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Suggest Treatment For Arrhythmia-induced Cardiomyopathy
Question: Dear Dr. Ilirii,
It is XXXX again. I have had disappointing news, which is that my medical clearance from the State Department for travel to Cambodia was denied and I was given clearance only for travel to countries with very modern medicine and hospitals with cardiologists. So I was approved for Class 2 only, not Class 1, which is World Wide availability.
I appealed this and have talked with one of the officer/physicians in charge and he told me any cardiomyopathy/heart failure or even history is an automatic denial. He had never heard of PVC-induced cardiomyopathy and said their office considers any cardiomyopathy a permanent condition. I sent him many links to studies on PVC-induced cardiomyopathy which shows that it is a curable condition. So now I must return to him for another EKG, holter, and chest x-ray, and exercise stress test, as well as either get a MUGA scan, cardiac catherization, MRI, SPECT test, or echo. They can find a cardiologist they work with but I am hoping my own cardiologist will do one of these tests, preferably just echo. I don't think I need catherization when my stress tests have been fine.
If I can demonstrate 6 months of being "totally cured with no medication" then I may be able to get upgraded to a Class 1 clearance. It turns out that it is exactly 6 months ago that I was finally taken off of carvedilol after 14 months on it. My last echo was only two months ago but that was just 4 months off medication.
I was given much scary infomation from this medical officer. He said cardiomyopathy is generally considered incurable, and those very few who recover require medicine, which would disqualify one for Class 1 clearance. He said 65 % of those with DCM die within 5 years, and 80% require at least one hospitalization in two years, which is why cardiomyopathy is almost always denied for any Class 1. He said it was not clear to him that pvc cardiomyopathy had a different course but said so far my records show I have no signs of it.
Do you believe I am truly cured? Should I continue to pursue this? Are you sure that my echo stats of two months ago will still be stable? If I see State Dept doctor, could I end up with an abnormal echo because "interpreter variation" could be so different that my heart function doesn't read as normal?
I'm very conflicted now. I feel physically fine, but I have extreme anxiety about my heart, so if it's possible I could need to be hospitalized suddenly in Cambodia, then I I would need to transported home to the US at great expense to my company and the state dept. I don't want to be a great risk for my team, when so many would be eager to take my place.
THank you so much, Dr Iliri. Your help is so great appreciated.
XXXX
It is XXXX again. I have had disappointing news, which is that my medical clearance from the State Department for travel to Cambodia was denied and I was given clearance only for travel to countries with very modern medicine and hospitals with cardiologists. So I was approved for Class 2 only, not Class 1, which is World Wide availability.
I appealed this and have talked with one of the officer/physicians in charge and he told me any cardiomyopathy/heart failure or even history is an automatic denial. He had never heard of PVC-induced cardiomyopathy and said their office considers any cardiomyopathy a permanent condition. I sent him many links to studies on PVC-induced cardiomyopathy which shows that it is a curable condition. So now I must return to him for another EKG, holter, and chest x-ray, and exercise stress test, as well as either get a MUGA scan, cardiac catherization, MRI, SPECT test, or echo. They can find a cardiologist they work with but I am hoping my own cardiologist will do one of these tests, preferably just echo. I don't think I need catherization when my stress tests have been fine.
If I can demonstrate 6 months of being "totally cured with no medication" then I may be able to get upgraded to a Class 1 clearance. It turns out that it is exactly 6 months ago that I was finally taken off of carvedilol after 14 months on it. My last echo was only two months ago but that was just 4 months off medication.
I was given much scary infomation from this medical officer. He said cardiomyopathy is generally considered incurable, and those very few who recover require medicine, which would disqualify one for Class 1 clearance. He said 65 % of those with DCM die within 5 years, and 80% require at least one hospitalization in two years, which is why cardiomyopathy is almost always denied for any Class 1. He said it was not clear to him that pvc cardiomyopathy had a different course but said so far my records show I have no signs of it.
Do you believe I am truly cured? Should I continue to pursue this? Are you sure that my echo stats of two months ago will still be stable? If I see State Dept doctor, could I end up with an abnormal echo because "interpreter variation" could be so different that my heart function doesn't read as normal?
I'm very conflicted now. I feel physically fine, but I have extreme anxiety about my heart, so if it's possible I could need to be hospitalized suddenly in Cambodia, then I I would need to transported home to the US at great expense to my company and the state dept. I don't want to be a great risk for my team, when so many would be eager to take my place.
THank you so much, Dr Iliri. Your help is so great appreciated.
XXXX
Brief Answer:
I would explain as follows:
Detailed Answer:
Dear XXXX,
I am sorry to hear your medical clearance was denied. In fact the State Department has its own rules in screening medical history and classifying certain individual health issues.
The officers/physicians in charge are just the performers of the protocol and should not be blamed for their limited knowledge in PVC-induced cardiomyopathy.
On my professional opinion you should be undoubtedly qualified to that level of medical clearance.
Remember you are not suffering from DCM, you have never suffered from such a cardiac disorder.
Arrhythmia induced cardiomyopathy is almost always a reversible condition, once the triggering responsible factor has been isolated and successfully treated.
And fortunately this is your case.
The previously performed cardiac ablation has definitely eradicated the arrhythmogenic focus in your ventricle, removing such way the main factor for maintaining the adverse electrical and structural remodeling of your heart.
Coming to this point, your healthy heart has shown its magnificent reverse remodeling, returning to a quite normal structure and performance.
All the above processes happening to your heart have been reflected by periodically performed cardiac tests (ECHOs and other imagine modalities).
I am sure that the newly repeated cardiac tests recommended by the medical officer will confirm that your heart is in completely perfect conditions without any adverse consequences in grade to disqualify you.
You shouldn’t be afraid of that slight inter-observer variability when having cardiac ultrasound (ECHO). At the end, the number will correspond with the previous tests.
MUGA scan may be a perfect alternative for quantifying LVEF as it lacks the slight variability of ECHO and has shown excellent correlation to other invasive tests (ventriculography).
I definitely exclude cardiac catheterization as a necessary screening procedure in your case.
Cardiac MRI would be a rationale alternative for quantifying overall cardiac performance and investigating specific structural details (myocardium, valves, blood vessels, pericardium, etc.) and at convincing the protocol observers/officers that everything is normal and you are free of any cardiac disorder consequences.
Having the test conclusions it would be clear that you may travel in Cambodia and any other places of the world without being afraid of heart failure recurrences.
At the end, I am sure you will be qualified and have that journey.
I believe that it will have a great beneficial impact not only in your career, but also in your psychological conditions (anxiety and obsessions).
Wishing you a great weekend!
Best regards,
Dr. Iliri
I would explain as follows:
Detailed Answer:
Dear XXXX,
I am sorry to hear your medical clearance was denied. In fact the State Department has its own rules in screening medical history and classifying certain individual health issues.
The officers/physicians in charge are just the performers of the protocol and should not be blamed for their limited knowledge in PVC-induced cardiomyopathy.
On my professional opinion you should be undoubtedly qualified to that level of medical clearance.
Remember you are not suffering from DCM, you have never suffered from such a cardiac disorder.
Arrhythmia induced cardiomyopathy is almost always a reversible condition, once the triggering responsible factor has been isolated and successfully treated.
And fortunately this is your case.
The previously performed cardiac ablation has definitely eradicated the arrhythmogenic focus in your ventricle, removing such way the main factor for maintaining the adverse electrical and structural remodeling of your heart.
Coming to this point, your healthy heart has shown its magnificent reverse remodeling, returning to a quite normal structure and performance.
All the above processes happening to your heart have been reflected by periodically performed cardiac tests (ECHOs and other imagine modalities).
I am sure that the newly repeated cardiac tests recommended by the medical officer will confirm that your heart is in completely perfect conditions without any adverse consequences in grade to disqualify you.
You shouldn’t be afraid of that slight inter-observer variability when having cardiac ultrasound (ECHO). At the end, the number will correspond with the previous tests.
MUGA scan may be a perfect alternative for quantifying LVEF as it lacks the slight variability of ECHO and has shown excellent correlation to other invasive tests (ventriculography).
I definitely exclude cardiac catheterization as a necessary screening procedure in your case.
Cardiac MRI would be a rationale alternative for quantifying overall cardiac performance and investigating specific structural details (myocardium, valves, blood vessels, pericardium, etc.) and at convincing the protocol observers/officers that everything is normal and you are free of any cardiac disorder consequences.
Having the test conclusions it would be clear that you may travel in Cambodia and any other places of the world without being afraid of heart failure recurrences.
At the end, I am sure you will be qualified and have that journey.
I believe that it will have a great beneficial impact not only in your career, but also in your psychological conditions (anxiety and obsessions).
Wishing you a great weekend!
Best regards,
Dr. Iliri
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you Dr Iliri. My own dr has agreed to do echo and I can submit the report. It has been two months since last echo. Are you sure it will ne normal? I need to demonstrate that I dont need treatment or close followup even though I am going for several short stays rather than extended stay. I shouldnt go if I pose a risk of endangering our project. This has made me feel like I am very much a high risk person still.
Do you think I am truly normal and able to do this?
Thank you so much.
XXXX
Do you think I am truly normal and able to do this?
Thank you so much.
XXXX
Brief Answer:
Your tests will result normal.
Detailed Answer:
Dear XXXX,
I totally understand your concern, and would like to reassure you that your new cardiac ultrasound is going to be normal.
You can perform it if this is needed to get your medical clearance.
All your performed ultrasound have shown a normal cardiac function and structure.
I am sure the next ultrasound will result the same.
You have nothing to worry about!
Just relax and don't think about it! Everything is going to be OK!
Let me know about your next tests.
Wishing a nice day,
Dr. Iliri
Your tests will result normal.
Detailed Answer:
Dear XXXX,
I totally understand your concern, and would like to reassure you that your new cardiac ultrasound is going to be normal.
You can perform it if this is needed to get your medical clearance.
All your performed ultrasound have shown a normal cardiac function and structure.
I am sure the next ultrasound will result the same.
You have nothing to worry about!
Just relax and don't think about it! Everything is going to be OK!
Let me know about your next tests.
Wishing a nice day,
Dr. Iliri
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Dear Dr Iiri,
I know I must trust in experts like you and my doctor and try not to think about the past so much. You are so positive and reassuring, I wish you could be my doctor in real life. Your patients are lucky as you truly seem to understand about the anxiety and emotional side of heart disease. My doctor is very good but doesn't understand why I am still very anxious at times.
I have my echo tomorrow. I pray it is normal. I have felt well, although I still worry very much about drinking and fluids and weight. I am always convinced that standing or moving after I've had a lot to drink makes me retain water. A doctor in the ICU told me this when I was sick when she grabbed the bottled water out of my hand and told me to put my feet up immediately and said I wasnt to get up. The fluid issue has scared me so much since- I know it's the hallmark of heart failure.
If I were to have worsening heart function, would I definitely have symptoms? I know you keep telling me that the numbers alone do not tell the whole story, but for the medical clearance board, even EF of 50 is considered lowered function. Praying that the steady state I've had of 65-70 (except that 64 which worried me) remains. It has been just two months since my echo- surely I will still be ok?
Thank you so much for everything, Dr. Iliri. I will let you know my results once I get them.
Best to you.
XXXX
I know I must trust in experts like you and my doctor and try not to think about the past so much. You are so positive and reassuring, I wish you could be my doctor in real life. Your patients are lucky as you truly seem to understand about the anxiety and emotional side of heart disease. My doctor is very good but doesn't understand why I am still very anxious at times.
I have my echo tomorrow. I pray it is normal. I have felt well, although I still worry very much about drinking and fluids and weight. I am always convinced that standing or moving after I've had a lot to drink makes me retain water. A doctor in the ICU told me this when I was sick when she grabbed the bottled water out of my hand and told me to put my feet up immediately and said I wasnt to get up. The fluid issue has scared me so much since- I know it's the hallmark of heart failure.
If I were to have worsening heart function, would I definitely have symptoms? I know you keep telling me that the numbers alone do not tell the whole story, but for the medical clearance board, even EF of 50 is considered lowered function. Praying that the steady state I've had of 65-70 (except that 64 which worried me) remains. It has been just two months since my echo- surely I will still be ok?
Thank you so much for everything, Dr. Iliri. I will let you know my results once I get them.
Best to you.
XXXX
Brief Answer:
Just take a deep breath and think about beautiful things. Everything is OK.
Detailed Answer:
Dear XXXX,
I am glad to have been helpful to you while going through this difficult period.
Anxiety and depression are common in cardiac patients, and I totally understand how you feel, because you have gone through a very difficult situation.
But that is all over now.
You should not think about it any more!
The past is over and in not going to repeat again.
At that situation, the nurse has tried to avoid standing up position and the possibility of leg swelling (which is exacerbated by this position) in cardiac patients.
But this is not the case any more. So you can drink a lot and perform a normal physical activity without being worried. Everything is OK now. You are a normal person, and you are able to do everything just like normal persons do.
You should try to put away those bad thought when they push into your mind.
The best way to do this is to stop yourself. You are the owner of your thought and you are the only one who initiates them and the one who decides to stop them or deviate them. Just try to think about something beautiful or happy when this occurs. Our thoughts are just like checks. They have no value without our firm. So try to manage them. You are the Boss of your thoughts.
I can assure you that your cardiac ultrasound will be OK. You should not make any predictions and think about the worst. It is not going to happen.
I am here to assist to you whenever you need me!
You can count on me!
Hope to have calmed a little your worried heart!
Let me know about everything!
Best wishes,
Dr. Iliri
Just take a deep breath and think about beautiful things. Everything is OK.
Detailed Answer:
Dear XXXX,
I am glad to have been helpful to you while going through this difficult period.
Anxiety and depression are common in cardiac patients, and I totally understand how you feel, because you have gone through a very difficult situation.
But that is all over now.
You should not think about it any more!
The past is over and in not going to repeat again.
At that situation, the nurse has tried to avoid standing up position and the possibility of leg swelling (which is exacerbated by this position) in cardiac patients.
But this is not the case any more. So you can drink a lot and perform a normal physical activity without being worried. Everything is OK now. You are a normal person, and you are able to do everything just like normal persons do.
You should try to put away those bad thought when they push into your mind.
The best way to do this is to stop yourself. You are the owner of your thought and you are the only one who initiates them and the one who decides to stop them or deviate them. Just try to think about something beautiful or happy when this occurs. Our thoughts are just like checks. They have no value without our firm. So try to manage them. You are the Boss of your thoughts.
I can assure you that your cardiac ultrasound will be OK. You should not make any predictions and think about the worst. It is not going to happen.
I am here to assist to you whenever you need me!
You can count on me!
Hope to have calmed a little your worried heart!
Let me know about everything!
Best wishes,
Dr. Iliri
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you so much Dear Dr Iliri,
I have just returned to work after echo, no changes EF 65. I have attached the report. Of course I have found something which concerns me, the FS being 28% down from 35% last time and sometimes as high as 55% in previous echoes. Is this anything to be concerned about? Also, EF reported as 65 (60-65) and was 64 last time. Two times prior it was reported as 65-70. I know I know I should know better by now but is this nothing? Last four echoes are all with same dr but first two with 65-70 were with one machine/tech and today and previous time were on a different machine/tech. Could that account for small variance in reading?
I have included the notes my doctor gave me for my medical clearance. I think, I hope, it will be sufficient to clear me for Class 1 clearance and travel to Cambodia. It was very scary to see my first reports from when my cardiomyopathy was diagnosed. I just have to remember it is in the past now.
You helped me so much today and through the last year. You have been so critical in me being able to understand my condition and start to move past it all.
Many many thanks,
XXXX
I have just returned to work after echo, no changes EF 65. I have attached the report. Of course I have found something which concerns me, the FS being 28% down from 35% last time and sometimes as high as 55% in previous echoes. Is this anything to be concerned about? Also, EF reported as 65 (60-65) and was 64 last time. Two times prior it was reported as 65-70. I know I know I should know better by now but is this nothing? Last four echoes are all with same dr but first two with 65-70 were with one machine/tech and today and previous time were on a different machine/tech. Could that account for small variance in reading?
I have included the notes my doctor gave me for my medical clearance. I think, I hope, it will be sufficient to clear me for Class 1 clearance and travel to Cambodia. It was very scary to see my first reports from when my cardiomyopathy was diagnosed. I just have to remember it is in the past now.
You helped me so much today and through the last year. You have been so critical in me being able to understand my condition and start to move past it all.
Many many thanks,
XXXX
Brief Answer:
My opinion:
Detailed Answer:
Dear XXXX,
I carefully reviewed your uploaded cardiac ultrasound and doctors report and I am glad to confirm my previous opinion on your perfectly normal cardio-vascular conditions.
I am sure that you are able to understand by yourself that these slight LVEF variations are just normal interobserver variability.
They all confirm the same normal cardiac performance.
You are actually free of cardiac arrhythmia and of any signs suggestive of cardiac heart failure.
In addition, there are no minimal elements suspicious of cardiomyopathy relapses.
So, to conclude, I would confirm in my professional opinion that you are completely eligible for Class I Dept Clearance.
Hope this will be also the official statement!
Wishing you a nice weekend!
Regards,
Dr. Iliri
My opinion:
Detailed Answer:
Dear XXXX,
I carefully reviewed your uploaded cardiac ultrasound and doctors report and I am glad to confirm my previous opinion on your perfectly normal cardio-vascular conditions.
I am sure that you are able to understand by yourself that these slight LVEF variations are just normal interobserver variability.
They all confirm the same normal cardiac performance.
You are actually free of cardiac arrhythmia and of any signs suggestive of cardiac heart failure.
In addition, there are no minimal elements suspicious of cardiomyopathy relapses.
So, to conclude, I would confirm in my professional opinion that you are completely eligible for Class I Dept Clearance.
Hope this will be also the official statement!
Wishing you a nice weekend!
Regards,
Dr. Iliri
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Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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