Post on 01-May-2020
War Story: Cardiac Anita Ralstin, CNP
Intro
20+ year old male Severe dilated cardiomyopathy ◦ EF 20-25%
Initial presentation in ER 11/14/2009 ◦ Hospitalized for CHF
Hospitalized 1/5/10; 2/18/10; 4/16/10; 5/19/10; 7/21/10
Patient Symptoms On Presentation
Shortness of breath Chest pain, nonexertional Swelling Fatigue Feeling “out of it” with dizziness Orthopnea PND
Physical Findings
Obese young man Hypotensive, orthostatic drop in BP Severe 3+ edema to the hip and in the
pannus Weeping ulcers of the legs BP 118/78, HR 110 Admit weight 530
Co Morbidities
Morbidly obese ◦ 70 inches and 550 pounds
Back Pain Chest Pain Ventricular Tachycardia
Issues Frequent hospitalization for CHF
exacerbation Medication intolerance ◦ Dizziness ◦ Hypotension
Diet noncompliance Not accepting diagnosis Not understanding implications Social/family support
Clinical Reality
Severe Dilated Cardiomyopathy Frequent hospitalizations due to
medication intolerance and dietary non compliance
Obesity Unable to exercise, cannot walk 50 ft. Weeping ulcers of the legs ?Hopelessness/?Depression
Right Focus
Face the hard facts ◦ Obesity limits options for transplant ◦ Heart condition limits options for weight loss
surgery ◦ Sodium intake has to be priority ◦ Heart is weak and needs BB, ACE-I to
improve heart function
Hypotension
He would stop taking carvedilol and lisinopril due to dizziness. ◦ Midodrine 5 mg added TID to stabilize BP ◦ Continued midodrine while starting low dose
carvedilol. ◦ Gradual increase in medications ◦ Midodrine dose has been reduced, but cannot
tolerate stopping ◦ Carvedilol 25 mg BID, no ACE-I
Sodium Restriction
Was eating potato chips and many other salty foods. Mother would bring to hospital. ◦ The frank discussion with both mother and
son changed behavior
Edema Weeping ulcers ◦ Continues on diuretic dose ◦ Greatly improved with reduction in sodium
intake ◦ Venous US showed venous incompetence Vascular surgery consult Edema clinic at Health South Completed program
Edema currently well managed ◦ He has ankles!
Activity Intolerance
At onset of symptoms unable to walk 50 ft
Started with 1-2 minutes of walking per episode
Gradual increase Now walking 30 minutes at a time. Feels “free”
Obesity Initial weight: 515 pounds ◦ Extensive fluid overload ◦ Obesity ◦ Limited work up Unable to do nuclear stress test or cardiac cath.
Current weight ~ 400 pounds ◦ Exercise and diet change ◦ Edema control ◦ Considered for bariatric surgery. Cost an
issue.
Sudden Death Prevention
Echocardiogram 1/11 ◦ EF 30-35%
History of ventricular tachycardia ICD placed for primary prevention
It Takes a Village
Cardiology Family PCP Home Health Vascular surgery and Health South Electrophysiology Bariatric surgery