Lower EF

[Whatnow714]

New echo shows EF 35-40% and hypokinesis is also now noted; my cardiologist reviewed it and feels EF is 40%; last echo was just in May and showed EF 40-45% but he's now saying that study was difficult to interpret because I was tachy (130-150) during the entire test. Current echo heart rate was in mid to high 60s with a change in my beta blocker in June.  Echo in 2010 showed EF 55%.

Cardiologist and EP say change, if any, is negligible but all I see is 35% and the addition of hypokinesis. I have no idea why EF isn't stable especially with reduced heart rate. Cardiologist says I just may not have been on the new beta blocker long enough (7 weeks) to reflect improvement. Apparently no other findings of cardiomegaly or heart failure were seen on recent echo so they're just calling it cardiomyopathy.

Any insight would be greatly appreciated as I have many questions and don't see either dr for weeks.  One question I will pose here is when should I get another echo?   Also, is there anything I can do to increase the EF and/or to ward off heart failure in the future??  Docs are supposedly conferring about changing to carvedilol and/or an ACE inhibitor but there are concerns about heart rate management with this beta blocker change and with my hypotension and an ACE addition.

[Whatnow714]

Saw cardiologist-he's not much help-very disappointing; right now his diagnosis is non-ischemic cardiomyopathy; says it was dilated in May but not on recent echo; will be starting carvedolol as soon as we can agree on a starting dose!!  He wants me to start at 12.5 twice daily because of my current dose of nadolol, however, when I looked up conversion, 12.5 bid is equal to 80 mg nadolol and I'm only on 20 mg nadolol !   My bp already on 20 mg nadolol runs 90-110/50-85--it fluctuates all over.  The usual starting dose is only 3.125 mg twice daily and I'm less than 110#; to me, he's starting at four times the recommended dose and after researching online, I've found adult males over 200# can barely tolerate 6.25mg starting dose!  Really frustrated with the entire visit.  

[itdood]

It sounds like you're reading the radiologists report that goes to your doc.  Is that correct?  Be careful with those things.  The radiologists doesn't know you or your history, they list things they can't "rule out".  It's not the diagnosis.  Diagnosis is a process, your doc wil take those findings under consideration in conjunction with everything else going on, then make a diagnosis.

[Whatnow714]

I'm just as confused as you are with all of this; a phone call from a dr with basic findings just doesn't cut it; I called my cardiologist and luckily he has an opening on Thursday for my long list of questions.

From the look of the report I finally got, the only finding is "estimated LV EF is moderately decreased by visual estimation 35-40%" and under LV Wall Scoring-"There is diffuse hypokinesis". When the cardiologist called last week, he just said cardiomyopathy. No type though.  The only reason I know tachycardia induced cardiomyopathy is that it was mentioned after my May echo.  

The only other change I see but isn't specifically abnormal is a reduction in both the LV FS (Mmode) 25.2%(>25%) down from 39.4 in May and LV EF (Mmode) 49.7% (>50%) down from 70.3 also in May- don't know what these measurements mean but I'm concerned with the seemingly large decrease in just 3 months.  

There's also mention in the text of trace mitral valve regurgitation,mild tricuspid regurgitation, and mild pulmonic valve regurgitation.

He mentioned a change to coreg in the call last week but I'm not sure why at this point if I'm not in heart failure unless that med is good for prevention of HF as well.

[itdood]

So I'm a bit confused, has your doctor diagnosed any issues?   I thought from your original post that they are diagnosing you with enlargement and less than optimal performance of the muscle.   If that's still the case, and the root cause is thought to be IST, then the goal would be rate control.  If the rate is controlled and those issues continue their current trend then it's something else.   Process of elimination.  

[Whatnow714]

Not sure... I will have to gently remind them that LBBB  is one of my diagnoses.

[ed34]

Is it ok to take coreg with LBBB?

[Whatnow714]

I believe they are considering a change from current beta blocker to Coreg  since it's apparently more effective in cardiomyopathy but not positive about that. They're concerned that it may not keep the heart rate down because it apparently has that reputation per my EP.  

I believe the statement pertaining to not being on beta blocker long enough refers to improvement in EF may take more time since it has definitely improved my heart rate.

Ischemia has not been mentioned since May when I had a Lexiscan stress test to check for ischemia, I believe, which was normal.  This was ordered after LBBB was unexpectedly diagnosed during my routine annual EKG.

[ed34]

We have to remember that an Echo can carry up to 10% error in EF calculation. This is why not many cardiologists seem concerned if it's above a certain level. This has been proved time and time again when patients have an Angiogram or other type of scan after an echo. 7 weeks on a beta blocker isn't long enough? I don't know exactly what they mean by this and what they are hoping to achieve from the beta blocker. It has obviously reduced your rate which is the main purpose of them, to stop the heart over working. If you have a resting rate of mid to high 60's, I fail to see why they would feel the urge to discuss medication changes anyway. The current rate is just fine, so while it's working I would leave it alone. It can take many months to get the right balance in some patients. They key issue here is to establish the cause for your hypokinesis. There must be a reason why the heart muscle is hypokinetic and the first thing which springs to mind is ischemia. Does it say the area of hypokinesis? Have you had any scans to test for ischemia, such as a nuclear thallium scan? or angiogram? What about a stress test? have you had one? and if so what symptoms did you get?

[Whatnow714]

There was no report of enlargement per my EP if by enlargement you mean cardiomegaly-enlarged heart; plus they haven't said what type of cardiomyopathy - restrictive, dilated, etc.  I believe their current theory is tachycardia induced since I've been seeing my cardiologist for about 8 years or so for IST.   LIke I said above, I have many questions!!  

Thanks for your input.

[itdood]

Hello, do you know what the root cause is for the muscle issues they are noting?  The hypokinesis and enlargement suggest that the cardiac muscle has some sort of issue going, there are many types of root causes for this.  Has that been identified?

Perhaps if you know the root cause you could solve that.