Re: Case of Severe CHF

Posted By Susie on November 18, 1998 at 21:58:22:

In Reply to: Case of Severe CHF posted by Don on November 18, 1998 at 03:00:49:






?A BRIEF HISTORY
I am a 42-year-old male with chronic atrial fibrillation, which began in autumn 1994. I currently smoke one-half pack cigarettes a day and do not drink alcoholic beverages. At that time, I washospitalized approximately a week.  Electrocardioversion was attempted, but was unsuccessful. The cardiologist decided to treat my dysrhythmia with medication. I was released on Lanoxin, Calan 240, and Coumadin.
I was hospitalized during the first week of May this year with CHF and started on a different medication regimen that consists of Lanoxin 0.25 mg BID, Coreg 6.25 mg BID, Coumadin (varies according to standing order PTs), potassium OS 1 tbsp. TID, mag. ox. 400 mg BID, and Lasix 40 mg BID. No cardioversion was attempted; apparently, I was not considered a good
candidate for this procedure. An echocardiogram was done with the following findings:
ECHOCARDIOGRAM:
TECHNICALLY LIMITED STUDY DUE TO THE PATIENTS BODY HABITUS.
Two-dimensional as well as color flow imaging and conventional Doppler were performed on this
patient.
INTERPRETATION
1.    Calcified aortic annulus, particularly the left coronary leaflet with slightly decreased but adequate excursion.  Doppler examination reveals peak systolic gradient of 15 mmHg with a mean gradient of 10, with moderately severe diastolic regurgitation.  The calculated aortic     valve area by Doppler is 1.8 centimeters squared.  Normal sized aortic root.
2.    Borderline enlarged left atrium measured at 4.1 cm.
3.    Mild diffuse thickening of the mitral leaflets with adequate excursion with diastolic fluttering of the anterior leaflet consistent with aortic regurgitation.  Doppler exam reveals moderately severe mitral regurgitation which seems to be a more eccentric jet toward the      posterior atrial wall.
4.    Markedly dilated left ventricle with end diastolic dimension measured at 7.1 cm.  There is severe global hypokinesis with the ejection fraction estimated at 20%.
5.    Normal sized right ventricle.
6.    Normal tricuspid valve with mild tricuspid regurgitation by Doppler.  The right ventricular systolic pressure is estimated at 38 mmHg, assuming CVP of 10.  This indicates the presence of mild pulmonary hypertension.
7.    There is no pulmonic regurgitation by Doppler.
8.    No pericardial effusion seen.
IMPRESSION
1.    Calcifications of the aortic valve with decreased but adequate excursion and mild systolic gradient by Doppler with moderately severe aortic regurgitation.
2.    Moderately severe mitral regurgitation.
3.    Dilated and severely hypokinetic left ventricle with ejection fraction estimated at 20%.
*This test was done two days after first May 1998 hospitalization.
I was hospitalized again the last week in May with severe dyspnea. This admission was considered medical rather than cardiac. I received an IV antibiotic (Azogantrisin, I think), IV Solu-Medrol,breathing treatments, ABGs, and my present cardiac medicines. PFT results showed 85% 02 sat.
Upon my release, 02 sat. was 95% on room air. In addition, a Doppler was done on the previous echo, which had been done earlier in May. The findings appear below.
ECHOCARDIOGRAM
TECHNICALLY LIMITED STUDY DUE TO THE PATIENTS BODY HABITUS.
Doppler was performed on the previous study of May 4, 1998.
INTERPRETATION
1.    Normal aortic root dimensions.
2.    Moderate thickening of the aortic valve typical for calcification with decreased excursion.
3.    Minimal left atrial dilatation, 4.1 cm.
4.    Normal mitral and tricuspid valves.
5.    Moderate to marked left ventricular dysfunction, 6.7 cm. With moderate symmetrical hypertrophy.  There is global diffuse hypokinesis with an estimated ejection fraction of 20%.
6.    Mild right heart dilatation.
7.    No pericardial effusion.
*This test was performed on Day 2 of my second admission.
I have three questions and any information given will be appreciated.
1.    Will you please expound briefly on the following points and how they relate to the interpretation of my echocardiogram?
        a.  Aortic regurgitation.
        b.  Moderately severe mitral regurgitation . . . toward posterior atrial wall.
        c.  Markedly dilated left ventricle.
        d.  Severe global hypokinesis.
        e.  Ejection fraction estimated at 20%.
        f.  Calcified aortic valve.
2.    Since I am taking the appropriate medications to increase cardiac efficiency, in your opinion, will the global hypokinesis and the left ventricular hypertrophy and dysfunction be erradicated or just decreased in their severity?
      3.    What is the difference between acute CHF and chronic CHF?
      4.    My mother has atrial fibrillation as well. Is there proof this condition is hereditary?
I realize that it would require too much space to answer all my questions, but any information regarding these issues will be greatly appreciated.
Thank you,
Don

For someone who is coming across as being scared to death with the diagnosis
that you were given, you are not acting as though you are, due to the fact that
you are still smoking.  My husband was a heavy smoker, ended up like you are
with CHF, but he quit smoking.  He had a quad by-pass done almost three years
ago.  Just before he was discharged, his doctor spoke to the both of us and
said that he had to quit smoking.  Then he said, "Your husband needs to stop
smoking and he will stop.  Either he quits on his own or he will die and then he
will stop smoking."  So you see my friend, even though you are smoking only
10 cigaretts a day, it's 10 too many.  You, like my husband, will quit, either on
your own, or you too will die.  Sorry to sound so hard about the subject but
guess I am telling it like it is.  You are asking the doctors to help you, you
spend time in the hospital, have time off from work, and cost the insurance
company a ton of money to help you out of your distress, and you aren't willing
to help yourself.  The choice is yours and yours alone, for there isn't anyone
you can tell you what to do.  Either you want to live or you want to die.  What is
it my friend?