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Archives
  1. Coreg with low BP and heart rate - from Bill D, 1/15/01
  2. Coreg and Diabetes - from Janet, 1/12/01
  3. How are EF numbers related to how we feel? - from Anna, 1/19/01
  4. Questions about exercise - from Sandra, 2/24/01
  5. Inherited heart problems, testing children - from Vicki, 2/14/01
  6. After recovery from CHF, how hard can we work when going back to our job? - from Peggy, 2/24/01
  7. Some news from the 2001 ACC Conference in Orlando, Florida, USA - from Dr. Marc Silver, 03-30-01
  8. Why are my numbers good but I feel bad? - from Joe L, 3/12/01
  9. Must my drug doses be high if I feel good at lower doses? - from Cheri S, 3/24/01
  10. Does Coreg lower Vo2max results? & more - from John D, 3/11/01
  11. Kidney function, dopamine & more - from Linda 3/24/01
  12. Edema in abdomen - - from Charlotte H 2/12/01
  13. Does a saline IV cause problems for a CHFer? - from Bill D 4/4/01
  14. Low EF patients and cardiac rehab: what target heart rate? - from Stephanie 3/31/01
  15. ACE inhibitors versus ARBs relating to potassium - from David A, 2/26/01
  16. Does heart enlargement mean heart failure is on its way back? - from Robin L, 5/3/01
  17. Steadying Coumadin levels - from William B, 2/27/01
  18. Will CoQ10 help me, hurt me, or be a waste of money? - from Cristina, 5/3/01
  19. Can stopping digoxin (Lanoxin) slow a CHFer down? - from Lee, 3/30/01
  20. How can I be absolutely certain I have edema? - from Earl, 4/29/01
  21. CHF and anemia - from Patty, 2/26/01
  22. How to get rid of fluid buildup? - from Christy, 3/4/01
  23. Are public pools too risky? - from Richard B, 6/6/01
  24. What qualifies one for home oxygen? - from Bailey, 6/6/01
  25. What do you think of EECP? - from Claudia, 6/6/01
  26. Pain, CHF, CHF meds, and sleeping difficulties - from Alice, 3/29/01
  27. Can you have both DCM and ischemic CM? & more - from Judy, 6/29/01
  28. Can pulmonary hypertension be successfully treated? - from Barry W, 6/18/01
  29. Can a person be allergic to a stent? - from Roxie, 3/5/01
  30. Fluid in the abdomen - what to do? - from Sylvia, 3/301
  31. Diastolic dysfunction - from Electra, 3/2/01
  32. Cath versus echo for EF measurement accuracy; wheezing and Coreg - from Mike J, 3/12/01
  33. Was it Scarlet Fever? - from Debbie, 3/11/01
  34. Questions about IV therapies for CHF - from Alex, 3/16/01
  35. My EF is now high - why do I still have CHF (symptoms)? - from Gail, 3/9/01
  36. Diastolic dysfunction treatment versus systolic dysfunction treatment - from Ruthie A, 3/6/01
  37. Could I have CHF? - from Pat, 6/28/01
  38. Missing drug doses - from Patti Brader, 6/2/01
  39. What do you think about external defibrillators? - from Don B, 7/2/01
  40. Standing up does me in. Do I have options? - from Brandy, 7/4/01
  41. CHFers sweating buckets - from Claudia S, 7/12/01
  42. I am worried and don't understand - from Kym, 7/18/01
  43. Is sex safe? - from Doug, 5/15/01
  44. Is yoga safe for CHFers? - from Claire E, 5/22/01
  45. How should an EMT (emergency medical technician) react to acute heart failure patients? - from Jeffrey, 7/28/01
  46. How can I relieve my son's puffiness? - from Lisa, 8/6/01
  47. Coxsackie virus tests question - from Tracey, 8/8/01
  48. Serious loss of appetite - from Cheryl, 5/8/01
  49. Amiodarone versus EPS - from Amelia, 5/28/01

Dr. Silver's Answers

 Bill D - If I cannot tolerate Coreg or cannot take a dose high enough to make my doc happy due to low blood pressure and/or low heart rate, is a pacemaker implant justified to get me with the Coreg program? Is this in the literature? Should such CHFers just cut way back on Coreg instead?

Dr. Silver - One of the most important advances in heart failure care has been the widely studied impact beta-blockers have on heart failure in terms of improved symptoms and survival.
     A question always arises about trying to get drug dose up to target, which is the doses we usually recommend since they are the doses used in trials. For example, if the heart rate drops too low with small doses of Coreg, then yes, we often do recommend getting a pacemaker to allow higher doses.
     Today I would suggest trying to cover all bases! There is recent information that multisite pacing (using 3 pacemaker leads instead of 1 or 2) also improves CHF patients. So I would consider evaluation at a heart failure center doing either the Medtronic studies or the Guidant Companion study as well. You might be able to benefit from both the beta-blocker and the pacemaker by geting one of the new "CHF pacemakers."


 Janet - Coreg raises blood sugar levels. If a CHFer develops diabetes while taking Coreg, should the drug be discontinued? If so, should adjustments be made to the rest of the drug regimen to offset the loss of Coreg? Regarding diabetes, are any diabetes meds absolutely not to be taken by CHFers?

Dr. Silver - Usually I see glucose intolerance (elevated blood sugar) happen in people who already had a predisposition to diabetes. Again, since these drugs are truly life-saving, having to watch blood sugar levels or even take diabetic medication is worth the effort.
     Often people are told they cannot take a beta-blocker because they have diabetes or emphysema. I have been able to get most patients on a beta-blocker successfully with a few tricks and very careful titration. Again, usually a heart failure center can do this in tricky situations. Well, I'll close but a question for all of you - Did you know that it was National Heart Failure Awareness Week last week? Check out HFSA.org and aboutHF.org for more info. Wishing you Success!


 Anna - How is ejection fraction related to how we feel? For example, how should I feel with an EF of 40% as opposed to one of 30%?

Dr. Silver - Over and over again I see patients and doctors responding to a number. Yes, while EF is one predictor of outcome, it is not the only one! Really how efficiently the heart is working is a complex interaction between many things including EF, resistance to blood flow, (we call this SVR or systemic vascular resistance), heart wall thickness, valve leakage, etc,... So the answer is that you probably cannot tell what your EF is just by symptoms. In general EF does not need to be measured at regular intervals over time either. If your doctor is constantly repeating the echo or MUGA to measure your EF, there should be a very good reason for that.
     I think how a person feels overall is best correlated with their exercise performance on a cardiopulmonary exercise test (CPX), which is explained in my book. I'd like to know how you all feel about this concept. Does knowing your EF sometimes affect you - either positively or adversely? Wishing you success!


 Sandra - Tai Chi and other types of exercise for CHF - what to choose? What if I am having a bad day - do I go ahead with my exercise?

Dr. Silver - Exercise, exercise, exercise,..., One of my patients made up a tee-shirt saying that. He did it because he said that whenever he asked me what to do, I responded, "Exercise!" Actually this concept is very different than what most doctors believed even 5-10 years ago. In the 1950s Dr. George Burch "cured" a group of patients with alcoholic cardiomyopathy by putting them at bed rest but also by keeping them away from alchohol and in the hospital. From then on, doctors considered bed rest essential for the treatment of heart failure.
     We now recognize that bed rest does initially lower the oxygen requirements of the body but eventually leads to altered muscle metabolism, loss of muscle mass and strength (atrophy), and further inefficiency of the heart, muscle and blood vessels. After a point, the patient gets worse instead of better with just bed rest. Therefore, for almost all patients some form of exercise is recommended.
     In general, walking or using a treadmill is just fine. Also, using the arms with some light "low weight - high repetition" exercises is also good. Perhaps the best way to evaluate exercise capacity as well as target heart rate in by doing a CPX or Cardiopulmonary Exercise test. Please see the book for more on that. Also note that many doctors will not know what this is and it is usually only done in Heart Failure Centers.
     Almost any form of exercise can be beneficial. T'ai Chi is actually a terrific exercise since it can utilize all muscle groups and can be adapted to almost anyone's capability. I practice the Yang short form and teach several movements to our patients.
     Finally, when it comes to exercise - like anything else - you have to use common sense. If you are having increased shortness of breath, then perhaps back off the exercise and discuss this with your doctor or nurse. If they assure you that the increased symptoms are not due to decompensated heart failure then perhaps a little light walking may be okay. However, always listen to your body. If you can't breathe when you are exercising, then don't exercise - get help.
     Wishing you Success!


 Vicki - Inherited heart problems - At what age should children of a parent with HCM (hypertrophic cardiomyopathy) be screened?

Dr. Silver - This is a really good question. Usually I suggest that screening begin in early adolescence, say around 12 to 13 years of age; But that is very depenedent on the type of Hypertrophic cardiomyopathy, the genetic pattern in the family, and especially whether or not there is a lot of early sudden death in the family. Often after a person finds out they have HCM they frequently want to get their children screened right away. This may provide some false peace of mind however, since the hypertrophy often does not manifest until the growth teen years.
     There used to be a good HCM site here in the USA that patterned itself off the British site. Is that still up and running? Jon - The HCM Association site is located at www.hcma-heart.com/
     Wishing you Success!


 Peggy - After recovery from CHF, how hard can we work when going back to our job? My husband has DCM and CHF and his doctor gave him the okay to go back to work with no limitations. His job requires heavy lifting. If there is chance for his heart to heal, will the heavy lifting interfere with this?

Dr. Silver - Again, people are very hesistant to push after being ill. The CPX (or Vo2max test) is the best tool since it reassures people that they can safely exercise again and can give them the most accurate target heart rates.
     Wishing you Success!


  - Some news from the ACC Conference in Orlando last week:

Dr. Silver - Jon recently directed folks to the site about Hypertrophic Cardiomyopathy at www.hcma-heart.com/. This is a wonderful site run by a very dedicated woman and her friends. They now have a terrific book available for education of patients and their families. Co-authored by Dr. Barry Maron, one of the worlds experts on HCM, this is the book to read if you have HCM. They patterned it after "Success With Heart Failure" but it is specifically for the HCM patient.
What's hot? ... The multisite pacing trials continue to show benefit for patients with heart failure. Two biggies - MUSTIC and MIRACLE - both had positive results so stay tuned. There are currently at least 3 trials ongoing with these devices so if you are interested, contact your heart failure center to check these out. Also, expanding uses for Coreg are being recognized: now even some class 4 patients may be eligible.
What's not? ... The trial that was ongoing with the blocker of tumor necrosis factor - RENAISSANCE - has been stopped; not because of a bad outcome but simply because the dramamtic response expected was not going to happen.
     Wishing you Success!


 Joe L - A recent echo indicated that my EF is up from 35% to 45% and my left ventricle size has decreased from 64mm to 52mm in the past year. My meds are Coreg, Cozaar, Lasix, and Coumadin. My doctor says I should be feeling better but I actually feel worse overall. My question is, how can I feel worse with the increase in EF and decrease in left ventricle size? I am very perplexed and so is my doctor. I hope you can give some insight. - from Joe L, March 12, 2001

Dr. Silver - This is a common question. Unfortunately, or perhaps fortunately, there is often little correlation between how you feel and the infamous "EF." Therefore if you don't feel good, even though your EF is okay, then something's missing. It might be you need a little more exercise or that your heart is not operating efficiently enough yet. So talk to your doctor. He should not be guided by the EF alone - nor should you.
     Wishing you Success!


 Cheri S - I have been on the same dose of Coreg (3.125mg twice a day) and Altace (2.5mg twice a day) ever since my heart attack in October, 2000. I am feeling very good right now. Is it always necessary to raise the dose of meds to get the full benefit even if you are feeling good? I keep waiting for my doc to raise the dose of my meds but he has not done so yet.

Dr. Silver - Another recurring question about dosing (see "Success With Heart Failure"). We know that there may be benefits with lower doses of meds there are often increased benefits with the higher or "target" doses. For example, there clearly is benefit seen with Coreg 6.25 mg BID but there is lower risk of death and more EF benefit with higher doses. Often doctors start with low doses and then if the person "feels okay" he may fail to raise the dose. Ask your doctor why you are not at target does - There may be a reason or this may prompt him to continue with the up-dosing required.
     Wishing you Success!


 John D - I recently had a Vo2max test done. My Vo2 rate was 16%; my last Vo2 test result a year ago was 20%. During the past year my CHF specialist has increased my Coreg from 25mg per day to 50mg per day. He attributes my decrease in Vo2max on my most recent test to Coreg. He said Coreg can blunt the Vo2 rate. Is this true? I currently walk 1.5 miles twice a day while a year ago I was only walking one mile a day.

Dr. Silver - This is actually a very difficult question. If all things are equal with the test (same effort and conditions, etc,...) then it is possible that the slower heart rate seen with a higher Coreg dose might lower Vo2max. However, there should be no change or a slight increase in the Vo2/HR measurement. Your doctor - who must be pretty good if he is checking Vo2 - should be able to help you understand why, and whether your new Vo2 is really unchanged or actually represents a worsening in oxygen delivery.
     Wishing you Success!


 Linda - My father has class 4 CHF. We recently took him to the hospital where the ER doc said he was a "little dry." They admitted him and gave him first saline, then dopamine to jump start his kidneys. How does the low sodium, limited water concern affect the kidneys, and can dopamine be used now and again to remedy things? We know about the possibility of a dopamine drip but our doc discourages that because he believes it affects mortality in a negative way.

Dr. Silver - I shudder with this type of question. Let's see: Did the ER docs see a low blood sodium level and tell your dad he was dehydrated (which could be wrong since a low blood sodium level means activation of the renin angiotensin system and he should have been retaining fluid in this state) and did they give him saline to "treat" this so-called "dehydration?" Are you and your doctor talking about some of the long-term oral studies with agents like milrinone and enoximone?
     If he's really class 4 he should be on (or have a good reason to not be on) digoxin, diuretics if he has lots of edema and an IV diuretic for awhile, an ACE inhibitor and perhaps a beta-blocker as well as spironolactone (Aldactone). If he's on these and not getting better, - see a HF specialist who can address whether IV inotropes could be helpful on a short-term basis.
     Wishing you Success!


 Charlotte H - Is it normal to retain fluid in the abdomen but nowhere else?
     Jon's note: I retain fluid in my face, hands and abdomen, and have never had swelling in my ankles and lower body except for my first CHF episode before diagnosis. There is a sizable minority of similar CHFers who have visited my site so this is a common topic.

Dr. Silver - The edema questions,..., First of all, you are right! Edema is leakage of the liquid part of the blood without most of the blood cells from the small vessels into the tissue spaces of the body.
     The production of edema is a complex situation based on the pressure "head" which the blood is under inside the blood vessels pushing it out; the oncotic pressures made up by albumin and electrolytes in the blood vessels holding the blood inside; as well as the thickness of the blood vessels that allow the leak to occur.
     For example, many patients know that when the left side of heart fails, it leads to increased pressures in the blood vessels in the lungs. When the blood in those vessels finally leaks into the lungs it causes the blood to go inside the air spaces in the lungs and the doctors hear that as crackles or rales and they tell the patient he has water on the lungs.
     Well, as this occurs time and again, the outside of the blood vessels thicken, requiring much more pressure to cause a leak. That's why many people with chronic heart failure are told they have clear lungs when in fact they are in profound heart failure.
     Now to answer the question: to actually get fluid in the legs there has to be increased pressure build-up from the left side of the heart back to the lungs, then to the right side of the heart, then to the abdomen, and finally the legs. In general, even a little bit of leg edema means there is significant increase in pressure in the entire circulatory system. A patient once told me her doctor said the leg edema of CHF was only a cosmetic problem. Hardly!
     Wishing you Success!


 Bill D - Every time you go to the hospital what's the first thing they do to you? They set up an IV and start dripping a saline solution into you! If the drip is fast, you'll go through 3 or 4 bags a day. After my last go round, when I couldn't breathe I got to thinking, "How much sodium is in those bags?"

Dr. Silver - The saline solutions are sodium chloride. They can cause you to get edema or worsen your heart failure - You betcha!
     Many CHFers are extremely salt avid and retain any sodium in the vicinity. <g> Usually we try and use minimal amount of IV fluids and usually use dextrose instead of saline. However, saline is frequently used and CHF patients often get way too much within the first few hours of being in the Emergency Room or on the hospital "floor." Even those only getting the right amounts can be very sensitive to it and it can worsen their heart failure.
     Wishing you Success!


 Stephanie - I have idiopathic cardiomyopathy with an EF of 15% and am currently in cardiac rehab. My question is about target heart rate. One of the rehab nurses really pushes me and thinks that a target heart rate for a healthy heart is what I should strive for. The other nurse is much more cautious and likes to keep my pulse under 100. What do you suggest as a target heart rate for a CHFer like me?

Dr. Silver -  This is a really important question. A study was done - not with CHF patients, but with regular folks - going for Rehab. They used the standard way of calculating target heart rate: 70% of 220 minus Age. Over 70% of these patients were exercising beyond their anaerobic threshold (see CPX in the book), which is dangerous.
     The best way to figure a suitable target heart rate is by doing a cardiopulmonary stress test (Vo2max). Since the calculation gets even harder with patients taking a beta-blocker (like Coreg), this is the best way. If you hospital does not do this kind of testing I would definitely shoot for the lower heart rate. The key in Rehab for the CHF patient is endurance. Also consider some weight bearing exercises (free weights).
     Wishing you Success!


 David A - Do you find that ARB medication (ACE Receptor Blockers) in general is more forgiving than ACE inhibitors when it comes to potassium retention? Does diet play a significant role when potassium levels are too high?

Dr. Silver -  There was one study suggesting that potassium levels rise slightly less with the ARB versus ACE inhibitors. However, both can cause potassium levels to rise and the prudent thing to do is to monitor the potassium levels when either drug is first started. As some of you may be aware, there are situations where we combine an ACE inhibitor and an ARB; here too, we must carefully monitor your potassium levels.
     Wishing you Success!


 Robin L - An echo done a little over a year ago while I was still taking an ACE inhibitor showed my EF to be 46%, later confirmed by cath. My left ventricle dimensions were in the upper normal range: diastolic of 5.4 and systolic of 3.7. My doctor then took me off the ACE inhibitor due to low blood pressure.
     A recent echo showed my EF at 56% but my heart got considerably larger: diastolic of 6.2 and systolic of 4.7, the increase happening in one year's time. Will this enlargement eventually decrease my EF? Does this mean that cardiomyopathy is progressing again? I don't feel as good as my doctors seem to think I should. I believe that I am holding what I call a constant layer of fluid throughout my face, hands, neck, legs and feet. Would this, along with fatigue, be a indicator of my heart enlarging? Is it common for a person's EF to go up but their heart to enlarge?

Dr. Silver -  Yes, yes, yes. In general, we think that ACE inhibitors and beta-blockers should be taken life-long. You are smart to observe the changes in your LV size and probably should be back on an ACE inhibitor - there may be ways to get around your low blood pressure.
     Wishing you Success!


 William B - I take Coumadin (warfarin) for blood thinning. What factors affect the amount I must take to get to a certain INR and stay there? I know that eating different amounts of food with vitamin K from week to week can affect warfarin blood levels. I am taking 10mg two days a week and 7.5mg the other 5 days a week, and I am just barely able to get to an INR of 2. If all "outside" factors are constant, including the amount of k-heavy foods I eat, what affects or controls the action of this blood thinner in my body? What can I do to "steady" my INR (PT)?

Dr. Silver -   In general, the absorbtion of the drug, its metabolism, and things that interefere with the drug's metabolism and/or its elimination from the body are what affect a drug level or its effect.
     I generally tell patients to eat the foods they like but ot keep their diet consistent and then let us adjust their warfarin around their diet. Unfortunately - and especially for decompensated CHF patients - the prothrombin time (INR) does vary considerably. There may be newer "blood-thinners" coming that won't require the frequent testing that warfarin does. Also, you should be aware that there is lack of agreement about who should be on warfarin; if it is for low EF patients only or not.
     Wishing you Success!


 Cristina - My doctor, Dr. Robert Berkowitz, seems to be against CoQ10. He is very knowledgeable in all other aspects of CHF. He has been involved in many clinical studies and insists that CoQ10 is just a way for someone to make money. What are your thoughts on CoQ10? Can I take it without telling him? Or will that harm me?

Dr. Silver -   CoQ10 continues to have supporters and detractors. Clearly the issue is not resolved. I favor use of CoQ in most patients but also tell them that if they have to choose whether to purchase their beta-blocker or the Q, buy the beta-blocker! Hopefully more trials will answers these questions. Please do not take something and not tell your doc. You should feel comfortable telling him about decisions you have made even if those decisions are not what they want to hear; Likewise, they should be able to support your decisions, even if not in line with their wishes.
     Wishing you Success!


 Lee - My cardiologist has tapered me off 0.25mg digoxin daily. This was a about a month ago. I now feel quite tired, even a bit SOB and cannot do as much as I did before. Could this be a result of stopping digoxin? I have DCM with an EF of 40% up from 29%. I take 20mg of Prinivil and 2.5mg Zebeta once per day. I also have an ICD due to polymorphic VT.

Dr. Silver -   Yes, Two large trials showed that certain people - and not infrequently - will decompensate after digoxin (Lanoxin) withdrawal. We also now think of digoxin affecting neurohormones more that having an inotropic effect. You are probably right - See your doctor. He should be familiar with these trials.
     Wishing you Success!


 Earl - I feel like I have a big buildup of fluid or water around my stomach, legs, chest, breasts, and arms, but not much around my ankles. I cough continuously when lying down. How do doctors properly check for water retention and know for sure? One doctor says that I do have fluid buildup and another says that I don't. How do I know what to believe? I need to know if someone can give me a test or something to be sure.

Dr. Silver -   The physical exam can be misleading. Doctors "look" for fluid by listening to the lungs, looking for enlarged livers, etc,... Leg edema may be a late finding. A right heart cath (see the book) can accurately determine your fluid status. A new device can thoracic bioimpedence can also reflect intrathoracic fluid. The BNP level may also be a way of checking for decompensation. Consider seeing a heart failure specialist for a thorough evaluation.
     Wishing you Success!


 Patty - Is it possible that CHF patients have anemia as part of CHF?

Dr. Silver -   Anemia and CHF are closely related. All docors are taught to look for anemia in a new CHF patient since a low blood count can decrease the oxygen carrying capacity of the blood and make the heart work harder. On the flip side however, patients who have chronic CHF may also develop anemia. It can be due to many things, including associated kidney problems, blood loss from the GI tract (which I think is often made worse by CHF and pulmonary hypertension) or even by too many blood draws.
     Years ago I studied this anemia and wanted to do a study with a new drug called erythropoietin but the company would not fund the study. Now about 12 years later, this drug has been shown to be of help in some CHF patients who do have anemia and no easily corrected cause.
     Wishing you Success!


 Christy - My mother has CHF and has gained about 30 pounds. Is there a way fluid can be drained off a person's body besides medications such as Lasix?

Dr. Silver -   Remember that getting rid of the fluid depends on a coordinated effort to get blood flow to the kidney (the job of the heart and the blood vessels) and then to get rid of excessive sodium into the urine - the water follows the sodium. Getting rid of excessive sodium into the urine is the job of diuretics (water pills). So we need to get the heart to function more efficiently through use of ACE inhibitors, beta-blockers, vasodilators and perhaps inotropes AND use one or more diuretics to finish the job. Doing one without properly doing the other will not get the fluid off or keep it off.
     In the book I discuss the concept of diuretic resistance, which happens to may CHF patients. Wishing you Success!


 Richard B - I've read warnings about exposing oneself to infections, such as in crowded elevators, etc,... I've been thinking about swimming in a public pool but wonder how much danger there is of infection?

Dr. Silver -   Here's a personal opinion: one of the major risks of pools is viruses. Remember summer polio outbreaks? Pools that are used heavily tend to drop their chlorination level. It is possible that if you have a cardiomyopathy which may be due to a viral syndrome, or if you have a genetic susceptibility to a viral disease, you'd be better swimming only if you know there is sufficient chlorine in the pool.
     Wishing you Success!


 Bailey - I have CHF and asthma. What is the criteria to qualify for home oxygen? By the way, I purchased your book and I encourage everyone with CHF to buy it. It is excellent!

Dr. Silver -   Thanks! There is a few different things to consider. One is what your insurance says. For Medicare I think you need a resting oxygen saturation below 89% to qualify. Others may differ. Another thing to consider is why you need supplemental oxygen. If you have heart and lung disease it would be good to find out which is the cause of the hypoxia (low O2 in the blood) - the heart disease or the lung disease. Discuss this one with your doctors!
     Wishing you Success!


 Claudia - I've been hearing about the use of external counter pulsation therapy for treating heart failure. What's the latest on this? Is this therapy helpful?

Dr. Silver -   EECP seems to have helped many people with angina. Early trials suggest it may also help CHF patients - good news! A trial for EECP for CHF patients has just started. Try and find a site near you to enroll. CenterWatch may be a good place to start looking.
     Wishing you Success!


 Alice - I have great difficulty in sleeping through the night. I have had CHF and LBBB for 7 years now; last being hospitalized 2 weeks ago. I am seeing a cardiologist. He said that it was okay for me to take a Tylenol PM nightly but all that does is produce 3 to 4 hours of uninterrupted sleep. The rest of the night I am either up wandering the house or I toss and turn. I do sleep on 2 pillows. I also have quite a bit of chest, arm and upper back pain, which my cardiologist says is probably muscular. I don't even ask him about it any more because he takes it so lightly. It is my belief that it is my discomfort that awakens me and the muscle pain is my heart muscle. What do you think? What can I do to get more rest? Can heart meds cause this sleeping disturbance?

Dr. Silver -   Yes to all above. These are very common complaints in CHF patients but you should find the cause. Note that excessive catecholamines can interrupt sleep. Catecholamines are substances such as adrenaline that stimulate your body to a higher degree of activity in some way.
     Also, sleep apnea is common is CHF patients. If nothing serious is found, then I encourage an exercise routine in the evening. Don't forget the warm milk (serotonin). Finally don't forget the big D : depression, which is a major cause of poor sleep in CHFers. I'll do more on this in the next book
     Wishing you Success!


 Judy - Is it possible to have dilated cardiomyopathy and ischemic cardiomyopathy? Also, I know from reading that you are big on exercise. What would be proper reasons for a person being told not to exercise?

Dr. Silver -   With both forms of the disease the heart is dilated (enlarged) - thus the confusion. However, we usually use the term DCM when we mean Idiopathic Dilated CardioMyopathy. Idiopathic means that we don't know what caused it. We use the term ischemic when the cause of the CM is coronary artery disease (blocked arteries). Sometimes doctors find "mild" coronary disease and say the DCM is "out of proportion" to the CAD. I usually don't buy that one. Unless you go into V-tach each time you exercise, you should definitely exercise; And ask more questions of your doctors.
     Wishing you Success!


 Barry - Is there any effective treatment for pulmonary hypertension? The only one of which I am aware is intravenous nitrous oxide. My pulmonary pressure is 46 on stress echo.

Dr. Silver -   There are actually lots of treatments but first you must figure out why you have it. If it is due to CHF, then treating that is the best way to lower pulmonary pressures. If it's PPH (primary pulmonary hypertension) then other treatments exist but you need to see a specialist.
     Wishing you Success!


 Roxie - A good friend has CHF. His first angioplasty with stent was done in July of 2000. He has been in and out of the hospital with heart and lung problems, plus rashes and fever that cannot be explained. He is a 52 year old man - not obese - with no known allergies, and is an ex-smoker) Could he be allergic to the stent?

Dr. Silver -   That's a new one on me. I don't know but will ask around.
     Wishing you Success!


 Sylvia - My husband has been accumulating fluid in his abdomen. What can be done to remove this excess fluid? It is interfering with his breathing. Our local doctors say that it will just return if removed. He also has an umbilical hernia which they are afraid to operate on because of the fluid. What is the danger of removing the fluid and how can it be done?

Dr. Silver -   Great question. Your doctor is right. If the fluid in the belly (ascites) is due to CHF and probably right-sided CHF, then tapping or draining it won't help. Make sure his CHF is being treated aggressively.
     Wishing you Success!


 Electra - I have been recently diagnosed with some diastolic dysfunction. My systolic function is fine. I am over 8 years post-bypass and am now 50 years old. I am also a regular exerciser. I have started having extreme fatigue, sometimes lasting 2 to 3 days after strenuous exercise (slightly above my target heart rate as determined by stress test).
     Can diastolic dysfunction cause such fatigue if I overextend myself? I was told by one doctor that if I had exercise problems due to diastolic dysfunction, they would be during the exercise or would stop me from exercising altogether. I do not understand the issue of diastolic dysfuntion and exercise. I would like to continue my exercise but I also don't want to overdo it. I recently had my yearly stress echo and there was no new ischemia but I do have some slight residual ischemia.

Dr. Silver -   Diastolic dysfunction is a really big problem. Perhaps 30 to 50% of all CHF is due predominantly to diastolic dysfunction, and it can be hard to treat. Remember that one major causes for it is ischemia. So, yes, it can cause the symptoms you describe. If some testing reveals ongoing ischemia, talk to your doctor about what can be done to improve the supply/demand imbalance. If you have angina, treating that aggressively would be a good place to start. By the way, EECP might be a consideration. There is a trial just starting for EECP and systolic dysfunction. If you have a normal EF then perhaps you could be considered if you had angina. Good luck.
     Wishing you Success!


 Mike J - I have heard many theories on EF and Coreg. My own EF by cath was 42% and by echo is 35%. I have a large chest and have been told this can give a less accurate reading by echo than cath. Which test gives the most accurate reading? Can Coreg cause wheezing at even a low dose of 3.125mg per day.

Dr. Silver -   Remember that EF varies from moment to moment due to various interactions with the blood vessels, medications, etc,... Therefore no single reading is "more accurate." Also remember that there is error (usually about 5%) in the measurement of EF, so really the 35% and the 42% are quite similar.
     Yes, Coreg can cause wheezing at low doses. Check with your doctor though, since lots of other things can cause wheezing as well.
     Wishing you Success!


 Debbie - My husband's ejection fraction is 35% right now, and the doctor wants to do a cath due to anterior heart circulation problems. Whether my husband's cardiomyopathy was viral or not has not been determined. His doctor asked him about Scarlet Fever as a child. My husband had high fevers as a child, along with febrile seizures, but doesn't know if he actually had Scarlet Fever since his parents didn't take their children to doctors due to their religion. How do we determine if his heart damage was caused by Scarlet Fever?

Dr. Silver -   Scarlet fever as compared to rheumatic fever usually did not cause permanent heart muscle damage. If your doctor is suspiciuous of coronary artery disease, then get that checked out first.
     Wishing you Success!


 Alex - Can you kindly explain in which situation IV therapy should be used for CHF patients? I would also very much appreciate your viewpoint on the difficulties and inconveniences in those standard IV therapies and possible advantages of Natrecor over them.

Dr. Silver -   In general, IV therapies are used in hospitals for decompensated patients who are not responding to oral treatments. Occasionally, IV therapies (diuretics and inotropes) can be given as an outpatient for decompensated patients. This is usually to let them get up to target dose on other meds and to stabilize them. They usually are not (should not) be given for prolonged periods without very specific goals in mind.
     Natrecor is a new intraveneous vasodilator (not an inotrope) that will be used in the same situations. It may have advantages: It causes excellent diuresis and normalizes blood flow without high risk for arrhythmias. Natrecor is now approved by the FDA and should be available soon in hospitals.
     Wishing you Success!


 Gail - My EF has improved from 20% two years ago to almost 50%, which I am told is normal. I still take all my meds with no reduction in dosage. Why do I continue to suffer from fatigue, shortness of breath, and edema if my heart is "back to normal?"

Dr. Silver -   Good question - but remember that EF alone dosen't mean much. I'd look for other causes of your symptoms, including lung disease. I would also do a cardiopulmonary stress test. After all you may still be very deconditioned from when you were sicker. Also, perhaps your meds need adjustment. Ask your doctor to work through it with you.
     Wishing you Success!


 Ruthie A - I took an ACE inhibitor for awhile when I was first diagnosed with CHF, but developed a bad cough and had to discontinue it. I am now on an ARB and am doing fairly well. My diagnosis is diastolic dysfunction.
     Are the parameters different than with systolic dysfunction regarding ACE inhibitors and ARBs? I keep reading that an ACE inhibitor is a more important and better therapy than an ARB. Is that true, and if so, am I missing out on something that would help me even more than what I am doing now

Dr. Silver -   You are on top of things in this confusing area. It turns out that many of the treatments for systolic dysfunction are also good for diastolic dysfunction - such as ACE inhibitors and beta-blockers. If you really had a cough related to the ACE inhibitor, then the ARB is probably a good substitute. I usually try 2 or 3 different ACE inhibitors in a patient before I say they are intolerant. Keep on reading!
     Wishing you Success!


 Pat - I'm currently taking 420mg verapamil daily and a fluid pill called triamterene. I also take 8 puffs of azmacort daily. I'm swelling during half of the week, generally worst by Thursday. I'm also coughing a lot. My cardiologist diagnosed me with MVP. I have a close friend with CHF who says my cough and symptoms are so similar to his own that he often wonders if I've been misdiagnosed. Since I've awakened at night with my heart racing several times, I'm not altogether sure my medications are the best for me. I realize I need to see another physician or confront my current one but do you have any suggestions?

Dr. Silver -   Ask your doctor the same questions you've asked here. You seem accurate in what you describe, so get it checked out. Why are you on the verapamil? Get it figured out so that it makes sense to you.
     Wishing you Success!


 Patti B - My 17 year old son was put on digoxin (Lanoxin) and Vasotec last year. He was born with congenital heart defects and as a result is having problems now with heart function. It has been a struggle to keep him on the meds. I know that it is bad for him to take these drugs and then miss a day or two, but I'm not sure why. I hope that if I can explain to him, he will understand how bad or dangerous it is for him.

Dr. Silver -   You're right, but will you convince him? Unlikely. The reason is that the medicines only last for limited periods. After taking a dose of Vasotec, the drug's effect wears off in a number of hours. Skipping a dose for a day allows the drug's good effects to go away and allows a rebound of the bad stuff the drug controls.
     However, the doctor should be doing that explanation for you. By the way, your son is not alone. We just opened a specialized clinic for adults who had congenital heart disease and now have CHF, which is very common. The staff is multidisiplinary (from various areas of medicine), so we usually have docs and nurses who put their heads together and think through solutions. We have been very successful since there are new faces. Teens especially seem to respond well.
     Wishing you Success!


 Don B - My 33 year old brother was just diagnosed with heart failure associated with dilated cardiomyopathy. His heart at the time of his cath was pumping at a 10% ejection fraction. I'm very concerned about sudden death, and spoke to someone at Red Cross about external defibrillators. Do you recommend this device? What else can you tell me about ways I can reduce the chance that he will die suddenly?

Dr. Silver -   Be sure to read the book regarding sudden death. ;-) The SCDHeFT trial finished enrolling last week so soon we'll know this answer. One option is amiodarone and even beta-blockers seem to reduce the risk. External defibrillators are not very practical. Make sure he is on optimal drug therapy and keep posted on the outcome of SCDHeFT.
     Wishing you Success!


 Brandy - I have peripartum cardiomyopathy and am on Toprol-XL and Zestril. My EF is 50%. Lately, every time I stand up, my pulse goes from 51 to 115. I am also very dizzy, even when I am just sitting around the house. My doctor put me on a Holter monitor, at which time I did not have these symptoms. He told me then that everything was within normal sinus rhythm. They do not want to investigate further my rapid pulse and dizziness. Could you tell me what other alternatives might exist for me?

Dr. Silver -   Good drugs but feeling bad. Many things might be wrong but the first place I'd look is your volume status. This is literally how much blood and fluid is in your body. Dehydration can produce these symptoms. If you are on a diuretic (water pill), ask your doctor to readjust dose or frequency. Too often when people go on ACE inhibitors and beta-blockers they get a lot better (a la EF = 50%) and the doctors forget to reduce the diuretic dose or allow higher fluid intake. See your doc!
     Wishing you Success!


 Claudia S - I would like to know why some of us CHFers sweat profusely with the least little bit of exertion. If I am in stressful situations, such as going to see my doctor, it's really bad. I know several people have mentioned this on Jon's message boards. I have looked everywhere for an answer. Neither my cardiologist nor my internist has an answer.

Dr. Silver -   I'm not sure of the answer either since so many factors are involved with sweating. However, in the past, a commonly overlooked symptom of heart failure was indeed sweating. So if there are no other reasons, and the sweating seems to vary with your heart rate or degree of CHF, it may indeed be a marker for your disease severity. Make sure you are doing all you can for the goal of having the best status possible.
     Wishing you Success!


 Kym - I am told I have left-sided heart failure. Is it possible to have right-sided failure also? Is there such a thing as double-sided failure? I swell in my face, hands, and abdomen very badly. One doctor told me these were signs of right-sided failure. I am worried because I am very young with 2 small children.

Dr. Silver -   It sounds like you have biventricular failure! Make sure you are getting treated aggressively. If you still have severe symptoms with lots of edema after standard therapy, make sure you're seen by a CHF specialist. (See the book).
     Wishing you Success!


 Doug - My wife has dilated cardiomyopathy and an ejection fraction of about 35 to 40%. She also has mitral valve prolapse with severe regurgitation. Is having sex a bad idea at this time? Her doctor has her on Coreg and just added an ACE inhibitor to her medications. Is there an answer to this question?

 Claire E - I have recently started doing yoga and am finding it rewarding and relaxing. Is yoga safe for heart patients? Are there any specific guidelines to follow? I seem to recall reading somewhere that Dr. Dean Ornish sometimes prescribes a regime of gentle yoga poses for his patients. Have you ever come across a "Yoga for Heart Patients" tape? Some of the postures are too difficult for me now but if they are safe, they can become long-term goals.

Dr. Silver -   As I say in the book, sex is a form of exercise - and for most, a very mild one at that! In general, doing mild exercise such as having sex or doing yoga is just fine. In fact, it is terrific. The best way to evaluate exercise limitations is with a CPX test (often called cardiopulmonary stress test or Vo2max test). We now firmly believe that exercise is really important for CHF patients.
     Wishing you Success!


 Jeffrey - How would you suggest that I - as an EMT - work to recognize (if they don't know) and treat a CHF patient in the pre-hospital setting? Should I call for ACLS right away or just go for a rapid transport?

Dr. Silver -   Excellent question; Most patients admitted with heart failure come in via the Emergency Room. However, there are various levels of decompensation. In fact, we believe that as many as 60% of patients who go to the ER could be treated and discharged. That's a long-winded way of saying that each patient you get called upon is different. Things we use to triage patients with CHF for include oxygenation (O2 Sat), heart rate, blood pressure, skin temperature, and orientation, associated chest pain. If you have a way of doing non-invasive hemodynamics (thoracic bioimpedence), that might be useful. Perhaps look at your hospital CHF triage forms or standing orders. Thanks for your interest.
     Wishing you Success!


 Lisa - My son has congenital aortic and supravalvular aortic stenosis. In just the last few weeks he has been waking up in the morning with puffy eyes - both eyelids and under the eyes. Is there anything I can do to relieve the puffiness? He also sleeps propped up with 2 large (firm) pillows and yet the puffy eyes continue. I have checked with our doctor and he thinks it is just a side effect of the CHD. I hope you can help!

Dr. Silver -   Has his CHD been repaired? He sounds symptomatic. Please see a pediatric cardiac team about this. Is the rest of his body puffy (have edema)? Is he on meds? Make sure you get these questions answered by your doctors.
     Wishing you Success!


 Tracey - What is the signifigance of a high Coxsackie viral titer? I have consistently tested positive for Coxsackie B4 (greater than 1:640) for more than a year. I have cardiomyopathy with an EF of 50%, which has also remained stable for the last year. Does it make a difference in my health if the titer changes (decreases)?

Dr. Silver -   The titre is a measure of your immune system's response to proteins contained in the Coxsackie virus. Sometimes we measure the rise of these titres in implicating a Coxsackie virus infection as the cause of a cardiomyopathy. Given your situation, it seems that your body simply manufactures a constant level of antibody - I don't think any change will be predictive in you.
     Wishing you Success!


 Tracey - My husband has had a severe loss of appetite. He has lost 20 pounds which he did not need to lose. There is no problem with him swallowing or anything; He just will not eat. Is this part of end-stage CHF or will it pass?

Dr. Silver -   Severe weight loss, as well as weight gain, can be seen in heart failure. The severe weight loss - which we call cardiac cachexia - is due to many things including fluid in the gut and liver which causes poor appetite from feeling filled up (called early satiety) and poor absorption of food.
     Also, lately we have found that the level of TNF alpha (tumor necrosis factor alpha - see the book) also contriubutes to the cachexia (muscle wasting). Often the person is retaining too much fluid and getting rid of the fluid can reverse the cachexia and the appetite improves again. Consider seeing a heart failure expert as soon as possible!
     Wishing you Success!


 Amelia - Does amiodarone have a high percentage of lung disease risk? Would it be less risky to have an EPS and take a chance of being off amiodarone?

Dr. Silver -   There is evidence that amiodarone might diminish the risk of SCD in CHFers. However, the real question is whether amiodarone (Cordarone) does it better than an ICD (defibrillator). That question will be answered when the SCD HeFT study appears. Stay tuned.
     For now amiodarone does have side effects, but they are less at lower does. Some things like lung, eye and liver function should be monitored. Ask your doctors more about this one.
     Wishing you Success!


About Dr. Marc Silver

Dr. Silver's book is great!  Marc Silver is a CHF specialist concerned with people as people, not cases. Author of the best seller Success with Heart Failure, he is an MD board certified in Internal Medicine and Cardiovascular Disease, specializing in treatment of people with congestive heart failure. He is currently Clinical Professor and Chairman of the Department of Medicine, as well as Director of The Heart Failure Clinic at Advocate Christ Medical Center. Dr. Silver is a Fellow of the American Colleges of Physicians, Cardiology, and Chest Physicians; founding member of the Heart Failure Society of America; and Co-Editor in Chief of "Congestive Heart Failure" journal. Dr. Silver not only answers questions here but is always a tremendous help to me as I write and maintain this web site  Dr. Marc Silver

All information on this site is opinion only. All concepts, explanations, trials, and studies have been re-written in plain English and may contain errors. I am not a doctor. Use the reference information at the end of each article to search MedLine for more complete and accurate information. All original copyrights apply. No information on this page should be used by any person to affect their medical, legal, educational, social, or psychological treatment in any way. I am not a doctor. This web site and all its pages, graphics, and content copyright © 1997, 1998, 1999, 2000, 2001, 2002, 2003, 2004 Jon C.

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