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Help understanding results - Part 1 - BKGD
My doctor didnt do much but tell me "it was not good" and refer me to another clinic for more tests. Posting in threeparts
Background
52 yr old male - 160 lbs 5' 08" about 13% bodyfat Typical BP 115/70 resting heart rate 75-80 non smoker 15 yrs healthy diet - weightlift 3-4x weekly, treadmill (max incline slow rate 3 mph) 3x weekly. Intermittent chest discomfort (pressure - kind of bubbling or fluttering feeling ) esp noticable if stressed.
Went in for diagnostic tests in 2008 - changed diet / exercise to improve cholesterol and blood pressure rather than taking statins and Ace inhibitors. LBBB and some small issues with perfusion noted - thought was I may have had a very minor heart attack at some time.
Follow up tests last month not very pretty despite perfect bloodpressure and HDL/LDL numbers. Ejection fraction of 0.21 - but my left ventricle is huge so ejection volume around normal of 70 mL. LBBB - but report does not seem to be able to categorize my condition - any help here ??
Background
52 yr old male - 160 lbs 5' 08" about 13% bodyfat Typical BP 115/70 resting heart rate 75-80 non smoker 15 yrs healthy diet - weightlift 3-4x weekly, treadmill (max incline slow rate 3 mph) 3x weekly. Intermittent chest discomfort (pressure - kind of bubbling or fluttering feeling ) esp noticable if stressed.
Went in for diagnostic tests in 2008 - changed diet / exercise to improve cholesterol and blood pressure rather than taking statins and Ace inhibitors. LBBB and some small issues with perfusion noted - thought was I may have had a very minor heart attack at some time.
Follow up tests last month not very pretty despite perfect bloodpressure and HDL/LDL numbers. Ejection fraction of 0.21 - but my left ventricle is huge so ejection volume around normal of 70 mL. LBBB - but report does not seem to be able to categorize my condition - any help here ??
MEDICAL PROFESSIONAL
Hey haritec,
You clear have had extensive testing till date and have figured out a great part of the problem.
In order to re emphasize the main points, you have a drop in the ejection fraction of the heart to 21%. Normal ejection fraction is about 55%.
One of the most important causes of drop in ejection fraction is blockages in your coronary arteries. You have had a stress test which reveals multiple areas of "ischemia" which indicates that there may be areas of heart muscle that are not getting adequate blood supply.
Talk to about your cardiologist about a cardiac catheterization in order to clarify this. It may be possible that the cardiac catheterization fails to demonstrate any blockages and other therapies might need to be pursued. But at this time, this needs to be conclusively determined as this is a major but a easily fixable solution.
Once this question is answered, there is a possibility of considering a cardiac resynchronization therapy (CRT) in order to correct the ill effects of the left bundle branch block (LBBB), as this is likely to benefit you if you truly meet the criteria for this device.
In my opinion, there are certainly options which are likely to benefit you and probably improve the ejection fraction of your heart.
Hope that helps.
You clear have had extensive testing till date and have figured out a great part of the problem.
In order to re emphasize the main points, you have a drop in the ejection fraction of the heart to 21%. Normal ejection fraction is about 55%.
One of the most important causes of drop in ejection fraction is blockages in your coronary arteries. You have had a stress test which reveals multiple areas of "ischemia" which indicates that there may be areas of heart muscle that are not getting adequate blood supply.
Talk to about your cardiologist about a cardiac catheterization in order to clarify this. It may be possible that the cardiac catheterization fails to demonstrate any blockages and other therapies might need to be pursued. But at this time, this needs to be conclusively determined as this is a major but a easily fixable solution.
Once this question is answered, there is a possibility of considering a cardiac resynchronization therapy (CRT) in order to correct the ill effects of the left bundle branch block (LBBB), as this is likely to benefit you if you truly meet the criteria for this device.
In my opinion, there are certainly options which are likely to benefit you and probably improve the ejection fraction of your heart.
Hope that helps.
One more question if you dont mind - any thoughts one what underlying would be causing such effects (I suppose you have already suggested it could be blockage of coronary arteries - will definitely see that pursued).
I am generally very healthy - never get sick, Squat / bench press etc heavy weights with out chest pain or shortness of breath more than would be expected for the weight I am lifting, only issue I have is have trouble with distance cardio - walking for miles is fine but running / rowing / biking long distances is difficult. I am surprised that my results from the tests look so bad yet I feel as healthy as I have for years.
I am generally very healthy - never get sick, Squat / bench press etc heavy weights with out chest pain or shortness of breath more than would be expected for the weight I am lifting, only issue I have is have trouble with distance cardio - walking for miles is fine but running / rowing / biking long distances is difficult. I am surprised that my results from the tests look so bad yet I feel as healthy as I have for years.
Thank you for the reply. A few questions if you dont mind
1) Regarding Ischemia - it seems the imaging scan was unclear as to whether there was ischemia and lack of perfusion or not as contrast adjustment seemed to make it go away or am I reading that wrong (layman here)
2) Does the above conditions explain the grossly enlarged left ventricle - It appears to be about 2x normal. Could it have gotten this way because I exercise and it was the only way for the left ventricle to keep up with cardiac demand due to exercise ?
3) The doctor I saw wanted me on Beta Blockers and Ace Inhibitor - I am not a big fan of medicines if there is another solution and so she said she would wait till I saw some other specialists in arrhythmias etc - but in your opinion should I get on these ASAP - Canadian Medical system is slow and I may be months before appt with specialists.
1) Regarding Ischemia - it seems the imaging scan was unclear as to whether there was ischemia and lack of perfusion or not as contrast adjustment seemed to make it go away or am I reading that wrong (layman here)
2) Does the above conditions explain the grossly enlarged left ventricle - It appears to be about 2x normal. Could it have gotten this way because I exercise and it was the only way for the left ventricle to keep up with cardiac demand due to exercise ?
3) The doctor I saw wanted me on Beta Blockers and Ace Inhibitor - I am not a big fan of medicines if there is another solution and so she said she would wait till I saw some other specialists in arrhythmias etc - but in your opinion should I get on these ASAP - Canadian Medical system is slow and I may be months before appt with specialists.
ULTRASOUND
Left Ventricle is moderately dilated with global moderate to severe systolic dysfunction
Details
Patient is in sinus rhythm with a wide QRS complex
The left ventricle is moderately dilated. There is norm left ventricular wall thickness. Left ventricular systolic function is moderate to severely reduced in global patter (minor segmental variation is seen but predominant appearance is of global hypokinesis) Septal modon (sp- ineligible) is consistent with conduction abnormaity. There is no thrombus.
the right ventricle is normal in size and function.
The left atrium is borderline dilated. Right atrial size is normal. The IVC? is normal in size with normal respiratory response. Image quality is inadequate to exclude a minor inter cardiac shunt at the atrium level.
The mitral valve is normal in structure and function. There is trivial mitral regurgitation that is within normal limits. An accurate RVSP could not be obtained due ta poor tricuspid regurgitation signal.
The aortic valve is trileaflet. The aortic valve leaflets are thickend but not restricted in mobility. Ho Hemodynamically significant valvular aortic stenosis. There is no aortic regurgitation present.
The pulmonic valve is not well seen but is grossly normal in structure.
The aortic root is normal size. There is aortic root sclerosis/calcification. The pulmonary artery is normal size.
There is no pericardial effusion
Left Ventricle is moderately dilated with global moderate to severe systolic dysfunction
Details
Patient is in sinus rhythm with a wide QRS complex
The left ventricle is moderately dilated. There is norm left ventricular wall thickness. Left ventricular systolic function is moderate to severely reduced in global patter (minor segmental variation is seen but predominant appearance is of global hypokinesis) Septal modon (sp- ineligible) is consistent with conduction abnormaity. There is no thrombus.
the right ventricle is normal in size and function.
The left atrium is borderline dilated. Right atrial size is normal. The IVC? is normal in size with normal respiratory response. Image quality is inadequate to exclude a minor inter cardiac shunt at the atrium level.
The mitral valve is normal in structure and function. There is trivial mitral regurgitation that is within normal limits. An accurate RVSP could not be obtained due ta poor tricuspid regurgitation signal.
The aortic valve is trileaflet. The aortic valve leaflets are thickend but not restricted in mobility. Ho Hemodynamically significant valvular aortic stenosis. There is no aortic regurgitation present.
The pulmonic valve is not well seen but is grossly normal in structure.
The aortic root is normal size. There is aortic root sclerosis/calcification. The pulmonary artery is normal size.
There is no pericardial effusion
Diagnostic Test Results
I typed these in from a scan of a fax - so may be some errors.
Myocardial Perfusion Imaging Including post stress and rest injection images with ECG gating and attenuation correction using TCT.
Stress Test
Pharcologic stress with Pipyrimadole, followed by low level exercise for 3:00 minutes. No Chest Pain but ECG changes cannot be assessed in the presence of left bundle branch block
This is a challenging study to interpret due to Hereogeneity of Myocardial perfusion in a markedly dilated left ventrical. Myocardial perfusin imaging shows Moderate to severe fixed decreased perfusion in the inferior to inerolateral septal walls, much of which corrected after the application of atennuation correction with residual moderate fixed defect in the periapical region, uncertain if a true reading as attenuation correction introdcued demonstrate decreased perfusion to the anterior wall that is not present with filtered back reconstruction technique. Moderate fixed decreased perfusion in the mid cavity to basal septal wall and basal anterior wall. No definite reversible perfusion defect is seen. Perfusion to the lateral wall is best preserved. Global Hypokinesis.
Using the Emory Cardiac Toolbox, the left ventrical ejection fraction on the post stress injection images measures 0.21, based on an end-diastolic volume of 331 ml and an end systolic volume of 262 ml.
Impression
Challenging study to interpret but this is an abnormal study. Several areas of fixed decreased perfusion including periapica inferior, inferolaterla wall and basal anterior wall may represent ares o fsevere ischemia or nontransmural infarct. Fixed decreased perfusion in the mid cavity to basal septal wall may be of similar etiology but it can also be do to the left bundle branch block. Thallium scan may be helpful to assess for viability.
Markedly dilated left ventricle with markedly decreased systolic function raises prossibility for superimposed nonischemic causes including cardiomyopathy and valvular disease. CLinical and echocardiographic correlations may be helpful.
I typed these in from a scan of a fax - so may be some errors.
Myocardial Perfusion Imaging Including post stress and rest injection images with ECG gating and attenuation correction using TCT.
Stress Test
Pharcologic stress with Pipyrimadole, followed by low level exercise for 3:00 minutes. No Chest Pain but ECG changes cannot be assessed in the presence of left bundle branch block
This is a challenging study to interpret due to Hereogeneity of Myocardial perfusion in a markedly dilated left ventrical. Myocardial perfusin imaging shows Moderate to severe fixed decreased perfusion in the inferior to inerolateral septal walls, much of which corrected after the application of atennuation correction with residual moderate fixed defect in the periapical region, uncertain if a true reading as attenuation correction introdcued demonstrate decreased perfusion to the anterior wall that is not present with filtered back reconstruction technique. Moderate fixed decreased perfusion in the mid cavity to basal septal wall and basal anterior wall. No definite reversible perfusion defect is seen. Perfusion to the lateral wall is best preserved. Global Hypokinesis.
Using the Emory Cardiac Toolbox, the left ventrical ejection fraction on the post stress injection images measures 0.21, based on an end-diastolic volume of 331 ml and an end systolic volume of 262 ml.
Impression
Challenging study to interpret but this is an abnormal study. Several areas of fixed decreased perfusion including periapica inferior, inferolaterla wall and basal anterior wall may represent ares o fsevere ischemia or nontransmural infarct. Fixed decreased perfusion in the mid cavity to basal septal wall may be of similar etiology but it can also be do to the left bundle branch block. Thallium scan may be helpful to assess for viability.
Markedly dilated left ventricle with markedly decreased systolic function raises prossibility for superimposed nonischemic causes including cardiomyopathy and valvular disease. CLinical and echocardiographic correlations may be helpful.
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