What next?

[jbann1]

Have had a scare with my dad, 80 years. He lives in a small town and his docs have either been on vacation or too busy and can't fit him in. Response is slow. Bypass surgery 24 years ago in a different city. Heart attack 26 years ago. Routine cardiac care-doesn't miss appointments. Admitted to ER 2 wks ago with terrible edema in lower extremities. Went to ER because docs (internist and cardio) out of town and said couldn't see for 2 weeks- They called in 20 mg Lasix 1xday, which was useless. Edema alarming so took to ER on a Friday night. ER did ecg and upped lasix to 40mg 1x day. ER report says no CHF. ER doc insisted cardio see him following Monday, where they did an echo, which led to diagnosis of atrial flutter. EF was 25-35. Had ablation last Friday. During consult surgeon said heart rate too low (46-50) and said he wished my dad been referred to him 3 months ago. He now has to go back to his cardio in a couple of days for another ecg.

Should he insist on a follow up echo?

Before the ablation surgeon said wait till January and re-assess for possible heart defib-pacemaker.  If this device can help, why the wait until January?

They left him on lasix, started him on coumadin.  Also, when I asked during the post surg consult if he had CHF, the answer was "I don't know-he should talk to his doctor."  Does any of this suggest CHF?

Thank you so very much. Getting attention and answers about something I have no knowledge of has been overwhelming, and the lack of response is frustrating and sad.

[CCFCardio MD1]

I am sorry you have had such a frustrating experience.   Based on the information provided, your father has impairment of heart function (EF = ejection fraction = fraction blood pumped out of the heart with each beat; normal EF is >50%).  This is termed systolic heart failure.

Congestive heart failure is fairly general term used to refer to variety of conditions that impair normal heart function.   Physicians have begun to move away from a diagnosis of "congestive heart failure" because it is too broad of a term.

I would do the following for a similar patient in my office:

1. Make sure the patient is on a proper medication regimen for systolic heart failure - this is an individualized process that need to be done with a cardiologist.

2. Repeat the echocardiogram to see if medications have helped improve his heart function (with the right medications, heart function can improve).  If the heart function has indeed improved, then a cardiac defibrillator is usually not beneficial.

3. If the heart function does not improve after using appropriate medications, then consider using a cardiac defibrillator.  This is a highly individualized decision and not all patients may benefit from a implantable cardiac defibrillator and in fact may be harmed by it.  That is why reassessing the heart function after appropriate medication treatment is important.

If you feel that your not getting the desired care or responsiveness, then I recommend seeking a second opinion, perhaps from a referral center.

[jbann1]

Thank you for responding.  We are still frustrated with the cardiologists office and are feeling ignored. So I would like to know your opinion on the following:  If this were your patient, how soon after the ablation would my dad have (or have had) the followup echo?  He did have a followup appointment with a nurse practitioner (we went expecting to see his cardio, only finding out when we got there that it wasn't to be).  No echo was done.  His heart rate was better-it was 53.  She said that because his heart rate improved he wouldn't qualify for insurance for a defibrillator pm-that he would have to experience a heart "event" in order for insurance to pay for it.  It sounded like she was saying he would have to die before he would qualify-and with luck his heart would respond to defibrillation intervention-then he could have a pm. I know I'm all over here-it would be helpful if you could tell me what, in your experience, would the criteria have to be in order for him to qualify for a deify pm?  (range of EF and heart rate).  Also, if they wont pay-how much would this cost us out of pocket?  You advised a second opinion and the family agrees, but my dad is so worn out from this experience that he is too weary to be put through it all again. He says he just wants his cardio to treat him (but he agress that the care is lacking and negligent) but is too tired to go to another city and start all over with someone else.  My dad is in central Indiana.  If we could get him to Cleveland Clinic, how long would it take for him to get an appointment?  I thank you so very much for any information you can give my family.  We are trying to help but he is growing weaker and more despondent. He is a giving man, and has been a vital hospice volunteer in his community forever, yet he can't seem to catch a break for himself..His internist recently confided to my family that the cardio group who cares (I use that term loosely) for my dad has a reputation for "passing the buck". Any info you can provide to help us out of this purgatory would be appreciated far more than I can tell you.