The Uncut Version – Straight From the Cardiologist

Mr. Glenn is a 50 year old with a PMHx of ischemic cardiomyopathy with history of myocardial infarction with PCI (three heart attacks treated at OPR), history of ventricular tachycardia s/p VT ablation and ICD. He also has had a TIA. He recently was at OPR in 10/2022 when he presented with NSTEMI and underwent PCI to OM and RCA. He has been getting majority of his care at Overland Park Regional. He was referred by primary care doctor. His first of the three heart attacks, acute myocardial infarction was when he was 39 years of age and he had sudden cardiac death. His ejection fraction was noted to be around 35%. He has a significant history of myocardial infarction in his family on both father and mother side. His father was in 40’s when he had a CABG. His mother has had a previous CVA. His second heart attack in April 2021. After this heart attack, he started to become more short of breath with heart failure symptoms. He had his 3rd heart attack on 10/2022 but he continues to have symptoms. He reports major issues with shortness of breath. He had to stop three times with the 6 minute walk test. He reports shortness of breath when shaving or climbing one flight of stairs. He denies chest pain. He is short of breath with laying flat. He sleeps on his side at this time. Denies swelling in his legs. He reports LH when exerting himself. Denies syncope. Denies ICD shocks. His quality of life is around a 3/10. In terms of other medical history, no other major diagnosis. He quit smoking in 10/2022. Prior to that, he started smoking when he was around 18-19 years of age. At his peak, he was smoking a pack a day. More recently it was a pack every 3-4 weeks. He is not chewing. He will vape occasionally. He reports that this is nicotine free.

He reports that symptoms have changed. He reports that he is dizzy whenever he gets up to move. He feels fatigued. He has been having some increasing depression. He was started on medications for this. His depression has improved. He had a ICD shock for the first time since having the ICD. He reports the shortness of breath is still present with daily activities. He got ICD shock when he was getting something out of his trunk. He did not pass out. His BP was around 120/80. He reports that he has been having some issues with cognition.

Assessment and Plan

Mr. Glenn is a 50 year old with a PMHx of ischemic cardiomyopathy with history of myocardial infarction with PCI (3 separate MI’s treated at OPR), history of ventricular tachycardia s/p VT ablation and ICD. He recently was at OPR in 10/2022 when he presented with NSTEMI and underwent PCI to OM and RCA.

1. Ischemic Cardiomyopathy
2. CAD with 3 previous MI’s most recent 10/2022 with PCI to OM and RCA
3. Ventricular Tachycardia s/p VT Ablation and ICD implantation
4. Tobacco Abuse (Quit in 10/2022)

I reviewed his TTE from 3/28. He has a severely dilated LV at 6.9 cm. His LV Volume Index is 116. His RV function is normal. His LVEF is around 20%. He has significant CAD with multiple PCI’s. However, on Cardiac MRI and ECHO, the majority of his myocardium is infarcted without viability, so I do not think there would be a benefit of revascularization. We repeated RHC which showed RA 12, PA 35/15, PCWP of 15. CI is borderline around 1.9. He underwent CPET on 06/2023 which showed VO2 of 15.2. VE/VCO2 ratio was 26.8. I reviewed his data from his PA sensor monitor. His BP is around 156/97. PA pressure is 17/4. He had VT shock. We will plan for RHC/Angiogram/ECHO next week to re-assess coronary disease and hemodynamics. I do think this is scar related VT. If there is a significant lesion, this will need to be discussed before PCI. However, given his ischemic history and recent PCI in 10/2022 we should assess. He may need transplant evaluation if he has recurrent VT. We will likely start him on AAT medications pending testing. We would likely start Amiodarone. I recommended restricting driving for at least 3-6 months.

Ischemic Cardiomyopathy

-He is on maximum GDMT. Continue Metoprolol 100mg BID, continue Entresto 97-103 mg twice a day, spironolactone 25 mg daily, and Jardiance 10 mg daily. He has been tobacco free since October 2022. -Plan as above.

12/6/23

Mr. Glenn is a 50 year old with a PMHx of ischemic cardiomyopathy with history of myocardial infarction with PCI (3 separate MI’s treated at OPR), history of ventricular tachycardia s/p VT ablation and ICD. He also has had a TIA. He had a NSTEMI at OPR and underwent PCI to OM and RCA in October 2022. He underwent Cordella placement as part of the PROACTIVE trial on 3/3/23. His first acute myocardial infarction was when he was 39 years of age and he had sudden cardiac death. His ejection fraction was noted to be around 35%. He has a significant history of myocardial infarction in his family on both father and mother side. His father was in 40’s when he had a CABG. His mother has had a previous CVA. His second heart attack in April 2021. After this heart attack, he started to become more short of breath with heart failure symptoms. He had his 3rd heart attack on 10/2022 but he continues to have symptoms. He is currently on disability. He used to work in IT. He is not doing this now given his heart failure. He was last seen by Dr. H Shah via telehealth on 11/3023 at which time he had ICD shock from VT. Planned RHC/Angiogram/Echo in a week stating that he may need transplant evaluation if he has recurrent VT. He restricted his driving for at least 3-6 months

The Cordella Device

BP per Cordella monitoring has been elevated 140s/100s with weight 282-285 pounds, mPA 6-13 He had an echo and a device check today, both pending final read. Pt presents today reporting that he has not been feeling normal for the last 6-8 weeks. He feels “fuzzy” in his head, like the “tail end of when your arm falls asleep” but not a spinning dizziness, just off. He has been more forgetful, which is not like him. He has absolutely no appetite and is completely off Ozempic. He is mildly nauseous, but has only vomited once (the night before his ICD shock). He is SOB, but not really worse than before. He is really tired, but not depressed. He has restless sleep and then falls asleep easily in the afternoon because he hasn’t slept well at night. He has no LE swelling or abdominal bloating. No weight gain. No orthopnea or PND. His HR does fluctuate between 50-100 bpm and feels irregular – while he is sitting and resting. Body mass index is 32.94 kg/m².

Past Medical History

Vitals: 12/06/23 1557 BP: (!) 144/84

BP Source: Arm, Left Upper

Pulse: 92 SpO2: 97%

PainSc: Zero

Weight: 129.3 kg (285 lb)

Height: 198.1 cm (6′ 7″)

Wt Readings from Last 3 Encounters:

12/06/23 129.3 kg (285 lb)

12/06/23 129.3 kg (285 lb)

08/30/23 130.6 kg (288 lb)

Patient Active Problem List Diagnosis Date Noted

• HFrEF (heart failure with reduced ejection fraction) (HCC) 07/05/2023
• Iron deficiency anemia 01/12/2023
• H/O cardiac radiofrequency ablation (ventricular tachycardia) 01/05/2023
• History of TIA (transient ischemic attack) 01/05/2023
• ICD (implantable cardioverter-defibrillator) in place 01/05/2023
• Former smoker 01/04/2023 Quit smoking 10/2022
• History of cardiac arrest 01/04/2023
• CAD (coronary artery disease), native coronary artery 12/20/2022 2012: STEMI w/sudden cardiac death at age 39; – PCI to LAD (OPR); EF 35%; Strong family history of early cardiovascular disease

Cardiovascular Studies Echo 3/28/23 The left ventricle is severely dilated. The left ventricular wall thickness is normal. Concentric remodeling. The left ventricular systolic function is severely reduced. The visually estimated ejection fraction is 30%. There are segmental wall motion abnormalities, as described below. Grade I (mild) left ventricular diastolic dysfunction. Normal left atrial pressure. The right ventricular size is normal. The right ventricular systolic function is normal. The pulmonary artery pressure could not be estimated due to inadequate tricuspid regurgitation signal. Left Atrium: Normal size. Mitral Valve: Normal valve structure. No stenosis. No regurgitation. The aortic root and ascending aorta are normal in size. No pericardial effusion.

RHC 7/5/23

1. Right atrial pressure was 12 mmHg.
2. Right ventricular pressure was 27/12 mmHg.
3. Pulmonary artery was 35/15 mmHg with a mean of 22 mmHg.
4. The pulmonary capillary wedge pressure was 15 mmHg.
5. The transpulmonary gradient was 7 mmHg.
6. The diastolic pulmonary gradient was 0.
7. Cardiac output by thermodilution was 5.1 L/minute with cardiac index of 1.9.
8. Cardiac output by Fick was 4.9 L/minute with cardiac index of 1.8. PVR was 1.9 Wood units

CPET on 06/2023 which showed VO2 of 15.2. VE/VCO2 ratio was 26.8

Problems Addressed Today

Assessment and Plan HFrEF related to Dilated ICM

– Last LVEF 20% LVIDD 6.9 cm from echo 3/28/23

– NYHA class III Stage C – Dry weight: 290 pounds

– NTproBNP 407 from 11/29/23 up from 335 from 8/30/23

– euvolemic on exam today

> PLAN:

– R/LHC next week

– echo and device check pending final read

– EKG today with ectopy including PVC, PJC and PAC with underlying NSR

PA pressor sensor monitoring

 – Cordella Goal PA Mean: 0-20 mmHg

Encounter Diagnoses Name Primary?

• HFrEF (heart failure with reduced ejection fraction) (HCC) Yes
• History of cardiac arrest
• ICD (implantable cardioverter-defibrillator) in place
• Ischemic cardiomyopathy
• VT (ventricular tachycardia) (HCC)
• Coronary artery disease involving native coronary artery of native heart without angina pectoris