Was seen today at the University of Wisconsin Cardiology Clinic by Dr. Heather Johnson (http://www2.medicine.wisc.edu/home/people-search/people/staff/3153/JOHNSON_HEATHER_M/), who specializes in Preventive Cardiology. I had originally sought a preventive cardiologist for some advice on my exercise routine with the blood pressure problems, but when I had the misadventure last week with the Dobutamine test, they called Dr. Johnson and she opened a slot for me immediately.
Dr. Johnson took the most thorough history I have ever been subjected to. She pursued every detail of every heart issue I have experienced over the past 10 years. Every medication trial, every procedure. She questioned me thoroughly about every symptom I have experienced, the timing, severity, and progression of each. She explored every potential risk factor, family history, the whole enchilada.
Having completed the interview, Dr. Johnson conducted an equally thorough review of my medical data. She had spoken with both the cardiologists who evaluated me last week, and read their reports. But that wasn't enough- she went back and looked at the catheter studies on video- and she uncovered details that weren't reflected in the written reports- things that I had never heard of- and pieced the facts together to a complete picture of what is happening.
For the medical folks- the next couple of paragraphs are going to get technical, so you can skip ahead. But the details were fascinating to me, so I will recount them here.
The good news is- no blockage in any of my coronary arteries. I have a dominant Right Coronary, which is a normal variation- and it's a BIG SUCKER. Wide open! Left Anterior Descending is wide open too. The interesting finding was the Circumflex- the one that loops around to the back side of the heart. No blockage, which was accurately reported- BUT- this guy took a lot longer to fill up when she watched the video. She showed me the video three times- and sure enough, there was a distinct pause in the filling of the Circumflex compared to its neighbors. The cause- endothelial cell dysfunction. The underlying reason- blood pressure and cholesterol causing and microvascular inflammatory reaction which is impeding the blood flow. Not going to cause a massive coronary- but the type of pathology which puts additional strain on the heart over time and contributes to the thickening of the heart wall.
The thickening of the heart wall is problem #2. The medical term for this is Left Ventricular Hypertrophy (LVH). The original echocardiogram in February 2012 described this as "mild", and my primary doc tried to reassure me that this wasn't a major abnormality. But seen through the eyes of the experienced cardiologist, this took on new meaning. At 48, I am a young guy for LVH to be occurring. Dr. Johnson went back through my entire record, looked at every BP reading over the past two years, and pieced together the progression of the blood pressures and the heart wall thickening. She went back and looked at the echo images as well. Turns out, the thickening of my heart walls is causing the left ventricle volume to collapse. The thickened walls come together and briefly stick to each other- kinda like your lips do when they are dry. A normal heart doesn't behave that way, but when the walls are thickened they are more likely to make contact and cause the walls to stick together and collapse the LV volume. This is most likely to happen when the patient is a little dehydrated and blood volume is down- particularly in setting like:
- Diuretic therapy (water pills, like I was taking for the blood pressure).
- Decreased fluid intake (like the 'nothing by mouth for eight hours' prep before last week's test).
- Vigorous exercise
- A tremendous understanding of the anatomy and physiology of the heart from years of study and experience;
- Carefully listening to the patient to get a complete understanding of the symptoms, the heart history, and the risk factors;
- Thoroughly reviewing every available piece of information- vitals, labs, imaging studies.
- Dietary consult to get proper instructions on the hypertension (DASH) diet;
- Specific exercise instructions:
- no more vigorous weightlifting- raises the blood pressure and strains the heart
- regular aerobic exercise- treadmill, to a moderately fast rate to strengthen the heart but not to the point of strain
- keeping strictly hydrated before, during, and after exercise to prevent the cavity collapse
- Medication adjustment:
- ACE inhibitor to reduce the strain on the heart and the endovascular dysfunction
- No more diuretics- these were inadvertently contributing to the problem
- Statin therapy to improve the cholesterol levels and reduce the inflammatory components of the endovascular dysfunction
- Fish Oil to augment the efects of the statins and correct the imbalance of the triglycerides and the good cholesterol
- Aggressive goals for blood pressure, cholesterol, and weight management.
- Additional imaging studies- a cardiac MRI, mainly to rule out other possible causes for the heart wall thickening.
- Follow-up lab studies to keep monitoring the cholesterol and the effects of the other medications.
When I left the appointment, I realized that I felt better already, simply by understanding the problem and the solution. It's gonna be a lot of work, and a lot of consistency- so I appreciate the support of all my friends and I covet your prayers. I am deeply thankful for the support messages you have sent this week. God has blessed me with many friends. I am also deeply blessed that God pointed me to Dr. Johnson- this lady is a terrific clinician and she is going to keep me alive- and thriving- for a long, long time!
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