Brief Answer:
I would explain as follows:

Detailed Answer:
Hello!

Welcome on - Ask a Doctor - service!

I understand that your clinical situation seems a bit complicated as the heart attacks have left severe myocardial impairment.

In such case first it is necessary to review your actual clinical conditions: that is the severity of the underlying heart failure symptomatology.

- If symptoms like shortness of breathing, fatigue, etc. persist, then a therapy optimization is necessary: adjusting diuretic daily dose; using vasodilators (ACEis, ARBs like ramipril, perindopril, candesartan, telmisartan, etc.); beta-blockers, aldosterone antagonists. This would improve your daily functional capacity. If the above isn't enough the addition of ARNI (angiotensin receptor-neprilysin inhibitor) is recommended to improve your clinical symptomatology.

- Another issue to consider is potential residual chest angina, that shows the presence of ischemic myocardial areas. Residual ischemia my lead to cardiac function deterioration and needs to be properly and timely addressed. Antianginal agents like nitrates could be of help. In addition, anti-platelets therapy should be carefully followed (aspirin, clopidogrel, etc.)

- If all the above issues have been exactly addressed and heart failure doesn't show improvement, then it is necessary to investigate whether there are eligible criteria for CRT (cardiac re synchronization therapy), which could improve cardiac function and heart failure symptomatology.

- Another option would be MCS (mechanically circulatory support), which is circulation assistance through device utilization.

In order to properly define your cardiac function and characterize all the cardiac tissues (especially fibrotic burden and its location) I would recommend undergoing a cardiac resonance imagine test.

Your should discuss with your attending cardiologist on the above mentioned issues.

Hope to have been helpful to you!

In case of any further questions, feel free to ask me again.

Kind regards,

Dr. Iliri

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Brief Answer:
Opinion as follows:

Detailed Answer:
Hello again!

Thank you for the additional information on your medical history.

I think that the main point to discuss with your cardiologist would be:

1. The addition of Entresto (ARNI) to your heart failure therapy. It would improve at some degree your clinical symptomatology;

2. The opportunity of having the CRT /cardiac re-synchronization therapy) which could increase your Ejection fraction from 10%-20% to 30% or higher.
But to follow this step, the eligible criteria should be met (presence of cardiac asynchrony and fibrosis extent/distribution).

The best method to clarify these issues would be undergoing a CMR (cardiac magnetic resonance imagine test).

So, it is worth discussing with your doctor on the above mentioned issues as it could help to improve your heart failure functional class and cardiac performance.

Let me know if this information is clear to you or you have any other questions.

Kind regards,

Dr. Iliri

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