me, the 64 rather than 70 concerns me. It was my same cardiologist but a different tech and different echo machine as it was a different office of his practice. Also he put that the image quality was merely "adequate". I noticed this echo was complete in under 5 minutes when usually takes about 20 minutes.

Other numbers I noticed were different: FS from 43% to 35%, diastolic function went from 1.41 to .89. Are those not significant changes? Mitral valve regurg went from mild to trace which I hope it stays.

My other concern is that my weight is steady, but is up about 3 lbs from about 6 months ago although I am exercising more and eating less. I am so so very careful about calories and probably undereat as I am usually only eating 1000 calories per day. I guess this is unrelated to fluid retention and my heart? All of the fluid obsession started when my former dr said even one pound gain for me meant I was going into CHF. Because of him I am so obsessed with weighing myself. I am at my lowest weight since age 13. Is it perhaps just my body trying desperately to get back to its "normal" weight which is about 15 lbs more than I am now? I am also still in process of stopping prozac which has always caused weight gain for me.

Thank you so much for everything dear Dr Iliri.
I wish you a happy weekend.

XXXXX
doctor
Answered by Dr. Ilir Sharka 2 hours later
Brief Answer:
My opinion as follows:

Detailed Answer:
Dear XXXXX,

It's nice to hear from you again.

I carefully reviewed your three uploaded echo reports. My personal opinion is they show merely the same evidence of heart structure and function.

Your left ventricular ejection fraction (and FS) is quite in perfect normal range. All that slight observed variability is completely dedicated by acceptable inter-observer (technician) accuracy.

Regarding diastolic function (E/A left ventricular filling pattern), I could explain it is highly LV load dependent. So, it may change from one day to the other while the real systolic and diastolic function are the same. It is not a reliable conclusive indicator.

I recommend disregarding all those slight variations, as they have no clinical significance.

Meanwhile, I would say that your actual body weight variations are not a sign of fluids overload (retention).

You shouldn't worry about this issue.

You are actually in an optimally balanced diet and this will help you maintaining a healthy life.


At the end, I advise you to relax as there is nothing to be stressed about.

Just enjoy your weekend and be happy.

Kind regards,

Dr. Iliri


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka 20 hours later
Thank you Dr Iliri. 15 months ago, I would have been grateful to have EF 35 to avoid needing ICD. Instead I was deemed cured and it seemed to be a miracle. Now I have had enough tests to understand there are these variations and yet my OCD gets the better of me anyway. You see my other cardiologist (one EP, one regular cardio) regularly finds my EF to be 60 and the one I saw yesterday always finds 65-70, as you can see on reports. I know 64 still good but if my other cardio had seen same difference, wouldnt it have been EF 54 and therefore considered too low? I know I am being simple-minded here, as I understand all the things which must be considered but in my mind I cannot forget that 64 is quite a bit lower than 70. And he usually uses the range 65-70, and yesterday a stark lonely 64. I am actually guessing he would know I would have been terrified with a 60-65 because I would think it was 60. But he said no changes and totally normal. I wish I hadnt needed this medical clearance form. I keep thinking- next time it will be 58, then 52, and lower and lower. I know it doesnt work like that but my OCD brain has such faulty logic.

Is EF like body temperature where normal could be 98 or 97 or 99 but only illness with fever or true hypothermia would take it out of the normal zone?

I wish I had seen usual tech on the usual machine but then I would not have explanation of the difference. I know I have to trust you and my doctors. If something was going wrong, someone would tell me. But the uncertainty in my brain hates that there is 64 (why not 65??) on my report. Dr said "it is exactly the same as before with improvement in valves". I will try to just keep remembering those words.

I am worrying for no reason, aren't I? I have always hated medical testing, my perfectionistic obsessive personality makes it so difficult. But I wish he had written 65! I have never even seen a number not ending in 0 or 5 on echo EF report before.

I apologize for my craziness and thank you again for your vast knowledge and kindness and patience.

Hope you are having a wonderful weekend,
XXXX
doctor
Answered by Dr. Ilir Sharka 3 hours later
Brief Answer:
I would explain:

Detailed Answer:
Dear XXXX,

You are right! You are worrying for no rational reason.

Let me explain that, if the alternative scenario of a consecutive EF decrease (58, 52 and so on) would hold true, then a medically detectable structural and functional cardiac disorder would be present in your last echo. It would exist an important valvular dysfunction, any heart chamber dilation, LV wall motion disorder (kinetics abnormalities).

But, none of the above mentioned hypothetical abnormalities is present in all your periodically performed cardiac tests. So, there is no scientific medical evidence to support the fear of such hypothetical cardiac performance deterioration.

As, I explained you before, all those measurement variations are due to the commonly encountered inter-observer and even intra-observer variability in accuracy found in cardiac ultrasound exam.

This is the only rational explanation in such case.

When getting measured the left ventricular EF, the technique applied uses approximation of cardiac geometry, so a slight variation in the utilized formula outcomes is always acceptable. That’s why, giving an approximate range (example 65-70) would be more correct than a single value (65, 64 or 68).

In my opinion, you shouldn’t worry about this issue, as there is no medical evidence to support a cardiac deterioration.

Hope you will find my answer of some help.

Wishing you a pleasant weekend!

Regards,

Dr. Iliri

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka 3 days later
Dear Dr Iliri,
Thank you so much. I don't know why I am struggling so much when the tests are always coming out okay. I focus incessantly on the numbers. But without anything suggesting a problem (valves/enlargement as you mentioned) there is no chance that my EF would just drop? I, unfortunately still go to a heart disease online community and people frequently are reporting that from month to month their EF will bounce from normal back down to 30/40, but I know I have to understand that they are not the same as I am- these are people with active cardiomyopathy and I don't have access to their full histories or medical reports. I know I have to move on. I must move on.

I will try to re-read your answers and not keep asking the same questions. But just for clarity, I must ask: heart function is not as capricious as I seem to think? I feel like even though I had an echo 4 days ago, I could be in heart failure today because perhaps I am not urinating enough or because my pulse in my wrist feels quite slow or weak. I keep focusing on how I must have walked around for months with a very depressed EF, and CHF and felt almost entirely normal, right up until my diagnosis when I experienced some shortness of breath. I wish I could trust that my body will feel weak and sick if something is truly wrong. I do remember now that even though my doctors said I didn't appear to have any edema in my legs and my lungs were miraculously clear, I did have taut shiny shins and a cough. I am just so shocked that such a body sensitive person as I am didn't realize I was in heart failure. But I am trying to take your advice and realize that that story is over.

About weight- Dr Iliri- I eat only about 1000 calories a day, and cycle 10 miles a day, every day. And yet my weight is up 3 lbs from 6 months ago. I don't understand how this is possible. I know I am not eating enough but I cannot eat more because I know I will quickly gain much weight and of course fear that it's fluid retention/heart failure. I don't understand how I can be eating so little and doing so much exercise and yet I put on weight. I am slim, but not overly so- BMI of 22. I do look thin but my weight is not low- however my collarbones are quite prominent. I just don't understand what is going on with my weight and therefore I am so fixated on my scale because my old doctor's warning about how the first sign of my impending death from heart failure after medication withdrawal would be creeping weight gain. I am now on 10mg of prozac, just every three days, down from 20 mg daily, so if weight has to do with Prozac, I hope that will resolve soon. I just wish I could stop weighing myself after every bite I eat or drink. It takes over my life and I even carry my scale in my work bag to use at work. It's quite insane, I know.

Last question- it's insane for me to think that I need to be recumbent to not retain water, isn't it? I keep feeling like when I am standing or moving, I retain water and though I want to be active, shortly after drinking, I feel compelled to sit as still as possible until I feel I've eliminated all the excess fluid. I am crazy. I know that. And sitting is no better than standing, I read. So unless I was lying down, I'm not increasing diuresis by staying still, am I?

Thank you so much, Dr Iliri. You are helping me so much. So sorry for the endless questions but I feel I get better understanding through all your answers and advice.

Many many thanks,
XXXXX
doctor
Answered by Dr. Ilir Sharka 13 hours later
Brief Answer:
My answer as follows:

Detailed Answer:
Dear XXXXX!

I completely understand the way you feel and your concerns.

I would reassure you that you have nothing to worry about. Let me explain as follows:

1. The heart function does not have such fluctuations. So relax. Nothing is going wrong with your heart. As long as you have no symptoms and your cardiac tests are OK, there is no need to repeat them very often, as we do not expect such fluctuations in your heart function. Your past medical history is just past and is not going to repeat again.

2. Regarding your weight. Three ponds are not any concerning weight gain. BMI 22 is just perfect. Besides, you should know that Prozak, like other drugs acting in the central nervous system (antidepressants, anticonvulsivants, antipsychotics, etc.) cause weight gain. So relax. It is not fluid retention.

3. Fluid retention is not related to physical activity. In fact contrary to that, while making physical activity, our plasma circulates faster (because the heart beats faster and harder) and it is filtrated more times in the kidneys, thus leading to increased urination and fluid elimination. So do not think about it any more.

I suggest you to try to think about something else, every time you think about measuring your weight. As I already explained you, our body weight is in a continuous change during the day because the food and drinks we take and the fluids and stool that we eliminate. There is no rational reason to measure your body weight frequent times during the day. It just makes you feel anxious, because you keep thinking and trying a possible cause for just some physiological changes.

Hope my answers will calm a little your anxious mind!

I am always here whenever you need to talk with me!

Wishing a nice day!

Dr. Iliri


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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