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  • pulmonary edema w/o swollen feet & hands?

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    Old 11-08-2003, 10:15 AM   #1
    ol'lady
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    Unhappy pulmonary edema w/o swollen feet & hands?

    My dad has chf. He's gotten along fine until recently. Now he is weak, out of breath when doing anything but sitting around, can't sleep (but says he doesn't have a problem with breathing when lying down), and has lost his appetite and is losing weight. He went to his general dr last week. He listened to his lungs, and his heart, did an ekg, did a chest x-ray, and said everything seemed fine. He then told him to ask his heart dr about it in a couple of weeks when he goes.

    I thought he probably has some fluid in his lungs causing him to feel bad. I have encouraged him to up his lasix a little. The heart dr told him he could adjust it as he felt he needed to. Could he have some fluid, enough to make him feel bad and it not show up as swelling in extremeties, and even not noticeable when the dr listened to him breathe? Could a little extra fluid also not show up in a chest x-ray? I am so worried about him. It breaks my heart to see him not able to do anything and feel so bad.

    Thanks so much for any of your opinions!

     
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    Old 11-08-2003, 10:27 AM   #2
    docrum
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    Quote:
    Originally Posted by ol'lady
    My dad has chf. He's gotten along fine until recently. Now he is weak, out of breath when doing anything but sitting around, can't sleep (but says he doesn't have a problem with breathing when lying down), and has lost his appetite and is losing weight. He went to his general dr last week. He listened to his lungs, and his heart, did an ekg, did a chest x-ray, and said everything seemed fine. He then told him to ask his heart dr about it in a couple of weeks when he goes.

    I thought he probably has some fluid in his lungs causing him to feel bad. I have encouraged him to up his lasix a little. The heart dr told him he could adjust it as he felt he needed to. Could he have some fluid, enough to make him feel bad and it not show up as swelling in extremeties, and even not noticeable when the dr listened to him breathe? Could a little extra fluid also not show up in a chest x-ray? I am so worried about him. It breaks my heart to see him not able to do anything and feel so bad.

    Thanks so much for any of your opinions!
    pulmonary oedema will show up on CXR. heart failure isn't just congestion tho, just low cardiac output will cause symptoms. increasing the lasix can actually make things worse in this situation by decreasing cardiac output further

     
    Old 11-08-2003, 10:30 AM   #3
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    Quote:
    Could he have some fluid, enough to make him feel bad and it not show up as swelling in extremeties, and even not noticeable when the dr listened to him breathe?
    Usually, if someone is short of breath because of fluid, you'll be able to hear crackles at the bases when listening with a stethoscope....it should also be kept in mind that there are other things that can cause shortness of breath, and that includes things like pneumonia! Swelling in the extremeties doesn't necessarily have to come if you only have minor left heart failure...the SOB will come first.
    Quote:
    Could a little extra fluid also not show up in a chest x-ray?
    Yes...but normally, if someone is in failure, you'll see changes on the x-ray consistent with pulmonary edema (which is not the same as fluid)....if your dad has CHF, then I'm sure the x-ray probably showed pulmonary edema, which the doctor saw, realized it was no different than x-rays in the past and probably will do what you suggested--up the lasix. What dose is he on right now? 80mg/day?

     
    Old 11-08-2003, 11:01 AM   #4
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    Quote:
    Originally Posted by docrum
    pulmonary oedema will show up on CXR. heart failure isn't just congestion tho, just low cardiac output will cause symptoms. increasing the lasix can actually make things worse in this situation by decreasing cardiac output further
    Hey docrum...what's up? I agree with everything you said but the lasix thing. Lasix won't make things worse if someone has pulmonary edema as long as you don't totally dehydrate them with huge doses of it. Lowering the cardiac output is one of the mainstays of CHF treatment as it takes the workload off the heart...which is the reason they give things like beta blockers, which are actually slowing DOWN the heart rather than helping it pump.

     
    Old 11-08-2003, 11:05 AM   #5
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    Quote:
    Originally Posted by butterflytrans
    Hey docrum...what's up? I agree with everything you said but the lasix thing. Lasix won't make things worse if someone has pulmonary edema as long as you don't totally dehydrate them with huge doses of it. Lowering the cardiac output is one of the mainstays of CHF treatment as it takes the workload off the heart...which is the reason they give things like beta blockers, which are actually slowing DOWN the heart rather than helping it pump.
    Actually....lowering the cardiac output is bad if the person has CHF as well as renal failure.

     
    Old 11-08-2003, 11:32 AM   #6
    ol'lady
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    Gosh, thanks for the speedy replies! He was taking 120 mg (60 2x a day) until last Jan. He fainted at church and ended up in the hospital. He has a pacemaker and they adjusted its range (this was the main cause of his lightheadedness) and also some of his meds as well. They brought the lasix down to 60mg (30 2x a day). Because of the strenghth of the tabs - he said it was easier to just take 40mg 2 x a day- and this is what he's been doing. But dr told him he could adjust this if he noticed swelling. He had done fine until this summer, he had some kind of a virus, which kept him down for about 3 weeks. And he hasn't felt as well since. He's even felt worse for the last few weeks. He doesn't sleep hardly at all. Dr gave him ambien, but its not working very well.

    My idea was-- since he is not as active now (because he isn't sleeping, and doesn't feel well) he probably has poorer circulation, and probably has a little fluid accumulated in his lungs. (I thought this was pulmonary edema! Shows how little I know.) But I don't want to be the cause of making things worse. I just thought the extra 20 mg 2 x a day wouldn't be a drastic change, but could make him feel better if fluid was the cause. He had a really bad problem with fluid after a valve replacement back in 1999- in hospital with pneumonia for 2 months after surgury. They put pacemaker in and after about a year of changing meds he improved greatly. He's 77.

     
    Old 11-08-2003, 12:17 PM   #7
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    Quote:
    Originally Posted by butterflytrans
    Actually....lowering the cardiac output is bad if the person has CHF as well as renal failure.
    if you don't have pulmonary oedema as seems to be the case in this scenario it definetely can make things worse.

    I wouldn't say lowering cardiac output is the mainstay of heart failure treatment. lowering systemic vascular resistance is, reducing intra vascular volume is, but reducing cardiac output not. betablockers work by reducing O2 consumption by the myocardium, upregulating adrenoceptors etc. in the long term beta blockers increase cardiac output!

     
    Old 11-09-2003, 07:33 AM   #8
    ol'lady
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    I've read that with left sided heart failure, often the first sympton is shortness of breath. Only when it eventually affects the right side also do you see swelling in the extremeties. I still think he is getting some fluid retention in his lungs, not a lot, but enough to bother him when exerting very much. I was just hoping it would be enough for his general dr to notice in the chest x-ray and do something about it. He did so well for a couple of years taking the lasix at 120 mg/day, I didn't think upping it 20 mg twice a day to get it back up to this level would be dangerous- as long as he's watching for signs of dehydration. Oh, lord - it's my job to worry!! Thanks for the info!

     
    Old 11-09-2003, 08:03 AM   #9
    spirlhelix
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    A question about Beta Blockers

    I see someone here knows a bit about beta blockers. Hi, Docrum. Can you answer a question for me?

    I have recently been diagnosed with, strange to say, hypertensive cardiomyopathy, severe left ventricular diastolic dysfunction, severe heart failure, Class 1, Stage 4. I've only had hypertension for three years. In that time, I've tried a lot of medications for hypertension, and I know there are a number I can't tolerate. One is beta blockers. The pharmacy refuses to fill a prescription for Coreg for me (which is fine with me, as all the other beta blockers make me want to throw myself out a window within hours of taking them). I think my intolerance of beta blockers and the significant structural damage to my heart are why I'm classified as end stage, even though I don't have noticable symptoms of CHF.

    So what other treatment options are available to CHFers who do not tolerate Beta blockers? Spironolactone is new to me and is the first medication to actually bring down my blood pressure without significant side effects. All the statistics say that beta blockers are the treatment of choice because they prolong life expectancy for CHFers. Spironolactone has also been shown to have this effect. So does are betas are still preferable, even though this other medication seems to work for me?

    Thanks for your thoughts!

    Pam

     
    Old 11-09-2003, 08:33 AM   #10
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    Quote:
    Originally Posted by ol'lady
    I've read that with left sided heart failure, often the first sympton is shortness of breath.
    You're absolutely correct!
    Quote:
    Only when it eventually affects the right side also do you see swelling in the extremeties.
    You are absolutely correct again! The most common cause of right heart failure is left heart failure!
    Quote:
    I still think he is getting some fluid retention in his lungs, not a lot, but enough to bother him when exerting very much. I was just hoping it would be enough for his general dr to notice in the chest x-ray and do something about it.
    I'm not sure to what extent this doctor examined your father, but like I said before, his x-ray probably does show pulmonary edema, it just wasn't any better or worse from the last time he saw the x-ray.

     
    Old 11-09-2003, 08:40 AM   #11
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    Quote:
    if you don't have pulmonary oedema as seems to be the case in this scenario it definetely can make things worse.
    Good point...but we can't say that there is no pulmonary edema 'cause we haven't seen the x-ray.
    Quote:
    I wouldn't say lowering cardiac output is the mainstay of heart failure treatment. lowering systemic vascular resistance is, reducing intra vascular volume is, but reducing cardiac output not.
    Good point. Sorry, I know what I wanted to say, but it came out wrong..you are clearly correct. I should have just left it at it lowers the workload of the heart (which at first can lower cardiac output, but obviously not in the long run)
    Quote:
    betablockers work by reducing O2 consumption by the myocardium, upregulating adrenoceptors etc. in the long term beta blockers increase cardiac output!
    Ahh, I didn't even see that you had written this. I totally agree. The thing is, though, Betablockers are slowing the heart down as well as reducing the stroke volume. By itself, it has the effect of lowering CO...the thing is though, obviously you're not just using beta-blockers for the treatment.

    Another interesting thing about CHF that it has in common with cirrhosis and nephrotic syndrome is that the intravascular volume is high, but the body (especially the kidneys) sees this as an apparent LOW intravascular volume because of a "flabby vasculature tree". So it's important that you take the kidneys in to account when treating.

     
    Old 11-09-2003, 08:48 AM   #12
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    Quote:
    Originally Posted by spirlhelix
    I see someone here knows a bit about beta blockers. Hi, Docrum. Can you answer a question for me?

    I have recently been diagnosed with, strange to say, hypertensive cardiomyopathy, severe left ventricular diastolic dysfunction, severe heart failure, Class 1, Stage 4. I've only had hypertension for three years. In that time, I've tried a lot of medications for hypertension, and I know there are a number I can't tolerate. One is beta blockers. The pharmacy refuses to fill a prescription for Coreg for me (which is fine with me, as all the other beta blockers make me want to throw myself out a window within hours of taking them). I think my intolerance of beta blockers and the significant structural damage to my heart are why I'm classified as end stage, even though I don't have noticable symptoms of CHF.

    So what other treatment options are available to CHFers who do not tolerate Beta blockers? Spironolactone is new to me and is the first medication to actually bring down my blood pressure without significant side effects. All the statistics say that beta blockers are the treatment of choice because they prolong life expectancy for CHFers. Spironolactone has also been shown to have this effect. So does are betas are still preferable, even though this other medication seems to work for me?

    Thanks for your thoughts!

    Pam
    I know that I'm not docrum, but since (s)he hasn't answered yet, I'll take a stab at this. There is something you said that is interesting when you mentioned that beta-blockers were the treatment for CHF. That is not totally true...the treatment of CHF requires more than one medication--especially in the end stages as you describe yourself to be in. The different drugs which have shown to reduce mortality are:

    spironolactone
    beta blockers
    ACE inhibitors or angiotensin-receptor blockers

    digoxin has been shown to reduce hospital visits and the hospital stay, but it doesn't have an effect on mortality.

    other drugs that are used for symptomatic control are:

    lasix, dihydropyridine calcium channel blockers (if there is no renal failure) etc.

    In terms of blood pressure medication, which is a little different, the recommendations in Canada is that the person be put on a beta-blocker (usually metoprolol here) or calcium channel blocker (amlodipine) or thiazide diuretic plus either an ACEi (usually ramipril) or an ARB (candesartan).

    I am surprised that you're only on one medication as there are a lot of them out there that should be used to treat your condition.

    When you say that you can't tolerate beta-blockers, what do you mean? How do you actually feel?

    The spironolactone is generally well tolerated by patients as I've seen, except it can cause breast growth in men! ACE inhibitors are also fairly well tolerated, though sometimes patients get a cough when they're on it. So I definitely think you should ask about these drugs to your doctor.

     
    Old 11-09-2003, 10:16 AM   #13
    spirlhelix
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    Bad reaction to Beta blockers

    Hi, Butterflytrans

    I have bad reactions to multiple drugs, and I am currently on spironolactone, diovan, and imdur. Beta blockers make me so suicidal that I become incoherent, sobbing inconsolably and obsessed with a method of killing myself. That's why I said they make me want to jump out a window. Literally. This within an hour or two of the *first dose* for water-soluble beta blockers. The fat-soluble just make me nearly comoatose for the first week, then I become suicidal after a week or so. My cardiologist told me I was at 50% risk of falling down dead in the next year without beta blockers. I told him I was at 99% risk of killing myself in a day while on them. And since the pharmacy refuses to fill them for me because of my history, it's a moot issue.

    I have glomerulonephritis: so far no one mentioned calcium channel blockers, so perhaps that is why they are not considering them. ACEs give me a cough, which compared to suicidal ideation is a perfectly laughable adverse reaction, but no one has thought of putting me on them.

    I was trumpting the spironolactone (50) because it's the only thing that has touched my blood pressure. In the last month, my BP has averaged 197/120. Even on Diovan 360 daily. I also take Imdur 30 ext. And so far, spironolactone is the only thing that has helped. My heart rate is down from average 110 to average 89. It's still coming down, and today it was 64.

    Another wierd thing is that some medications to treat heart failure are titrated according to symptoms, but I don't have any symptoms. Class one. So that's not an issue for me.

    Interested to hear your thoughts--if spironolactone works for me, but not beta blockers, am I still at high risk?

    Last edited by spirlhelix; 11-09-2003 at 10:18 AM.

     
    Old 11-09-2003, 01:41 PM   #14
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    Quote:
    Originally Posted by spirlhelix
    Hi, Butterflytrans

    I have bad reactions to multiple drugs, and I am currently on spironolactone, diovan, and imdur. Beta blockers make me so suicidal that I become incoherent, sobbing inconsolably and obsessed with a method of killing myself. That's why I said they make me want to jump out a window. Literally. This within an hour or two of the *first dose* for water-soluble beta blockers. The fat-soluble just make me nearly comoatose for the first week, then I become suicidal after a week or so. My cardiologist told me I was at 50% risk of falling down dead in the next year without beta blockers. I told him I was at 99% risk of killing myself in a day while on them. And since the pharmacy refuses to fill them for me because of my history, it's a moot issue.

    I have glomerulonephritis: so far no one mentioned calcium channel blockers, so perhaps that is why they are not considering them. ACEs give me a cough, which compared to suicidal ideation is a perfectly laughable adverse reaction, but no one has thought of putting me on them.

    I was trumpting the spironolactone (50) because it's the only thing that has touched my blood pressure. In the last month, my BP has averaged 197/120. Even on Diovan 360 daily. I also take Imdur 30 ext. And so far, spironolactone is the only thing that has helped. My heart rate is down from average 110 to average 89. It's still coming down, and today it was 64.

    Another wierd thing is that some medications to treat heart failure are titrated according to symptoms, but I don't have any symptoms. Class one. So that's not an issue for me.

    Interested to hear your thoughts--if spironolactone works for me, but not beta blockers, am I still at high risk?
    Interesting, interesting. You are still at high risk 'cause it sounds like you still have high blood pressure. Interesting also that you have a GN...what type of glomerulonephropathy do you have? Is it focal segmental glomerular sclerosis? Since you have renal problems, they'd have to put you on a "NON-dihydropyridine" calcium channel blocker...so that would be either verapamil or diltiazem. So you said you had a cough on ACEis eh? I noticed you're on an ARB (the Diovan) so that's good for your CHF, but I'm not sure if you're supposed to be on it if you have any degree of renal failure. How have your renal function tests looked like?

    So it looks like you're on a number of medications to help you with your CHF...here's one thing that I'm confused by. Well, two things....do you know if you have systolic or diastolic heart failure? If you're asymptomatic, how did they know that you had heart failure in the first place? What is your ejection fraction from the echo?

     
    Old 11-09-2003, 05:10 PM   #15
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    More Facts

    Oh, I forgot to say my blood pressure for the past week has averaged 132/89. Today, it was 121/78. After three years of not budging down to a normal reading on anything, I'm very impressed with spironolactone.

    My glomerulonephropathy is viral. I have recovered from the virus itself, and my kidneys are left with mild scarring. My renal numbers look good right now, which seems wierd to me, in light of my heart's rapid deterioration in the past three years, ostensibly due to hypertension. My last serum creatinine was 1.2, and my proteinuria was under 500. I have been on verapamil before, but it did nothing for my blood pressure, so after trying it in combination with various other medications, it was eventually replaced with something else.

    According to my echocardiogram, I have both diastolic and systolic dysfunctions. Here were the findings:

    COMMENTS:

    1) The left ventricle chamber is dilated.

    2) The right ventricle is mildly dilated.

    3) There is borderline concentric LVH.

    4) The left atrium is enlarged.

    5. The global LV systolic funtion is severely reduced. Ejection fraction estimated at about 20% or less.

    6) The mitral valve is thin and mobile. There is moderate to severe mitral regurgitation. The pulmonic valve is thin and mobile. There is no aortic stenosis or mitral stenosis.

    7) The tricuspid valve is associated with mild tricuspid regurgitation though structually normal. This estimates an RV systolic pressure probably about 50-55 mmHg which is modreately to severely elevated.

    8) Technically this study is adequate for interpretation.

    CONCLUSIONS:

    1) Severe LV systolic dysfunction with chamber dilatation in a pattern which is questionable for ischemic cardiomyopathy but is not clear-cut. There are no obvious clear-cut wall motion abnormalities but there is some suggestion of a wall motion abnormality involving the septum.

    2) The septal abnormality could be due to the pateint's pulmonary hypertension which is moderate to severe.

    3) There is left atrial dilatation, left ventricular chamber dilatation.

    4) The mitral inflow signal is abnormal consistent with diastolic dysfunction.

    The cardiogram was done three weeks later and seems more normal in several respects.

    Interesting question about learning about my heart problems without symptoms.

    The reason I had an echocardiogram despite the lack of symptoms was because I'm an astrologer. I ran a chart to see if I was healthy enough to go back to work, and it indicated I was (or would be soon) quite sick. I had very few symptoms, and most of them sounded like anxiety, so I focussed on the one thing that I figured would have them do a thorough workup: I've had a fever for three years. Usually low-grade, but it never went away until I started on spironolactone. So I requested a workup for fever.

    I know that there is an early phase of heart failure that is asymptomatic. I ran the chart when the Moon, which shows the disease process, was at 00 of Capricorn, indicating I was just at the beginning of the disease process. That's how I got diagnosed without symptoms.

    In the process of the workup for fever, I had a chest x-ray that showed an enlarged heart. Within a week, I was in the ER for a hypertensive episode (as usual, no symptoms--BP of 260/180 was caught at a doctor's office and they insisted I go to the ER) and they ran an electrocardiogram. The verified that an echocardiogram was in order, and you can see the results above.

    Strange but true.

     
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