Endothelial Dysfunction

[wiles1030]

I am a 39 yr old female that has been diagnosed w/Endothelial Dysfunction and Metabolic Disorder and still have uncontrolled blood pressure and heart rate. We have been working with this problem and unexplained arm pain and heaviness since July 05' and I am now starting to experience being winded upon any type of activity, including a shower. My cardiologist has done a heart cath, heart CT, stress test, & blood work which have all come back normal.  We have even looked for secondary sources of HP w/Renal CT, 24 hr urine, possibility of some tumors, and blood work and those have come back normal also. I do experience swelling in the legs, feet, hands, and mid section and it's not uncommon for me to gain 5-8 lbs in a week or so; the diuretics help some but not always.

I am currently taking Micardis, Toprol XL (100 mg 2x daily), Imdur (30 mg 2x daily), Digoxin (240 mcg daily), Maxide, Lasix (PRN), Potassium, Amaryl, Glucophage, Tricor, Paxil, and Pravachol.  

Any information on the possible causes will be greatly appreciated.  

[cardiovance]

Dear Wiles1030:

Lifestyle modifications are key to managing your complex condition. These include but are not limited to stopping smoking, exercise, and weight loss. Obviously, all of these under the direction of a physician. In addition, a low-fat, low-salt diet may not provide all the nutrients for complete heart health. A new supplement, CardioVance, is tailored for women's heart health. CardioVance incorporates Omega-3 Fish Oils, CoEnzyme Q10, L-arginine, Calcium and Vitamin D, and a powerful multivitamin into a convenient daily nutrition pack. Both the L-arginine and omega-3 fish oils may help women to improve endothelial dysfunction and promote a healthy cardiovascular system. More information on women's heart health can be found at www.cardiovance.com.

Good luck,
Cardiovance

[Fionajnz]

Have you seen a pulmonologist, if not, that is the obvious next Dr to review you and your problems.  National Jewish in Denver is the best pulmonology hospital in the USA.

I am going through a similar experience at 41yo, lots of different systems affected and many medical problems that have suddenly emerged, including cardiac and pulmonary. Its been really hard for the Drs to work out what symptoms are due to which system.  I have had severe SOB for months after developing a cardiomyopathy post partum.  They did extensive lung function testing which showed muscle weakness on inspiration and expiration and 50% reduction in diffusion capacity (the exchange of oxygen and carbon dioxide), I also had other total body weakness made worse I think by the steriods they put me on.

One diagnosis that they have all kept mentioning is a myositis of which there are several types.  May be worth reading about.  The other thought I had was whether you have had your adrenals tested, if not then that is probably worth doing too.  Mine were totally messed up from some meds and I felt a bit better when that issue was treated.  

Time is what seems to have helped the most, along with meds and a very patient orientated PCP, who keeps good contact with me and my husband.  

I wish you well, I think I have seen every specialist that is possible, often at the suggestion of other specialists we are working with.  There is nothing wrong with trying to find answers and advocating for your own health.  Keep your chin up and I hope you find some relief soon.

Fiona

[wiles1030]

Thanks for the wonderful advice and information.  I have a follow up appointment with my cardiologist on Monday and I have planned some very stright forward questions for him and the first one is can we start with a clean slate (medication wise).  I have noticed that I am now real winded when doing any type of activity and this has been getting increasing worse over the last 8 days; so I am really starting to wonder about CHF we have a family history of it and many other heart problems.

Any input is greatly appreciated.

[PikaPika88]

Wow!  I counted, 12 kinds of chemical bullets/smarties mix.  Dr asked me to take 2 kinds, I tried one, not work..  Tried the other one, not work... Finally, swallowed all two.  I felt like a broken wings butterfly.... lost in the air!  End up I've a very early fatty liver so I don't have to take any!  Now, they all said I didn't have heart problem.  All symptoms are due to anxiety!  But too late, my liver is having a sign of fatty... (very sad).  Didn't heal one and broke the other.......  Hope you're getting well soon.

Pika.

[Carolina03]

Wiles,

Did your cardiologist perform an adenosine challenge to reproduce the arm pain? She or he can do this with a sonogram of your arm. Microvascular disease will not show up on standard tests. That's the point of the article I sent. Modern cardio tests were not designed to look for small vessel disease.

Please go to a large tertiary or academic center to seek comprehensive care from someone with experience treating small vessel disease. Your endocrinologist should be working with your cardiologist, etc.  

If you have metabolic syndrome with pre or full blow diabetes, then you are at high risk for small vessel disease which can affect the vascular system throughout the body.

I was told that small vessel disease tends to harm the kidneys first, that is why I am on a diuretic even though I don't have CHF. Eplerenone, the diuretic I take isn't approved for FDA use other than left-sided heart failure but for unknown reasons it helped me. We thought it was placebo-effect at first. But placebo is short-term. I went from Class III Angina to barely Class I in four weeks. Was it time or the medication healing? Hard to say. I'm willing to concede it was both on top of ALL the excellent self-healing strategies cited by "HealThyself."

If there's one criticism I'll launch at the CCF cardios -- God bless their charity -- its their propensity to embrace the "that's all you can do" line of doctoring. Yes, standard medications are critical, but so are the patient's own initiatives, perhaps even more so in certain cases.  

Anyway, I'll get off my soapbox now.

Cheers everyone.

Caroline

[Healthyself2]

So you're off the Imdur -- I think that's good.

Endothelial function produces N.O. as needed.  I believe that, although the nitrates work short term, they degrade that natural endothelial function over time, worsening your disease.

What can people do to promote a healthy endothelial system throughout their body?

* Longer duration daily mild to moderately aerobic exercise
  Do enough to drink a liter of fresh water.
* Healthy diet with fruits and veges.
  Do some exercise and eat an orange.
* Less meat.
* Less sugar.
* Eliminate all unnecessary medications.
* My motto is no blood thinners, beta blockers, diuretics.
  It's all one system - without healthy blood, you can't
  have a healty vascular system.
* Eliminate stress.
* Eliminate debt - become financially healthy
* Eliminate negativity - be happy.
* Enjoy life - define yourself as a normal person not a patient.
* A glass of red wine with dinner every night.
  (if you're not an alcoholic)
* Perhaps a good Multi-Vitamin.

This will promote a healthy vascular system, improve coronary capacity, and greatly reduce the risk of any vascular event.

[Gaspipe]

Hi you are the kind of person that makes me wonder what goes on in the minds of some docs. you are young and on so many meds how could anyone .. doctor or not know what in god's name is going on . I mean you may be having many types of meds interacting with one another as well as so many organ systems being affected.If I were you I would surely seek another opinion and try to that unruly list of meds weaned down Good Luck Gaspipe

[Carolina03]

Wiles,

I've been under the care of a cardio who specializes in endothelial dysfunction due to microvascular disease, and was in the Women's Ischemia Syndrome Evaluation (WISE) study sponsored by the NHLB for this type of heart disease.

The first piece of advice that I'll give you is to EXERCISE 30 minutes, six days per week. I've been told by my cardio and a friend who's a cardio at Mayo that this is the single most important thing you can do to reduce inflammation, stave off complications and improve the quality of and prolong your life. Ask your doctor what type of exercise is appropriate for you. Perhaps you can join a cardio rehab program. Please do this. It helped me get over the initial depression of my diagnosis, too.

As I'm sure you've been told, diet is important: small meals, low-carb, high fiber and lots of fruits and vegtables. I've ALMOST given up high-sugar foods such as desserts which tend to raise my glucose level and BP.

The good news is that after several months of lifestyle changes and medical therapy, including an ACE-inhibitor (lisinopril), diuretic (eplerenone), statin (vytorin) and foltx my symptoms improved. The bad news is that my coronary flow didn't. In other words, the medications helped my symptoms but didn't seem to improve my heart's blood flow. That's why exercise is so critical: you're feeding your heart. Exercise can improve diastolic dysfunction, too -- a type of heart failure that we're prone to.  

My cardio and the research team who are studying the data from the WISE study think that inflammation plays a role in the disease. Unlike "classic" heart disease where stents and other procedures provide at least temporary relief, endothelial dysfunction is hard to treat. There are no magic bullets or cures. Yet.  

The other piece of advice I'd like to share with you is to develop a routine of breathing exercises, possibly enroll in a yoga class tailored for people with health conditions. Clinical evidence supports breathing, meditation and yoga in reducing blood pressure.

One last bit of info from the Wall Street Journal:


Doctors Focus New Attention
On Heart Disease in Women

Latest Studies Spur Calls
For Better Testing, Treatment;
Exploring the Use of MRIs
By RON WINSLOW
February 14, 2006

Recent research into how heart disease differs between the sexes is prompting calls for fresh approaches to improve its detection and treatment in women.

Provocative findings from a decade-long study argue that many women have a form of heart disease that is fundamentally different and harder to diagnose than in men. Thus, problems are often missed early on in women, when prevention and treatment strategies might be more effective in preventing heart attacks, heart failure and other serious consequences of heart disease.

To counter this, researchers say that women and their doctors need to be especially persistent in tracking down the problem when chest pain and other symptoms arise. Doctors also need to pay more attention to symptoms that occur more frequently in women, such as fatigue and shortness of breath. In addition, doctors are looking closely at certain tests, such as magnetic resonance imaging, that aren't commonly used now but could help detect hidden heart disease in women.

The findings are expected to stimulate new research into treatments. Women are more likely than men to report recurrent chest pain after such standard remedies as bypass surgery and balloon angioplasty, partly because those procedures don't always reach areas where disease occurs in women. But drugs such as statins, aspirin or ACE-inhibitors, already standard for high-risk patients, may be helpful for women who have the more-hidden form of disease.

Overall, researchers say, women need to be especially vigilant about strategies that can reducing the risk of heart disease, including staying fit, eating a healthy diet and avoiding or quitting smoking.

The impetus behind these messages is growing recognition that for many women, chest pain and other symptoms arise not from obstructions in the large arteries of the heart, as commonly found in men, but from tiny vessels that branch off those arteries to deliver blood to heart tissue.

As a result, disease in women is often not detectable via standard diagnostic techniques, including treadmill stress tests and angiograms, which use X-ray technology to let doctors watch how blood flows through key arteries. Indeed, based on such tests, doctors often tell women their arteries are clear and their hearts are fine. But, too often, the symptoms persist and women either muddle through or embark on a frustrating series of additional tests, researchers say. When the disease is finally diagnosed, it is often at an advanced stage, when its toll on women can be particularly harsh.

"So often these women who have open arteries [on an angiogram] are told they have no problem," says C. Noel Bairey Merz, a cardiologist and medical director of women's health at Cedars-Sinai Medical Center, Los Angeles. "We need to stop reassuring them."

Dr. Bairey Merz is chairwoman of the Women's Ischemic Syndrome Evaluation, a major study sponsored by the National Institutes of Health to examine gender differences in diagnosis and the role of sex hormones in heart disease. The study, launched in 1996, involved 936 women who were referred for angiograms because of chest pain.

In reports published earlier this month in the Journal of the American College of Cardiology, Dr. Bairey Merz and her colleagues identified a disorder of the small vessels in women, which they called "microvascular dysfunction."

The heart's primary job is to circulate freshly oxygenated blood to the brain and other organs throughout the body. To keep healthy, the muscle that does the work needs some of that blood too, and it is supplied by the coronary arteries. Blockages in those arteries starve the muscle of oxygen, leading to chest pain. Major obstructions in the large vessels often causes a heart attack.

Blockages in much smaller vessels, whether caused by disease or by functional problems in cells lining the vessel walls, similarly deprive heart muscle of oxygen-rich blood and can also cause heart attacks -- though not typically in the classic fashion of plaque that ruptures in a large vessel. Exactly how the obstructions in large and small vessels might lead to different outcomes for women isn't yet understood, researchers say. The main issue for now is that when the disease is hidden from conventional diagnostic techniques and the patients are given a clean bill of health, the problem is likely to get much worse before it gets treated, with more potentially dire consequences.

Estimates based on WISE data suggest that blockages in the tiny vessels that branch off the arteries may be the major culprit in as many as three million women. One likely reason for the gender differences is the impact of the sex hormone estrogen, which may protect women against heart disease in their younger years, but make them particularly vulnerable when levels plummet after menopause.

Researchers do note that some six million women in the U.S. have heart disease based on the conventional diagnosis of obstructions in the large arteries. Moreover, some men also develop disease in smaller vessels. Accurately evaluating chest pain symptoms is often daunting for doctors in both men and women patients.

But many heart experts are calling for more research to make sense of emerging differences. "We need to take this knowledge and create a systematic plan for how to deal with it," says George Sopko, project officer for the study at the NIH's National Heart, Lung and Blood Institute.

Researchers have long reported that women often lack the tell-tale chest pain that typically predicts serious disease in men. In women fatigue, trouble sleeping and shortness of breath may be symptoms of impending heart trouble that doctors miss. In addition, says Dr. Sopko, radiating chest pain that often accompanies the onset of a heart attack in men appears to occur less often in women, who are more likely to feel pain in the shoulder or arm. Women are also less likely to experience a fluttering of the heart, he says.

To detect heart disease in small vessels, doctors have a number of diagnostic tools to explore besides traditional angiogram and treadmill stress tests. Widely available techniques, such as thallium stress tests and stress echocardiograms can help doctors determine whether adequate blood flow is getting to heart tissue in patients whose chest pain persists despite having clear large arteries, Dr. Sopko says.

Researchers are also looking at other approaches that use magnetic resonance technology. One such test, known as phosphorous-31 nuclear spectroscopy, was a strong predictor of women in the WISE study who were likely to develop future heart trouble in women with chest pain but clear arteries on an angiogram. That test isn't routinely used, but is available at some research centers. In addition, WISE researchers are pilot testing a coronary angiography procedure using MR technology instead of X-rays in hopes that will also prove effective in detecting disease hidden from the conventional exam.

The issue of how to treat women with disease in the small vessels is still being explored. Dr. Sopko and other researchers recommend treatment with statins, ACE-inhibitors and aspirin in women with microvascular dysfunction even as they await results from future studies on whether they reduce heart attacks in such patients.

Another hindrance is awareness. Both the NIH and the American Heart Association have launched campaigns in the past couple of years to educate women about heart risks, but a recent study indicates only about half of women know that it is the leading killer of women.

Write to Ron Winslow at ron.***@****

--------------------

Blessings,
Caroline

[Cleveland Clinic]

wiles,

Thanks for the post.

You are on a lot of medicines. Its hard to tell exactly what is going on with you, but there are some concerns with your medicines such as Im not sure why you are on digoxin if you have normal cardiac function and Maxide and Micardis both contain the same medication(HCTZ).

If you are on maximal doses of the medications and still have high blood pressure, I would agree with the evaluation of other causes of hypertension.

I would have a hard time attributing your symptoms to endothelial dysfucntion and if your cardiac workup were truly normal, look at other causes of your symptoms such as pulmonary issues or thyroid dysfucntion to name a few.

good luck