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Forum Name: Heart Failure

Question: Pulmonary Arterial Hypertension due to Pulmonary Venous Htn


 dmamacher - Tue Dec 07, 2004 7:52 am

In the beginning of this year I had two mild strokes. Minimal damaged occurred. In September I was diagnosed with Pulmonary Arterial Hypertension (mild) and later learned that it was due to Pulmonary Venous Hypertension, left dystolic failure. Echo shows dialated left ventricle . The left ventricular end systolic diameter is 4.0 cm and the LVED is 5.8 cm. Ejection fraction is preserved at 60%. The left atrium is dialated at 4.4 cm. My physicians seemed very unconcerned over these finding although I continue to become more symptomatic.

My question is, is this something I should worry about. Other than diet, exercise and the meds that I'm already on, should there be more treatment? I've been told I was ok, just diet, exercise, quit smoking (of course) and come back next year. I'm on CCBs and read they are not good for heart failure patients. I certainly don't feel ok and seem to be slowly spiraling downward. I'm very concerned.
 Dr. Yasser Mokhtar - Tue Dec 07, 2004 11:24 am

User avatar Dear dmamacher,

The causes of diastolic dysfunction are:
1. Hypertension.
2. Aging.
3. Coronary disease.
4. Cardiomyopathy including:
a. Hypertrophic cardiomyopathy.
b. Restrictive cardiomyopathy caused by Infiltration of the heart muscles by abnormal substances.

You mentioned a few things only out of the echocardiogram report, but you did not mention the left ventricular different walls' thicknesses.

If you have thick walls, this could be secondary to hypertension which is one of the commonest causes of diastolic failure.

You are already taking an antihypertensive medication. It is a combined medication with a calcium channel blocker and an ace inhibitor. Personally, i don't like combination medications because sometimes you can not tritrate up to the maximum dose of each medication if needed, but if this what your primary care provider thinks is best for you, that's fine with me. The treatment of diastolic heart failure is treatment of the cause in addition to targeting the impaired relaxation and filling.

Certain types of calcium channel blockers are not sometimes good for heart failure patients because they decrease contractility but you have a good ejection fraction so there is noting to worry about from that point.

What are the symptoms that you have been developping that are making you concerned?

Please, stop smoking all together and be very compliant with your medications and your blood pressure (if it is high) has to be very well controlled.

Thank you very much for using our website http://doctorslounge.com and i hope that this information helped and waiting for your reply.

Yasser Mokhtar, M.D.
 dmamacher - Tue Dec 07, 2004 12:31 pm

Thank you for responding Dr. Mokhtar.

To answer your question, the left ventricular wall thickness and calculated mass index are normal.

What has me concerned is how I feel now. I fear the progression and wonder how bad it can get and still allow me to come to work. Just several months ago I was highly active. Even though I have been obese since I was 8 years old, I've always maintained high activity. But...It was like a switch was turned off. One day I woke up and all I could do was sleep. This is not an exageration. Even though the CCBs seem to give me some goods days now, I am short of breath on minimal exertion have extreme weakness at times. I also have periods of dizzyness where I feel that I will surely pass out. The palpatitions are getting worse with periods of pounding. Holter showed that I had PVCs with Bigeminy runs about two months ago. Also,during one 6 minute walk test my O2 went down to 81. During the next test at a different Dr's office, my Blood Pressure rose to 175/158. But, I completed the test with no periods of resting. I did not ask what my respiration rate was but it was high enough to cause around my lips to go numb.

I moved my 75 year old mother in with me 3 months ago. SHE has more stamina than I do on many days. She has emphysema and is on O2.

I know my body and can appreciate some changes due to aging, strain of weight, smoking etc. But this does not seem like a natural progression in the least.
 Dr. Yasser Mokhtar - Tue Dec 07, 2004 1:54 pm

User avatar Dear dmamacher,

Thank you very much for the update.

The easiest explanation to your symptoms is the lotrel. It is known to cause fatigue and somnolence.

There are other explanations though. What you are suffering from might not have anything to do with pulmonary hypertension and the pulmonary hypertension might have nothing to do with the left ventricular diastolic dysfunction that you have or there may be other factors contributing to the development of pulmonary hypertension.

What you are describing is very consistent with sleep apnea which is a condition that affects a large portion of the obese population. Please, talk to your doctor about this possibility and see what he thinks.

If your oxygen sats dropped during exercise, may be you need oxygen during exercise.

Patients who have pulmonary hypertension might be dependant on blood coming back to the heart to generate enough blood pumped out to the tissues and thus feeling that you have enough energy, so the 80 mg of lasix that you are getting might be a little bit too much for you.

Palpitations might be caused by the fact that your potassium level in the blood is low even though you are getting potassium and the lotrel has a medication that might increase the potassium level in the blood. i would recommend checking your electrolytes including magnesium, calcium and phosphorus and thyroid function tests.

Thank you very much for using our website http://doctorslounge.com and i hope that this information helped and waiting for your reply.

Yasser Mokhtar, M.D.
 dmamacher - Tue Dec 14, 2004 8:08 am

Well I finally had my sleep study and although I do not yet have the offical report, the tech told me that I did stop breathing during REM sleep and that my 02 dropped to 84%. I will get the official results when I see my Pulmonologist on the 11th of January. I imagine this explains my decline in to Left Diastolic Disfuntion and Pulmonary Hypertenstion.

I would like to pose another question. With Left Ventriclular End Diastolic diameter dialtated at 5.8, systolic diameter of 4.0 and left atrium dialated at 4.4, does this mean the diagnosis would be dialated cardiomyopathy? Or would it still be heart failure since my ejection fraction is normal?
 Dr. Yasser Mokhtar - Mon Dec 20, 2004 8:55 pm

User avatar Dear dmamacher,

Thank you very much for the update.

The upper normal diastolic diameter is 5.6 cm, i don't think that 0.2 cm is a great deal. About your left atrium, it is enlarged (most probably secondary to the diastolic dysfinction), and the only draw back is that some patients with left atrial enlargement develop atrial fibrillation (an abnormal heart rhythm) and it is sometimes difficult to cardiovert them back to a normal rhythm.

Regarding cardiomyopahty, it is a heart muscle disease associated with heart dysfunction. Distinction between various types of cardiomyopathy relies on the echocardiographic evaluation, the echo is a good tool to detect various types of cardiopmyopathy, in your case, if you have cardiomyopathy it is going to be of the dilated type since you have left ventricle dilatation. In the early stages of dilated cardiomyopathy, sometimes it is difficult for the echo to immediately spot dilated cardiomyopathy as it is usually able to. For the time being, i assume that you don't have cardiomyopathy as your ejection fraction is normal.

Having sleep apnea, causes hypertension and this in turn can cause diastolic dysfunction, so if you are diagnosed with sleep apnea, you will be offered some treatment options according to what your doctor sees of benefit and this will help in the control the high blood pressure and of the diastolic dysfunction as well.

If obesity is a problem, i think it is best to try losing weight as sometimes patients with mild sleep apnea get cured with weight loss.

Thank you very much for using our website http://doctorslounge.com and i hope that this information helped and waiting for your reply.

Yasser Mokhtar, M.D.
 dmamacher - Sun Aug 21, 2005 6:51 am

It's been some time since I've posted but I have an appointment with my Cardiologist and would appreciate some advice.

I am hoping this post will include my other history but briefly, I am 47 years old and have Pulmonary Arterial Hypertension due to Pulmonary Venous Hypertension, Left Diastolic Dysfunction. I can add to the other posts that my Sleep Study revealed that I had extremely mild Sleep Apnea which the Pulmonologist decided was not significant enough to warrant treatment.

I've been wearing a 30 Day Event Monitor due to PVCs. My Cardiologist's office called and said they've found "a lot of PVCs with bigeminy, trigeminy and Inappropriate Sinus Tachycardia".

My question would be, should Inappropriate Sinus Tachycardia be considered when my Left Atrium is 4.6 cm? And would you please advise me of questions that I could ask my Cardiologist during my visit or tests that should be considered under these circumstances? I can not take Beta Blockers due to a history of allergy to this medication.

I appreciate your time.

Diane
 dmamacher - Sun Aug 21, 2005 6:56 am

Correction to my post.....Left Atrium measured 4.4 cm during my Heart Cath in 2004.
 Dr. Yasser Mokhtar - Tue Nov 01, 2005 4:14 pm

User avatar Dear Diane,

Thank you very much for the update.

i don't think that there is a relation between your mildly enlarged left atrium and inappropriate sinus tachycardia.

Chronic inappropriate sinus tachycardia has been described in otherwise healthy persons, possibly secondary to increased automaticity of the sinus node (the pacemaker of the heart) or an automatic atrial focus located near the sinus node. The abnormality can result from a defect in nerve control of sinus node.

Treatment of inappropriate sinus tachycardia requires beta blockers, but since you are allergic, calcium-channel blockers, or digitalis, alone or in combination can be tried. In severe cases, sinus node radiofrequency or surgical ablation may be indicated.

If your cardiologist is not an electrophysiologist (cardiologist specialized in arrhythmias), may be you can ask him if it is worth it for you to be evaluated by one.

If most of the arrhythmias occur by night, and if you gained some weight, may be your sleep apnea has gotten worse and you need to be treated for it.

If you have not had a thyroid profile, i think it is a good idea to have one done.

If still, a definitive cause for the pulmonary hypertension is to be found, and if you have a history of smoking, may be a lung function test is in order.

Thank you very much for using our website http://doctorslounge.com and i hope that this information helped.

Yasser Mokhtar, M.D.

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