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EF 15 percent: treatment plan, long-term health?
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EF 15 percent: treatment plan, long-term health?

My husband is in the hospital due to recent falls, fatique and extreme shortness of breath. He had an Echo and found 15 percent ejection fraction rate. He is constantly in a-fib with a heart rate sometimes in the 130's. He's had a-fib for over 10 years and it was better controlled 10 years ago, than within the last two/three years. He's now on Lasix and he has lost over 35 lbs in water. He is also super morbid obese, which does not help the situation. And echo one year ago showed an fraction rate of 50 percent. Recently, even talking and walking has become a challenge. Dr. changed his medication: added in potassium, doubled his metropolol, kept digoxin, stopped amiodarone. No other issues in his bloodwork. Cardiologist's only treatment plan is the medication to control the a-fib. What do think of this treatment plan? No talk of cath or pacemaker. I think this is because of his size. Unfortunately, I have not been present each time the cardiologist has visited. Hospital is planning on discharging him to a sub-acute rehab in two days because of his loss of strength. The admitting Internist told him that he could live till he is 70, which I think is overly optimistic. I am concerned about his life expectancy, expecially with the upcoming move to rehab.  
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1124887_tn?1313758491
Thanks for your reply and nice words! :) By the way, Oslo isn't what it was, now we have a high crime rate and generally it's a bit unpleasant. Anyway,

If the AF has persisted for a decade, it's somewhat unrealistic to hope it will turn into normal sinus rhythm permanently. This is not necessarily problematic, because people can live well with AF (you can ask Jerry, our community leader at HR community, he's a nice guy who has lived well with AF for a long time). However, it's EXTREMELY IMPORTANT that the ventricular response is normal (should be sinus rhythm + 10-20% in heart rate, you need this because the atria isn't working properly and the heart is somewhat less efficient). This is often a puzzle, especially with obesity, because even if the resting heart rate is normal, slight exercise can make the heart rate hit the sky.

An alternative is so-called His bundle ablation with a pacemaker. In other words, the conduction system between atrias and ventricles is cut off, and a pacemaker stimulates the heart.

I know this is somewhat brutal, but your husband needs to understand that this is serious. Weight loss is definitely necessary, an EF of 15% indicates severe heart failure. He can live a good life, I'm sure, but it depends on weight loss, correct exercise (only as described by cardiologists), healthy lifestyle and proper medication. Stay in close tough with the doctors and follow their advice.

I hope everything will be OK with you!
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1124887_tn?1313758491
This is really a question that should be answered by professionals, but I can share some thoughts.

It seems pretty obvious that the high heart rate (plus obesity) has overloaded the heart, and the result is dilation and reduced EF. This must be confirmed and treated, I suppose that's why the doctor doubled the beta blocker. If the A-fib is permanent, using antiarrhythmics like Amiodarone is somewhat pointless, and this is one of the medications with most and most dangerous side effects. I think your doctor has made the correct choice (but that's really not up to me to decide).

There is a good chance the EF will improve when the tachycardia is cured (the a-fib is better controlled). Weight loss is also necessary. I would possibly ask Kenkeith in the heart disease community, I believe he improved his EF from 13 to 59%, or of course, a cardiologist in the expert forum.

Best wishes to you!
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1506148_tn?1289752250
It is good to hear your opinion. The cardiologist said the same thing about the Amiodarone. The potential "toxic" side effects don't make it worth the risk, if it isn't working.  All the doctors/staff have reinforced the weight issue repeatedly. My husband is in EXTREME denial about this issue -- so hopefully this situation will wake him up.

If the a-fib is permanent, is there any other treatment options?

I am new on this community and really appreciate your suggestions of who to reach out to on this board.
Thank you again~
PS - It's cool you're from Oslo.  
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1124887_tn?1313758491
Thanks for your reply and nice words! :) By the way, Oslo isn't what it was, now we have a high crime rate and generally it's a bit unpleasant. Anyway,

If the AF has persisted for a decade, it's somewhat unrealistic to hope it will turn into normal sinus rhythm permanently. This is not necessarily problematic, because people can live well with AF (you can ask Jerry, our community leader at HR community, he's a nice guy who has lived well with AF for a long time). However, it's EXTREMELY IMPORTANT that the ventricular response is normal (should be sinus rhythm + 10-20% in heart rate, you need this because the atria isn't working properly and the heart is somewhat less efficient). This is often a puzzle, especially with obesity, because even if the resting heart rate is normal, slight exercise can make the heart rate hit the sky.

An alternative is so-called His bundle ablation with a pacemaker. In other words, the conduction system between atrias and ventricles is cut off, and a pacemaker stimulates the heart.

I know this is somewhat brutal, but your husband needs to understand that this is serious. Weight loss is definitely necessary, an EF of 15% indicates severe heart failure. He can live a good life, I'm sure, but it depends on weight loss, correct exercise (only as described by cardiologists), healthy lifestyle and proper medication. Stay in close tough with the doctors and follow their advice.

I hope everything will be OK with you!
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995271_tn?1408549100
My father ended up needing a heart transplant by the time his hit 15% ef.  He was a bit different though because he was normal weight but had a massive heart attack.  It wasn't reversible.  

I've seen echo and MRI movies of hearts with EFs that low.  There's barely any movement in the left ventricle by that point.  Instead of a nice hard squeeze and a lot blood forcing out it barely does anything.  Since the blood tends to stay in the heart longer than it should there might even be higher risk of stroke, though I'm not sure.

It seems his EF dropped significantly in the last 6 months.  Did anyone give you a reason for this?  That seems like a rather abrupt change in a short time without having some sort of major event like an infarction.  

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612551_tn?1247839157
As my AFib condition was mentioned as reference, I can add that while I am in permanent AFib my EF is about 60%, so it is in the good range.  Still, I am short of breath and take a beta blocker and a calcium channel blocker to keep my resting HR below 100.  With the combination of BB and CCB (may not work for some to combine these) my resting HR is more in the 70s.  It was around 130 without treatment.  I also take an anticoagulant, standard treatment for AFib (Warfarin).

All this said, I still notice my reduced tolerance for physical work/exercise, due to the reduced efficiency caused by the AFib.  I am a bit overweight too at 250 pounds.  I am about 6' 6" so I can get by well at 230.  I am again working on dropping that 20 pounds and I know it will increase my physical strength.  This is another support statement for your husband to lose weight.  

It sounds like you are an angel to your husband, and I hope he appreciates it.
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1506148_tn?1289752250
Hi, is_something_wrong; itdood, Jerry_NJ,
Thank you so much everyone for responding to my post. Sorry for falling off the face of the community board like that. Life got a little crazy and I apologize for not responding until now.  Dear husband (DH) was transferred to the rehab facility -- and unfortunately it's an hour away from home. Geeze, I wish I could get frequent flier miles for my visits.

When DH left the hospital, his HR was 100. The cardio Dr said his Afib is chronic now. They tripled his metropolol, added digoxin, lasix, and he's still on warfarin and one other that I can't remember.  The Dr did not suggest any other tests to figure out why he developed the EF of 15%. DH lost over 50 pounds in fluids while in the hospital from the IV pushed Lasix.

Now that DH is at the Rehab Facility he is on oxygen all the time, but they only check his heart a couple times a day. Today he stood for the first time in 17 days, and took a couple of steps. DH was a little short of breath and his joints ached. Because of Is_Something_Wrong comment about exercise and heart rate, I asked DH to see if they could check and see what his heart is doing while he's having a PT session.  

Is_Something_wrong and everyone: do you think that the Drs have not suggested a pacemaker because DH has A-fib and flutter?  The flutter was diagnosed 10 years ago, along with the a-fib.

Also, for some reason, in the hospital, the doctors called DH's condition pre-Congestive Heart Failure. I don't understand this at all?!? Is this like being a little pregnant?  Either way, I will reinterate how serious this is to DH and let him know that we are talking about him from NJ, to Norway to PA.  

Itdood: I'm sorry to hear that your father had a heart attact. Is your father doing okay now with his new heart? Did he have many symptoms before getting to the 15% EF? Your decription of the heart with the low EF is very visual. The doctors did not say anything about DH having an infarction or stroke. The Drs did run a bunch a blood tests. Does something like this show up in blood work?

DH does have severe lymphadema.  Would the 15% EF make the lympahdema worse too?  If the blood would pool in the heart, would other fluid pool too? Just a thought, since DH's lymphadema has really bad before he went to the hospital.

Jerry_NJ: Thanks for jumping in and responding too. Don't jump too fast, don't want you to get out of breath. HaHa. Were you ever afraid to exercise because of your condition? Seems to be a catch-22 with this condition. Need exercise enough to increase strength and build stamina, but don't want to overload heart?

DH has heard from everyone that he needs to lose weight. But has he really "HEARD" it?

And Jerry, thank you for the kind "angelic" compliment. My halo is blushing and but it's also quite lop-sided. LOL.  

Again, thank you everyone for your responses and helping me through this. Your experiences and insight are wonderful and I am more hopeful.
~ Best regards, mich_rabbit
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995271_tn?1408549100
My father has done exceptionally well with the transplant.  It's been 22 years!!  He looks great, exercises all the time.  He's passed his retirement age but keeps working full time.  He just had his yearly checkup and his EF is 68% which is excellent.

A 15% EF will definitely make water retention much worse.  That's what congestive heart failure is all about.  The poor blood flow means fluids will start to build up in extremties.

Conditions like afib and aflutter cannot be paced aways.  Pacemakers are mostly used to speed up a very slow heart rate.  Sometimes they can be used pace-out certain other rhythms but I've bever heard of it being used for afib and aflutter.
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1506148_tn?1289752250
Wow!  22 years is amazing after a transplant. It sounds like your Dad is doing the right things - living a healthy lifestyle and listening to his doctors. 68% EF is great!  

I'm learning so much about DH's condition. It makes sense that the water retention would build up in the extremities with such low pressure. Now I understand why the Drs look to the lower legs for swelling.

When I spoke DH's Visiting Physician, he thought for sure that the cardio dr would put in a pacemaker.  But this was never brought up in the hospital. The cardio dr did review DH's heart history too.  

And, I seem to remember when DH was diagnosised 10 years ago, the heart clinic said he wasn't a candidate for a pacemaker. But I couldn't recall the specific reason -- maybe it was because he has both afib and aflutter.

Hopefully getting all the excess fluid out of his system, changing his meds, and continuing to lose weight will be enough to keep him motivated to get through the rehab and get his health back on track. It's going to be a long road.

All this EF talk makes me wonder if I should get mine checked.  Or maybe I should just get off the couch and go exercise. Smile.
  
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1124887_tn?1313758491
Hello,

I assume there is a good chance the condition is reversible. I'm not familiar with the term pre-CHF, but I assume this is the explaination. Tachycardia-induced heart failure (it seems this is the case here) will likely get better after curing the tachycardia.

The pacemaker: I guess ablation with pacemaker (His bundle ablation) is the last option when treating A-fib (and atrial flutter, they are more or less treated equally, though atrial flutter is a little more risky and I think most doctors prefer flutter to convert into fibrillation, even if it sounds strange). I think the problem with A-fib is, you can have a perfectly normal heart rate at rest, but work, daily life and exercise is difficult, because the heart rate can go into the 200s just by walking.

The fibrillation/flutter itself can be ablated, but with permanent fibrillation, there is a chance it will return almost immediately.

Yes, if your husband will follow the advice you mentioned in your last post, there is a great chance this will resolve. Yes, it's going to be a long road, and he will need all the support he can get, both from doctors and family.


By the way, did you ask this question to Kenkeith at the heart disease community? I believe his condition was similar to your husband and he can give you great advice. His EF is at 59% now.

I really hope he will be OK!

(PS: I'm sure your EF is fine :)
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1506148_tn?1289752250
Hello!
Thank you again for your explanation. This makes sense.

While DH was at the hospital, I watched the heart monitor in the hallway often and he was constantly in afib at a various rhythms and then it would show Tachycardia spikes usually when DH was doing something very physical.  Now, DH's resting HR is in the 90s.

Last night, DH finally admitted that he is scared, and he understands that because of his condition that he is at high risk for a stroke. I told him that I agreed that having a severe heart condition, being overweight, plus all of the other complications makes this a very serious situation. But this is his chance to change and make things better by listening to the doctors, following their advice and losing weight will definitely make the biggest difference. All the great messages you and the others have emphasized. By talking with everyone on this board I was able to really hear DH and hopefully give him some advice that will help motivate him.

Based on your first post to me, I did find Kenkeith's profile on the heart disease community and I reached out to him via a direct message. I didn't want to post my original  message in two areas (wasn't sure of the protocol here on MedHelp) -- so I sent KenKeith a direct message and said "is_something_wrong" suggested I contact him.  

Should I have not contacted him that way? How should I get KenKeith to talk to me?  Could you direct him to this question on my behalf?  I would love his perspective.

Thank you again for your support.  I wish I had a crystal ball to know where the upcoming bumps will be on this long road to recovery.


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1124887_tn?1313758491
Of course you can ask everyone here. It's our "job" to help you (well, we are not medical professionals, but we try to do what we can, especially the community leaders/top answerers). I just sent him a message. No guarantees, but I hope he will take a look at your situation. The reason why I suggested you could ask him, is the amazing recovery from severe heart failure.

The doctors are the professionals, and they know what must be done. Weight loss is, of course, strictly necessary, and so is removing the cause of the heart failure. It seems that high heart rate may be the cause.

I hope you get a reply from Kenkeith, and in the meantime, I wish you both good luck. I know this is difficult for you both. I often worry about my father, who had bypass surgery done one year ago. He quit smoking, started exercise and lost weight. Support from the family is extremely important. Everything is OK with him now.

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1506148_tn?1289752250
I am so glad I found this site.  Thank you for helping answer many of my questions during this crazy time.  And if I hear from KenKeith, I hope to learn from his experience too.  

I completely understand your concern for your father, even though he's doing well after his bypass surgery. I think with every major event like this - it does take family/community support to have the greatest success.

Tomorrow my husband and I meet with the social worker at the rehab facility to discuss his progress and next steps. From my untrained perspective, he won't be going anywhere soon. So, I'm not sure if DH will have access to a cardio specialist until he leaves there. But I plan on asking this question tomorrow and to find out if they have any other plans besides PT.

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