Question about EF for Dr Fett.

[Nikki Ramus]

Hi, I was dx'd in April '06 with an EF of 40-45% in June '07 my EF was 55-60% so my cardiologist weened me off my meds, I was given a routine echo 1yr after being off the meds and my EF went down to 40-45%. Therefore my Dr put me back on Coreg, after 6mtths my EF is 45-50%. Is this common in ladies with PPCM? My Dr said that she does not think I will ever be able to come off the meds as she thinks my heart can not function without it. Do you think that this will be the case?

Nikki

[JAMESFETT]

You can still recover. You are not yet 3 years post-diagnosis. We have reported continuing improvement with treatment up to 4 years post-diagnosis (see "Recovery from severe heart failure following peripartum cardiomyopathy" International Journal Gynaecology & Obstetrics 2009 Feb;104(2):125-7). In that report we found many patients who required longer than 1-2-3 years to reach recovery levels. Even on this web-site, we have documented that approximately 1/3 of recovered patients required more than a year to reach those levels, including some who didn't reach them until 4 years post-diagnosis. The fact that your LVEF went down when you first weaned off medications indicated that you had not yet reached full recovery--which is why we always check the LVEF about 1 to 2 months after discontinuing medications to be sure that the recovered level is sustained.

What is your current dosage of Coreg? These are the things you can discuss with your cardiologist about and reach a decision with him/her:

1)Try to reach the maximum tolerated dosage of carvedilol (up to 25 mg twice daily), and see how much benefit that gives in terms of LVEF on echo. Any increase in carvedilol should be in small steps, such as 3.125 or 6.25 mg at a step, so that the dosage is tolerated, and not too much BP lowering.
2)If you have not reached 50 to 55 % at that time, consider the addition of an ACE-inhibitor, starting at small dosage, and working up if/as necessary, with the goal of reaching recovery levels again.
3)Consider having a cardiac MRI with gadolinium enhancement to see if there is any 1' enhancement (inflammation) or 10' enchancement (fibrosis). If there is 1' enhancement, suggesting inflammation--which can also be indicated by a serum high sensitivity C-Reactive Protein between 5 to 10 mg/liter or higher--then one could consider endomyocardial biopsy, especially to see if any viral DNA/RNA is present in the heart muscle.

I wouldn't give up on the possibility of healing more until AT LEAST 4 years post-diagnosis on treatment has been reached. I'd be glad to talk with you about any of these issues, as well as with your doctors. Best wishes,

JD

[Nikki Ramus]

Dr Fett, Thank you for your response that is good to hear there is always hope.
I am only on a very low dosage of Coreg 3.125mg in the morning and 6.25mg in the evening. I have low blood pressure and the medication drops my bloody pressure even lower so when I am on a higher dosage I get blurred vision and dizzy spells.

My Cardiologist thinks that maybe I developed PPCM during my first pregnancy 6yrs ago and it was never picked up, so she has suggested that there is a possibility that my heart has been damaged for so long and that is why it will never regain full function without the meds.

[JAMESFETT]

You can work with your cardiologist on the very slow increase of medication. There are some guidelines for that on my thread, "Questions that PPCM patients may wish to ask their doctors." Sometimes, when one medication, such as Coreg causes too much lowering of B.P., it is better to stay at the tolerated dosage and add a different class of medication, such as the ACE-I lisinopril, starting at only 2.5 mg daily, if you and your cardiologist want to work that out.

The reason I think you could improve is because in June, 2007, your LVEF increased to 55-60 % (right?). What medicatioins were you on then? That level of performance, even on medications, speaks for a pretty intact myocardium (heart muscle). A cardiac MRI, showing 10 minute late gadolinium enhancement at this stage, would suggest fibrosis (scarring), which is less likely to lead to improvement. But if there were no evidence for fibrosis on that exam, I would be optimistic that you are still in the window for which improvement can come, especially when and if you can tolerate ACE-I and B-B.

[Nikki Ramus]

Thank you Dr Fett you have really helped me.