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What is the cause of the deteriorating heart function?

Answered by
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Dr. Sameer Maheshwari

Cardiologist

Practicing since :2010

Answered : 661 Questions

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Posted on Wed, 8 Aug 2018 in Hypertension and Heart Disease
Question: My mother had a tee done last week and it showed the following that was a concern:
1. Eccentric hypertrophy
2. Left atrial volume index is moderately enlarged, 47.69 cc/m2.
3. Right ventricle enlarged 4.2 cm at base. Global right ventricular systolic function appears mildly depressed.
4. Tricuspid annular plane systolic excursion (tapse) is 1.7 cm. Estimated PA systolic pressure is 49 mmHg.
5. Mild regurgitation in the mitral valve
6. Moderate regurgitation in the tricuspid valve.
7. IVC enlarged and collapses <50% with sniff, suggesting high right atrial pressure of 15 mmHg.
Also, she has a history of afib.

Echo three years ago showed that the pulmonary systolic pressure was 31 mmHg. Right ventricle was normal at 2.4 cm at base and tricuspid annular plane systolic excursion was 1.9 cm. Also, it showed that there was mild regurgitation in the tricuspid valve, and the ivc was normal and collapses at >5% with sniff suggesting normal right atrial pressure of 3 mmHg.

It seems that in three years her heart has gotten a lot worse. What can be the cause of this and what can be do e to improve or not worsen her condition? Also, what is the prognosis for someone with these echo results? Thank you.
doctor
Answered by Dr. Sameer Maheshwari 35 minutes later
Brief Answer:
Needs optimization of Diuretic dose

Detailed Answer:
Hi,
Welcome.
This is Dr Sameer, cardiologist.
Looking at the scenario of the echo you have written here, where both atrium are enlarged and ventricles are normal sized, it looks to be similar to Restrictive cardiomyopathy.
You have not written about the Left Ventricular function (LVEF), is it normal or reduced?
Coming to current status, as per echo it looks like your mother is in fluid overload state. As the right sided pressure are high with dilated IVC, she needs to increase the dose of Diuretic.
A Fib is due to enlarged Left Atrium, which is very common in such patient.
Yes definitely the condition has deteriorated from past echo where RV function was normal.
I think increasing the Diuretic dose will make her feel better.
It would be of great help if you tell the medicine she is taking.
Hope this helped.
Thanks & take care
Above answer was peer-reviewed by : Dr. Vaishalee Punj
doctor
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Follow up: Dr. Sameer Maheshwari 4 hours later
Her ejection fraction is 55-60%.
Metoprolol 25 mg, lisinopril 10mg, lasix 20 mg, potassium, glipizide 10mg twice a day, flecanide 100 mg twice a day, lipitor 10mg, and coumadin.
What can cause this worsening? Could it be from the afib and/or other factors? What can be done to improve heart function and prevent any worsening? Also what can be done to improve the pulmonary artery systolic pressure of 49mmhg and the right atrial pressure of 15mmhg? Also the right ventricle enlargement and the moderate tricuspid regurgitation?
Also her bnp has gotten worse from 200 to 400 in three years. In the echo done in the past, they said she had diastolic heart failure but no mention of that in the most recent test. Also, she complains of strong heart palpitations when she lies down , even when she is not in afib, and don't know what is causing that. Sorry, for the rambling, any insight and recommendations you can provide to help improve her condition will be greatly appreciated. Thank you.
doctor
Answered by Dr. Sameer Maheshwari 1 hour later
Brief Answer:
Increase the dose of Lasix

Detailed Answer:
Hi,
Welcome back.
The medicines which she is taking are absolutely fine. She just need to increase the dose of Lasix to 40mg or 20mg twice daily. It would help her in improving the symptoms & gradually lower the right sided pressure.
I would Also recommend to to add a blood thinner (preferably Eliquis 2.5mg twice daily) to prevent blood clot formation in heart. It is important for every patient with AF to receive anticoagulant as chances of clot formation is very high. So do ask your cardiologist regarding the same.
Diastolic heart failure can be improved only symptomatically and most of the drugs do not have proven efficacy in right heart failure.
Another important drug which is beneficial in Right heart failure is Digoxin which can be started 0.25mg once daily which keeps heart rate in control & decrease hospitalization.

Rest keep fluid intake limited as per her urine output & never exceed it. Avoid exertion.She will be fine.

Thanks & take care
Above answer was peer-reviewed by : Dr. Prasad
doctor
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Follow up: Dr. Sameer Maheshwari 29 minutes later
Her appointment with the cardiologist is on the 8th. Can she wait to ask for the diuretic to be increased? Also she is on coumadin. Do you think eliquis will work better? Thirdly, what about the pa systolic pressure? It increased from 31 to 49. And is there something to prevent the tricuspid regurgitation from getting worse. Is the bnp increase from 200 to 400 a sign that heart function has declined? Finally, what about prognosis? Thanks again and sorry for all the questions.
doctor
Answered by Dr. Sameer Maheshwari 20 hours later
Brief Answer:
Detailed answer ahead

Detailed Answer:
Hi,
Welcome back.
Sorry I missed that she is already on Coumarin, so you need not change it to Eliquis. It is good enough.
Secondly the increased BNP & TR (PASP) denotes that the is now getting more stretched which is because of fluid overload in right side of heart. So you can yourself increase the dose of Diuretic (lasix). These are not a sign of heart function getting worse but are signs of fluid overload.
Finally about the prognosis, these patient have survival less than normal and further prognosis depende on the severity of symptoms patient has. Persistent dyspnoea due to fluid overload defenitly decrease the survivol.
If you have any more questions, feel free to contact.
Thanks & take care
Above answer was peer-reviewed by : Dr. Prasad
doctor
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Follow up: Dr. Sameer Maheshwari 3 hours later
Hi. I just got a response from my mother's cardiologist. He said the reason the ivc and pa were elevated was because she was in afib at the time of the echo. She was cardioverted and now she is in normal sinus rhythm. So he says these numbers should improve. Do you agree, or do you think the diuretic should still be increased? Thank you.
doctor
Answered by Dr. Sameer Maheshwari 38 minutes later
Brief Answer:
She should improve eventually

Detailed Answer:
Hi,

AF further decreases the cardiac output in a patient with an already compromised heart. So bringing it back to sinus rhythm will definitely help her improving these symptoms.

If she still remains symptomatic then you can increase the dose of Diuretic. So no need to increase now, just watch for few days.

Thanks
Take care


Above answer was peer-reviewed by : Dr. Arnab Banerjee
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