Treatment Options for CHF.

[larrye]

My 86 y/o father is 15 years post bypass, 8 years post RFA for atrial flutter, 4 years post pacemaker implantation for Atrial Fib, 2 MI's. Was doing quite well until a few months back when a CT showed pleural effusion. Echo was done and he was put on a diuretic to get rid of the edema ... and was recently taken off the diuretic after a followup CT had good results. Echo indicated that he's developed valve disease (mild to moderate mitral regurgitation with moderate to severe tricuspid regurgitation and moderate pulmonic regurgitation) and for the first time, moderate CHF (LVEF 35%) ... previous LVEFs had always been in the 50's). Left ventricle normal in size, left atrium mildly enlarged, right atrium moderately enlarged, right ventricle moderately enlarged with RVSP 36.4mm. He tires more easily than he used to ... and earlier in the day, but he's certainly still able to get around, drive, go out to dinner/shows. He's also on Tenormin, Lipitor, and Warfarin. Other recent relevant test results: Sodium=133, Potassium 6.1, BUN 26, Creatinine 1.3, BNP 346.8 .

My questions are these: His cardiologist has told us that they do not do valve replacements/repair for his type of valve disease. I wonder whether it's just that they feel at 86 with a 35% EF ... that he's just a poor risk.

1. What treatment alternatives should we be looking at besides the tenormin/diuretics? Should we push for another opinion on the valve surgery? Any other options?

2. Can moderate exercise be beneficial ... either to raise the LVEF or to extend life expectancy by strengthening the heart muscle function that he has left? I always thought that regular exercise strengthens the heart and therefore makes it easier for whatever remaining heart muscle to do its job.

I know he's getting up there in age, but I want to do whatever I can to help him and to extend his life. Thanks so much for your help!

Larry

[Cleveland Clinic]

1.  Tricupsid valve surgery is very difficult and fails quite a bit.  I don't think any surgery or aggressive procedures are going to be of any help.  I am assuming that he is not having much chest pain.  One medications that I would recommend, cautiously however, because of his mild kidney dysfunction, is an ace inhibitor or an ARB.  They have been shown to prolong survival in heart failure.  He probably also needs to be on a diuretic at this point.  this will not prolong his life but will improve his symptoms.
2.  He should continue to exercise as this will benefit him greatly in terms of his survival.

[larrye]

I've spoken with my Dad's cardiologist. I asked him about an ACE inhibitor, and he felt that since he is doing well on a Beta blocker, he would like to leave him on that. He's also on small doses of Lasix and another (potassium sparing?) diuretic. Comments? Are the benefits of an ACE well-known over and above Tenormin?

What should a person with a 35% LVEF be able to do in terms of activities? He tires so easily ... even from walking around a little bit ... I wonder whether his EF has gotten worse since it was last taken. Thanks.

[larrye]

Appreciate your concern. He was back at the cardiologist today and he didn't even do blood work ... although he is going back on a diuretic every other day. And the cardiologist has a great reputation. I wouldn't get too caught up on Creatinine. The reference values are very variable. Mine has actually been at 1.3 at times and I am not concerned, has a lot to do with muscle mass and there are even some labs that go up to 1.4 . I agree on the Potassium, although 6.1 is far from horrible. Do some research and you will find that it's on the borderline of "moderately high" (6.0 being mildly high). But thank you.  

[maggiemag]

The upper limit of creatinine is 1.2 for some labs.  All I can say is if my BUN was 26 and my creatinine was 1.3 plus a horrible 6.1 K, I would be at the doctor's office.  The BNP of 300+ is difficult to interpret unless you know what his baseline is.  For me, anything over 100 would be of concern.  Of course, he's your father, not mine,   but I would be very concerned.

[larrye]

I realize the potassium is high. The others (except the Creatinine, which is normal) are out of normal range, but only very very slightly. He's on a Beta Blocker (Tenormin), and was on a diuretic until a couple of weeks ago to clear out the pleural effusion (which it did according to a followup CT). But he's not on a Ace-Inhibitor. The potassium was taken before he was taken off the diuretic ... so it's possible that now, it is closer to normal range if not normal.  

[maggiemag]

I am not a doctor either, but the labs you list are all abnormal.  The potassium alone warrants immediate attention.  He should be on an ACE inhibitor as well.  If his cardiologist knows all these labs and is not doing anything, then you need another opinion right away.  It sounds like he is having an exacerbation of his CHF.  Moderate exercise at this point I do not think would be a good idea.  What he can do is strictly watch his sodium intake, keep it under 1500 mg./day, and watch his fluid intake.  Too much fluid would worsen things.  IMo, he is being undertreated.  Good luck.

[bzmed]

I am NOT a medical professional so take this for what you are paying for it :-)  It is my understanding that valve issues that are a result of issues like enlargement of the heart are usually handled with medicine because if it wasn't for that primary problem the valves would be ok.  His valves are not structurally abnormal it is just his heart is changing shapes which makes the valves not close as well.  They try medication to remedy the primary problem because then the valves operate normally again.  Also, as we become older it takes much longer for us to recover, we are more prone to infection (such as those nasty ones that float around hospitals and the risk of post surgical complications is much higher.  So his risk at 86 is obviously much greater than someone at 46.  Hope this helps.

[larrye]

BTW, BP seems under control ... is generally in the area of 130/85