How can my mother manage breathing and heart issues at 77?

Question

Hi doctor,

My 77-year-old mother has a leaky heart valve, a weak heart function at 30 percent, a coronary stent, and a pacemaker. She has atrial fibrillation and struggles to breathe.

She cannot eat or drink without feeling bloated. Her kidney function is poor, with a GFR of 23. She is taking Creon for pancreatic issues. She also has low blood pressure, nausea, vomiting, sleep apnea, and ongoing stomach pain with worsening nausea.

She was discharged from the hospital today, but was never given a clear explanation. She is becoming weaker and sicker, especially with stomach-related symptoms.

Please help.

Answer 1

Hi,

Welcome to icliniq.com.

I understand your concern.

The details you have shared show involvement of multiple body systems, for which the patient needs to be on multiple medications.

It would have been helpful if you could share all the medical reports, including details such as the most recent echocardiogram, baseline laboratory results (especially kidney function), and any other imaging or cardiac catheterization reports.

With a history of stent placement, a weak heart with an ejection fraction of 30 to 35 percent, a leaking valve (which I assume is secondary), shortness of breath, and elevated Pro-BNP levels (pro–B-type natriuretic peptide), this suggests advanced cardiac pathology. There is also a pacemaker in place, which I assume is an implantable cardioverter-defibrillator (ICD), given the history of shock delivery on two occasions. The underlying cardiac condition appears to have affected the heart chamber size, as evidenced by the presence of atrial fibrillation.

A weak heart with a stent requires mandatory medications, and without these medications at optimal doses, the heart cannot function properly. If these medications are not taken or are underdosed, the heart may decompensate, leading to worsening dyspnea due to fluid buildup in the lungs. Decompensation can also result in cardiogenic shock or very low blood pressure, which may be insufficient to meet the body’s requirements and can cause dysfunction of other organs, such as the kidneys and liver.

I would strongly recommend an in-person consultation with a cardiologist, preferably an electrophysiologist, who can examine the patient, assess disease severity, and optimize cardiac medications as needed at this stage.

The physician can also adjust the doses of Eliquis (Apixaban) and Amiodarone based on liver function tests, thyroid function tests, and kidney function. Low blood pressure may also necessitate medication dose adjustments. The electrophysiologist will interrogate the intracardiac device and modify therapy according to current needs. The dose of Toprol (Metoprolol) may also need adjustment based on heart function, atrial fibrillation rate control, and blood pressure response. The need for device upgrades, such as upgrading an ICD to cardiac resynchronization therapy (CRT), should also be evaluated.

In addition, percutaneous valve repair procedures may be considered. All of these measures may provide symptomatic benefits.

Regarding non-cardiac conditions, including pancreatic insufficiency, sleep apnea, and reduced kidney function, a multidisciplinary approach is essential. If kidney function is stable, advanced therapies may not be required at present, and management may focus on medication and fluid adjustments.

Sleep apnea should be evaluated, and therapies such as CPAP (continuous positive airway pressure) or BiPAP (bilevel positive airway pressure) may be recommended, as these can also improve symptoms of shortness of breath.

Pancreatic insufficiency requires symptomatic management, and given the persistence of symptoms despite treatment, a detailed discussion with a gastroenterologist is advised. Lupus is managed by rheumatology, and a rheumatologist’s evaluation is essential if the disease is active.

All of this care would be more effectively coordinated if the patient were hospitalized, as inter-specialty communication is easier and more suitable for comprehensive management.

I hope this has helped you.

Please feel free to reach out to me again for further queries.

Thank you.

Answer 2

Hi,

Welcome back to icliniq.com.

I understand your concern.

Other than the pancreatic medications she is already taking, additional medications such as prokinetic agents may be started to regulate intestinal motility and improve digestion.

I would recommend starting Itopride hydrochloride 50 mg twice daily, taken half an hour before meals, and continuing it for at least 15 days.

Similarly, if there is an issue with acidity, capsule Dexlansoprazole 60 mg once daily may be given, provided she is not already on another proton pump inhibitor. For further relief, syrup Sucralfate, 2 tablespoons three times a day before meals, may be added.

Increasing dietary fiber and avoiding greasy and oily foods can further improve digestion, reduce acidity, and relieve constipation, if present. Exercise, physiotherapy, and walking, if feasible, are also important for better digestion. These measures should help improve nausea; however, if nausea persists, tablet Ondansetron 8 mg, taken two to three times daily half an hour before meals, may be considered.

BiPAP settings can be adjusted if she is experiencing breathing difficulty, which may help improve her symptoms. In addition, keeping the patient propped up using two or three pillows may provide symptomatic relief along with BiPAP support.

Controlled lupus is a positive factor, as uncontrolled lupus would require steroid therapy, which can worsen cardiac hemodynamics and lead to fluid retention, something that should be avoided in a cardiac patient. As the above measures take effect, her restlessness should gradually subside.

Regarding hospice care, it essentially focuses on comfort-oriented treatment that is already being provided but may need to be adjusted based on her symptoms and clinical condition.

I hope this has helped you.

Please feel free to reach out to me again for further queries.

Thank you.