Question for the Doctor

[Delores]

Dr Fett: I saw my GP today, and talked with him about beta blockers. He says that my blood pressure is too low for the use of a beta blocker. He also doesn't want to use a bb because I am asthmatic. Evidently, bb's are known to cause wheezing. That leaves me on 50 mg of Cozar (ARB). He wants to drop me to 10 mg of lasix to help raise my blood pressure. I'm also starting on Prozac to help with the anxiety. Do you concur that this is a wise course to take in treating my condition. Should I be more proactive in any area of my treatment. I don't want to miss any opportunity to heal fully. Thanks for your insight. Delores :)

[JAMESFETT]

Hi, Delores. What you are saying makes sense. It would be difficult for me to make specific recommendations on your treatment because I don't have your entire history, findings, details of previous treatments, etc. So I must leave that to you and your physicians. What I do with PPCM is to try to make general recommendations, such as:
1)use diuretics as needed for fluid overload,
2)include an ACE-Inhibitor (or if not tolerated, then an ARB (as you are taking),
3)include a beta-blocker if able to tolerate, first choice may be carvedilol
4)don't take digoxin any longer than absolutely needed and if one never needs it that's good,
5)have adequate anticoagulation if EF less than 35 percent,
6)keep on treatment a minimum of 1 year,
7)when you decrease medications, do it gradually, and monitor heart function with symptoms and echos,
8)monitor blood potassium ,magnesium, and supplement if needed.
9)monitor kidney function with blood creatinine.

James

[SusanD]

When I was having problems with hypotension, my cardio changed my ACE to a sustained release, reduced my lasix as tolerated and maintained that a beta blocker was essential to my recovery (as shown by research) and acknowledged that they do not have as much bp lowering effect as an ACE and the diuretics.

Of course your Dr. has the treatment info and konws you and your other health conditions the best, but there *are* beta blockers that have minimal effect on beta receptors in the lungs and will therefore not aggravate pulmonary problems as much as some of the older line beta blockers.

It is a tricky balance with the right meds and maintaining a good blood pressure and often requires discontuing one drug and starting another with watchful waiting. Hang in there, talk things over with your Dr. and let us know how you are doing.

[Delores]

I won't see my GP again for a month. Would it be worth it to schedule a closer appointment to discuss meds again, or is it okay to wait?

[SusanD]

Delores, is your GP titrating and taking care of your meds or is your cardio ? A cardio might be able to get an overall better picture of what is going on and titrate your meds more according to specific CHF guidelines which DO mandate the use of a beta blocker. As I mentioned earlier, my cardio felt a beta blocker was so important that he played with the ACE dose and Lasix dose more just to accomodate the use. Also, you may reach a point in your recovery where the Lasix is not needed and only serves to decrease your BP even more....but again, this should be discussed with your cardio.

[Delores]

Hi Susan. I thought it was a little odd, but my cardio wanted my GP to manage my meds. Maybe because he started me on them after my initial ER visit. My GP seems to think that he is treating me properly. Maybe it would be worth another visit to the cardio? My next appointment with him isn't until November. I want to be proactive, but I'm not sure that my GP isn't doing the right thing afterall. My bp is stable now, and my fluid is under control, so I guess I'll stay the course for the time being.

[Karen T]

HI Delores
I have been having troubles with my BP as well (70/40), feeling like I'm going to black out, nauseated, etc. My PCP had been talking with my Cardio and my PCP started changing my meds (cut way back on my lasix and slowly cut back on my ACE), but it got to a point that my PCP was no longer comfortable changing meds, so she sent me back to my cardio. While waiting for an appts., I ran out of my ACE all together and actually started feeling better!! When I met with my cardio and filled her in on where things were at she agreed to stop my ACE. She said that one could make an arguement to keep me on a low dosse of ACE and cut back on my BB, but seeing how I was feeling better, we'd stop the ACE for now. I'm having an echo in Oct. I was almost due for my annual anyways.
I feel very confident that my PCP will contact my cardio if/when needed and also knows her limits, and when its time to send me to see the cardio. Hopefully your PCP and cardio can work something out.
Karen

[Delores]

Thanks Karen. That was very helpful. I do trust my doctor, and I'm sure that he is like your doctor in knowing his limits. :)

[tabs]

Karen, I, too, had problems with low BP. We cut out the diuretic completely unless my weight went up rapidly and lowered and split my ACE. I take Altace which is a once a day med with a therapeutic dose of 10mg. We went to a 7.5 mg dose with 2.5 mg in the morning and 5mg at night (or the reverse). As my heart got stronger and my BP increased and I stabilized we upped it to 5mg twice a day. About 3 years later, once we stopped playing with my coreg and I was truly stable we went to the once a day 10mg dosing.

I give this example because I truly belief that getting the right meds is important even if the doses are not in the "therapeutic" range. It may take longer to heal, but I belive it is still shorter then none at all.

It might be good to do some research on the different meds and what the current CHF guidelines are so that you can make an educated argument for your care.
Twilah