A 67-year-old patient with HTN, hyperlipidemia, and an EF of 45% comes to your office for a second opinion. He had an exercise test and was told that his HR recovery was abnormal. His physician told him not to worry unless his heart function deteriorates. He is not convinced and wants your opinion and treatment.
What should you recommend?
Abnormal HR recovery predicts mortality in all patients; however, there is no treatment. A delayed decrease in HR after exercise or an abnormal HR recovery predicts all-cause mortality in healthy adults and in patients referred for exercise testing—independent of ischemia. However, at this time, there is no treatment to improve abnormal HR recovery.
A 41-year-old man presents to the CCU with CHF symptoms. On examination, he has elevated neck veins, severe peripheral edema, and S3 gallop. He is started on medication and has improvement in all of his symptoms. He has a PET scan, which shows a large area of hibernating myocardium. His cardiac catheterization reveals mild disease in the right coronary artery, a focal 80% lesion in the circumflex, and a focal 70% lesion in the LAD. All of his lesions are type A American College of Cardiologists/American Heart Association score. His EF is 15%.
According to randomized clinical trials, which of the following is the best treatment for this patient?
CABG. This patient has left main trunk equivalent with low EF. He is a candidate for CABG with left internal mammary artery to the LAD. CABG will prolong his long-term survival compared with PTCA/stent.
A 28-year-old woman comes to your office for a second opinion. She had peripartum cardiomyopathy and wants to get pregnant again.
You obtain a TTE, which shows a normal LV. What should you recommend?
She should undergo exercise testing for better assessment. Recurrent peripartum cardiomyopathy occurs in 20% of patients with normal resting LV function but abnormal stress ventricular response. Recurrent peripartum cardiomyopathy with decompensation occurred in 41% of patients with abnormal resting LV function.
A 78-year-old retired federal judge comes to your office for follow-up. He has long-standing HTN and has undergone PTCA/stent for a mid-LAD lesion. He has normal LV function and is active and healthy. Currently he is on ramipril (Altace), atorvastatin, and aspirin. He heard on television that the combination of aspirin and ramipril increases mortality.
He wants your opinion. What is your answer?
Although this has been seen in retrospective trials, it has not been validated in a randomized trial; therefore, continue the current regimen. In a substudy done by the Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto Miocardico, aspirin did not decrease the mortality benefit of lisinopril after MI or increase the risk of adverse clinical events. There have been some retrospective studies to assess this question that have had conflicting results; therefore, it is best to stay with the current regimen.
A 56-year-old man with dilated cardiomyopathy with an EF of 15% comes to your office for an opinion regarding medication. He is in NYHA class II and wants to know about biventricular pacing. He heard on television news that this may save lives. His ECG shows a sinus rate of 71, a PR interval of 210 milliseconds, a QRS duration of 188 milliseconds, and a QT/QTC of 364:427 milliseconds.
Refer the patient for biventricular pacing based on QRS duration. Patients with QRS duration greater than 150 to 160 milliseconds derived the greatest benefit from biventricular pacing.
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