Diastolic Heart Failure

I really have two questions. I have had my last two angiograms at the Cleveland Clinic. I have 6 stents and some ischemia. My LVEDP was 24 mmhg each time. My E/A ratio is low as shown on an echo.

I have been diagnosed with Diastolic Failure, but due to my general symptoms of heart failure (congestion, total fatigue and SOB and angina) and an enlarged left atrium I believe I have Diastolic Heart Failure. My cardiologist here in Alabamy fired me due to a heated argument, so I am in the dark while looking for a new Doctor.

I have found this to be the least researched type of heart failure, in fact I have found differing opinions regarding medical treatment on prestigious web sites. What do you think is the best course of medicine to take for this condition? I realize you do not have my chart with my history, but I have had an mi and stroke simultaneously in 2003, and another stroke in 2005. Hi BP and tachycardia under control.

My second question has to do with former ulcers in my stomach and small intestine eight years ago, due to abuse of NSAIDs. Now I cannot tolerate even an enteric coated baby aspirin without very bad "Gut" pain or ulcer pain. So I have been taking Plavix sine June of 2003. I am starting to have the ulcer pain again, and I am afraid that the Plavix is hurting me. The CC performed 3 CBC test and my RBC was a tad low on each, along with some more probably unrelated abnormal results, high MCV, high MCH and  low percentage of neutrophils.

My second question is can I start coumadin or Wafarin? My prothrombin time is very fast even while taking 75 mg of Plavix per day. I have very high cholesterol and thick blood. I cannot tolerate statins at all. I get the lethal side effects immediately.

Thank you so much and say hello to Dr. Krasuski for me :)
I am very thankful for this site.

Jack

[Cleveland Clinic]

I don't think you should start warfarin before the anemia is further worked up.  It appears to be macrocytic, which may still be due to bleeding, however, you should also consider gastritis leading to Vit b12 deficiency (pernicious anemia) or folate deficiency.  They should be checked.  

As far as diastolic dysfunction is concered, you are right that it is sometimes very difficult to treat.  In fact, we don't have many agents that help.  There is some evidence that angiotensin receptor blockers may be helpful.  Of course controlling your blood pressure and keeping you heart rate as low as tolerable should alieviate some of the symptoms.  The other caveat is that CAD can cause diastolic dysfunction, and if you notice that your symptoms are getting more severe, further CAD work up may be necessary.  

[Jack54]

Thanks so very much for your answer Doc. Now I will ramble just to relieve some stress :)  My last 2 caths and angiograms were performed at the CC. I received my last stent on 5/24/07 in my very proximal LAD. The cath report states it was a very risky procedure. That was the 4th in and end to end (kiss me) series and the last I can have in my LAD. I was left with a 40% blockage in the middle of this line of stents. My next treatment for my LAD will be A CABG.

I started having bad angina again, so I went back to to the CC on 9/18/07 for a MID-CAB evaluation. I had the cath on 9/19/07 and a 50% blockage was found in a 2 year old OM1 stent. The FFR was .90, so nothing was done. I was rejected for surgery and to this day,

I do not know why. I never got a chance to talk to my CC doc after the cath. 2 off duty nurses told me that they would not do the MID-CAB surgery on anyone that smoked. I had quit but had started back to maybe 5-6 per day. I smoked one walking to report for the cath and immediately was berated by the student that was to perform the cath.

I am very afraid to stop the Plavix. I did for 5 days this late January for sinus surgery, while having an 8 month old stent, and in May, I had to have another stent. My abdomen is swelled and very tender, but I thought it was ascites until it became so tender and painful. I also have lower extremity edema.

I have researched many web sites for suggested treatment for Diastolic Heart Failure and the majority have mentioned ACEi's or ARBs if ACEi's cannot be tolerated. Along with SLOW ACTING calcium channel blockers, beta blockers, judicious use of nitrates (probably fast acting, which I am using) throughout the day, and the use of diuretics only to prevent congestion. DHF is very sensitive to changes in blood volume because it directly effects cardiac output, due to preload I believe.

My LVEDP in May was 24 mmhg and in September was 27 mmhg. My left atrium is also enlarged. I am almost sure that I have pulmonary hypertension due to the sudden increase in congestion and productive cough. Above I erroneously stated that my LVEDP was the same each time it was measured. It appears to be getting worse. I have been trying to exercise, is this OK? This is all that I ask this time. You said above to keep my heart rate as low as possible. That would appear to rule out exercise? I am going to double my dose of Coreg CR if my HR does not come down. My BP could also stand to be lower.

I need to get on the horn and find a cardiopsychologist  :)

Again thanks so much. I guess I will stop the Plavix for a while and see how my small intestine does.

[Cleveland Clinic]

I would not stop the plavix unless instructed so by your cardiologist.  Having a stent put in May of this year may require for you to be on plavix much longer.  check back with your CCF cariologist before stopping anything.

[Jack54]

Thanks so much again. I will check with my doctor at the CC.

[chrisr]

Hello Jack,
I really sympathize with your situation and believe I have a similar condition only its Dx as Diastolic Dysfunction  in my last stress echo done at CCF in May 06. However after reading your results I cannot find anything on LVEDP in my report ? Some of the results are:  Aorta @ leaflest – 2.8cm; LA – 3.8cm; LVID (Dia) – 3.8cm; LVID (Sys) – 1.9cm;  Intravent septum – 1.3cm; Post wall thickness – 1.3cm; EF – 55

FINDINGS: LV- normal in size and syst. function. Baseline LV diastolic function is consistent with abnormal relaxation (Stage 1)

They Rxed:  Coreg 6.125mg, Diovan 80/12.5 HCT, Vytorin 10/20, Coumadin 5mg (for mech valve) and Asp 81mg. I was on Plavix (hated it) after my stent implants early 05 but was glad to get off it after my second CABG in Sept 05. I believe the Diov 80/12.5 does a good job esp as a diuretic (saves taking a sep diuretic pill). It was lately upped to 160/12.5 to further control my BP.
However I still get CD with exertion/activity with weak legs (due to the DD) so scared to do much exercise although this is highly recommended. I have returned 3 times to CCF but still cannot get a satisfactory treatment protocol for the DD. I would also like to change my doctor at CCF but cannot get any good recs. I have tried unsuccessfully to get my records on line (My Charts). If you do I would like to know how to go about accessing this. The local cardios here in Tampa are willing to do more stress tests/angio but because of my complicated past procedures would prefer CCF although my present cardio there refuses to do anything further.
I would appreciate your thoughts and wish you a speedy recovery.

ChrisR

[Jack54]

So sorry to hear of all of your heart related problems. It sounds like you have really "been through the mill". You make me feel like a whiner, although I will be having CABG before long. You have had 2, and that is amazing. You must be a very strong individual.

The only way that I know of measuring the Left Ventricle End Diastolic Fill Pressure (LVEDP) is while doing a cardiac catheterization. I had one in May and one in September at the CC in Cleveland.

I see that your left atrium is " LA – 3.8cm". Mine is 4.1 as measured by a normal echo. This is enlarged. Slightly, but still enlarged. 4.0 cm is the high range reference. The reason I mention this is the high LV filling pressures enlarge the LA. I would almost bet yours has grown larger, due to the time you mention having your last echo.

DHF leads to congestive heart failure, due to high pulmonary venous pressure. This really high fill pressure is transmitted or passed through the LA to the pulmonary vein. Moisture, mixed with a tad of blood can be coughed up (pink froth) due to the high PE pressure within the lungs. I have a productive cough. No signs of blood though.

It is possible to develop Afibs also, especially if your LA becomes large enough to interfere with the RA.

As you know, this is the latest of the "heart failures" to be detected. I suppose this is due to all of the new technology? Anyway, I have been researching DF or DHF. What I have found treatment wise is:

1) Keep your heart rate as low as normal. (This makes me wonder about exercise although I have read that it is good for DF).
2) We are very susceptible to changes in our blood volume, especially LOW BLOOD VOLUME, so be very judicious in the use of diuretics and long acting nitrates.
3) Use fast acting nitro throughout the day. I don't know how many times. I have constant angina anyway, so....I am doing it 5 or 6 times a day. I am going to increase treatments after a trip to the pharmacy. I have known blockages that cause the angina.
4) SLOW ACTING calcium channel blockers are chemically important to help our LV relax, indirectly. It does not truly relax it I do not believe that there is any medicine, so far, that causes our LV to relax during the diastolic phase. These CCBs are recommended.
5) Remember low blood volume leads to low cardiac output, so do not dry yourself out. I was taking Lasix, but I went on a really low sodium diet, and retain much less fluid. I haven't had to take Lasix in over 3 weeks. If my cough gets much more productive, I may take a dose. I do not like that medicine.

I am glad you mentioned "My Charts". I have been aiming to get that set up, but can't remember to do it. At this point I do not know how, but I will definitely find out, and let you know. I/we have spent enough money there to have access to this feature, although I do have all of my medical records from the CCF. I had to pay $35. I have the phone # for ordering medical records if you need that.

As far as recommending another doctor, I cannot recommend mine. He is in the training division :(  (long story there) They have a very good website where you can see all of their credentials and interest in the field of cardiology, or the specialties.

Best of health and happiness to you,

Jack

[chrisr]

Thanks for the info Jack. It has given a much better perspective of my condition.
All my EKGs have always mentioned LAE (left atrial enlargement) and you may be right
about it being larger a year after my last real Echo. I probably will need to see an EP since I have been recently  having an increased number of PACs which I read can indeed be the precursor to Afib which is terrible by itself. I have also read where LAE can lead to a very asymmetrical heart causing above normal valvular leakage?

I agree with you about the exercise. Worry about doing it and worry about the negative effects of not doing it.  
Coreg seemed to be doing a good job of keeping down my HR but lately this has risen to the 70s and I may have to increase my dosage although it does little for my BP. Diovan/HCT does a better job for me but it also reduces my blood K and now worry about low blood volume/dehydration.
I have mainly a systolic BP problem but can never convince my wife to cooking without salt so have to rely on the diuretics and use a lot of Low Na V8 with its high K to counteract the Na.
About the long acting nitrates – are you referring to Imdur? Tried it once but did not agree with me? I have relied more on the Nitropatch helps with CD and also always lower my BP. Do you have a similar experience?
Yes I would be glad to get the contact # for My Charts at CCF.
For my CABG I was referred to a top cardio/surgeon team the former is now a director of something and it is difficult to see him now. Then I was referred to my present cardio for followup and seem to be stuck with him. He is with Cardio Vascular medicine in the F15/16 floor area. The first cardio was in the F24/25 area a floor above. Do you know the difference?  And how to get into this area since it seems to have the better doctors? I am really trying to avoid having to go to CCF on an emergency basis. Its also going into winter time and I do not like the winter in Cleveland.

I really appreciate your time in explaining all about DHF and look forward to any follow up info you may get.
Thanks again and God’s blessings.
ChrisR

[Jack54]

You gotta lower the salt my friend :) About the "My Charts" program, I do not have their #, but I do have a # where you can call and order your charts. It is done by an outside agency and I really didn't like their service that well, but it was well worth the $35 I spent.

I forgot to mention that ACE inhibitors are great for the treatment of DHF. If you cannot tolerate them, then take the newer class of ARBs that do the same thing, but in a different way. I took ACE i's for 3.5 years and all of a sudden developed the notorious adverse side effect of a cough and I also had some strange throat constriction. I have been off of them over a year. Since being off of them, I have tried all of the ARBs and they have really drained me of my strength and energy, so I have not taken them a lot.

I have found out, since beginning to study DHF that ACE and ARB treatment can prevent heart remodeling. This could be one reason why I developed DHF. Who knows?

Yes my cardio is located in the F 15 area. I probably wont see him again. I do not see why you should have any trouble changing doctors, if you find the one you want. That is the problem, I know. I am sure that you are aware that the CC has a hospital in Miami. Are they as reputable as the Cleveland doctors?

I have just found some rather disturbing information about left atrial enlargement, while trying to help a patient on the other board. Knowledge is power, and by helping others, I always learn things to help myself. This information will shock, but help you also. I think that it explains why I had to go to the hospital a couple of weeks ago, after feeling like I was close to death for 2-3 weeks. I may have been having afibs and not aware of it at all. One thing is why did the hospital not find them. I only spent the night and one day in the hospital. Maybe they stopped. I did not enter the hospital for heart related problems.....Just extreme fatigue and weakness.

I will stay in touch with you and try to figure out the "My Chart" deal.

Be happy and healthy

P.S. You must get you BP under control asap.

http://conversations.acc.org/modules/conv/acc/0904d/transcript_print.asp

[Jack54]

I forgot to mention that I started my old ACE inhibitor back (altace) and no adverse reactions so far (1.5 weeks), knock on wood. If I develop the reaction, I will force myself to live with the side effects of the ARBs!

Let me know what you think of the info in the link...

[chrisr]

What a fantastic article on LAE which is really related to HBP and DD. Are these articles regular features of ACC? I would really like to link up with some more.

I notice you are on Coreg SR. I was offered this by my GP but only as 20mg which I thought was toomuch higher than the regular 6.125mg I usually take. Do you find the SR form controls your BP better without much side effects? I worry about the low pulse and the nightmarish side effects. I may consider taking the higher dose (10mg?) since the Diovan even at 160mg seems to have little effect on my BP! What were your side effects of Diovan? I had tried Altace some time ago and had the voice/throat side effect also induced when I switched to Cozaar. My BP can be as high as 160/90 in the am but would usually dip to 130-120/70-80 in pm and no doc has ever been able to explain this or to find a control!

Thanks again Jack.