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