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Q. Can heart failure cause lower limb microvasculature resulting in more fragile skin?

Answered by
Dr. Muhammad Zohaib Siddiq
and medically reviewed by iCliniq medical review team.
This is a premium question & answer published on May 14, 2022

Hi doctor,

My wife has cardiomegaly, HFpEF 50 to 55%. Moderate PAH (44 mmHg) by the echo. NT-proBNP of 1130 pgs/ ml. She had COVID-19, and was in ICU; massive systemic glucocorticoids or other catabolic steroids saved her, but during her ten days in the hospital, NT-proBNP was 5,000 pgs/ml; fasting glucose 330 mg/dl. She had Parkinson's for seven years, cognitive impairment (dementia) for five years, and is in a nursing home. They exercise no more than 120 minutes total/week in five sessions. She uses a wheelchair otherwise but for transfers to bed or toilet. Only TV as an activity. Legs are almost always dependent. She can not tolerate compression socks. She has OSA resulting in excessive daytime sleepiness and EDS; she is not tolerant of CPAP. She is currently taking Apixaban 5 mgs q12, Donepizel 10 mg mornings, Diltiazem er 360 mg q24, 25 mg Metoprolol, Carbidopa/Levadopa 25/100 2 tabs tid, Levothyroxin 150 mcg, Azilect 1 mg morning lactose. Just started keyless about 500 mg tid. Is it probable some damage has been done to lower limb microvasculature resulting in more fragile skin? Would that cause more damage when scratched, especially if the skin is dry? Would HF, as described, contribute to this condition? If so, how and what can be done to retard progression? Would more walking help. Would physical therapy help? Please respond only if you are highly experienced and credentialed in either area. Thank you very much.

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Hi,

Welcome to icliniq.com.

Sad to know about her multiple comorbidities. She has heart failure with preserved ejection fraction. What can be done to reverse heart failure or slow the progression? Adopt the following measures:

1) Control her blood sugar levels. HbA1c (hemoglobin) should be less than eight.

2) Control blood pressure. Controlling BP will regress her heart's hypertrophy, and heart failure will improve.

3) Control heart rate to less than 90 bpm.

4) Exercise.

5) Weight reduction.

6) Optimizing thyroid status.

7) For OSA (Obstructive sleep apnea), if she can not tolerate CPAP (continuous positive airway pressure), then ENT (ear, nose, and throat) consultation will be of help, whether they can do some surgery to treat OSA.

8) Please share her ECGs (electrocardiogram), echocardiography, and other reports.

Regards.

Hello doctor,

Thank you for the reply.

What I want to know about is the photo I thought was attached. It is the possibility of leg and foot ulcers that concerns me. Does edema damage the microvasculature of the skin? How does being in a wheelchair all day except for 15 minutes of exercise each day for four days/week contribute to the leg foot sores you see? I will get an echo, but they did not send ECG.

Thank you very much

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Hi,

Welcome back to icliniq.com.

Long-standing edema may cause ulcers. Do not let her put her legs in a dependent position. Instead, keep the leg slightly raised, like 15 degrees, while lying on the bed. Leg passive physiotherapy and active movements will also reduce edema.

Regards.

Hi doctor,

Thank you for the reply.

I have other things now but want to keep in touch with you. Unfortunately, the NH will not give enough exercise even though many specialties advise it. I would like to follow up with you later or tomorrow, but I must get offline soon.

Regards.

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Hi,

Welcome back to icliniq.com.

Ok, sir, thank you. You can ask questions at any time. Whenever I have time, I will reply.

Regards.

Hi doctor,

Thank you for the reply.

I will upload the echo. Regards.

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Hi,

Welcome back to icliniq.com.

Ok, sir, upload or type. Also, send ECGs.

Regards.

Hi doctor,

Thank you for the reply.

I do not have ECGs. I will request. I showed your answer to my primary. My cardiologist says primary knows cardiology well. He agreed to your response. Please keep all personal information confidential. She was very tired today. Up 12 hours but often very fatigued. She wakes up when her friend visits. I think I mentioned ICU for covid-19 with NT-proBNP 5000 pgs/ml. Evidently, more damage had been done by SARS or massive IV. Systemic steroid, which probably saved her life. She was in ICU for five days. Thank you for reviewing. Not sure the cardiologist has ECG. No recent ones. Perhaps NP would order. Regards.

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Hi,

Welcome back to icliniq.com.

Her echocardiography reports are well within normal limits. The enlarged LA (left atrial) diameter may be due to atrial fibrillation. Her echocardiography does not show signs of heart dysfunction but raised NT-proBNP levels to favor heart failure. Atrial fibrillation can also raise levels as well thyroid disorders. Myocarditis caused by Covid-19 also causes raised NT-proBNP levels. I do not know whether echocardiography was done before suffering from covid-19. I hope she will improve with multidisciplinary care and coordination. In older age, the physiology of the body needs time to improve.

Regards.

Hi doctor,

Thankyou for the reply.

Few in our country get profit from Nhs get quality care. The in-house multidisciplinary teams and primary care sign to support the policies of the NH. Since businesses control them, basic but not extensive preventative care is given. Without intervention in OSA and atrial fibrillation, will the left atrium continue to enlarge? How long before physiological processes remodel the left ventricular, so heart failure causes hospitalization and a shortened time to death. Even where VADs are reliable, our medicare government system will not pay for a ventricular assist device for anyone whose comorbidities are irreversible and lethal.

Yes, no dysfunction heart compensates for now, but we do see the beginnings of, I believe, pressure when ventricle or left side in diastolic mode, I think. Thyroid seems to have been corrected with 150 mcg Levothyroxine. Can thyroid nonetheless contribute to HF? Interesting point about afib; yes, I guess that stress can damage heart cells. I will try to upload a pre-covid echo. The echo you see was taken 18 months after discharge from covid hospitalization. In what ways could covid have damaged her heart? Does it seem that heart damage is progressing if the next NTproBNP is higher? What is your experience? Would you estimate a time range to the heart becomes decompensated? At what rate would you estimate her LVEF would decrease annually? Yes, proBNP 5,000 pg/ml. Could that reflect more permanent damage to myocytes or atrial enlargement? She sleeps poorly; how will this damage the heart?

Thank you very much for taking the time to read and understand.

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Hi,

Welcome back to icliniq.com.

No, the atrium will not continuously enlarge in atrial fibrillation per se; it progressively enlarges in case of mitral valve disease. Left ventricular dysfunction is unlikely to occur if the heart rate is kept under control at around 90 beats per minute. Atrial fibrillation patients are at risk of stroke; she is being given a blood thinner to prevent stroke. She does not need VAD (ventricular assisted device). Both hyperthyroidism and hypothyroidism can cause heart dysfunction but are unpredictable when caused. If thyroid status is kept normal, then it will not cause dysfunction.

Covid-19 myocarditis is a well-known entity in which covid-19 virus antibodies or the virus itself causes inflammation in heart muscles, which may lead to damage and rhythm disturbance or LV (left ventricular) dysfunction occurs. Sometimes it is very mild myocarditis and clinically not significant. Cardiac MRI (magnetic resonance imaging) is done to see whether there is inflammation in heart muscles or not. NT-proBNP levels should go down as heart damage improves. Serial NT- proBNP levels will tell about progression or improvement. Decompensation in the case of myocarditis is unpredictable. Acute myocarditis is rapidly progressive; fulminant myocarditis is also rapidly dangerous; chronic myocarditis slowly progresses and improves with medicines. Only NT-proBNP levels do not tell about the irreversibility of damage. Sleeplessness does not affect the heart.

Hi doctor,

Thank you for the reply.

When I first spoke with the electrophysiologist, I thought he said anatomic and physiologic remodeling would occur. I must agree with you about MVR as I recently had intervention surgery to reduce the regurgitant. The diltiazem keeps my wife's HR below 90 except when she is upset. PCP noted the difference but did not connect its cause. What medicines improve myocarditis? The proBNP has been going up slowly but went from about 900 to 1100 pg/ml in five months. Blood was drawn this morning, and hopefully, the lab will test for NT- proBNP, and BNP as they have been.

Thanks again.

#

Hi,

Welcome back to icliniq.com.

Remodeling of the left atrium occurs if there is mitral valve stenosis or regurgitation and LA (left atrium) size increases over time. LV (left ventricle) remodeling occurs when there is persistent tachycardia due to atrial fibrillation or other causes that result in LV dilatation and dysfunction. If BNP (brain natriuretic peptide) levels are high due to heart failure, these will come down when the heart stabilizes. Still, other causes like atrial fibrillation cause BNP to rise, thyroid issues, chest infection, etc. and raise BNP levels.

Regards.

Hi,

Thank you for the reply.

Perhaps I should stop trying to understand as this is complicated. Still, when you address tachycardia, I take, in context, ventricular tachycardia but a node that stimulates contraction to find its way to, or develop in, LA causing atrial tachycardia, which could result in LA enlargement? I do not think an electrophysiologist wants to ablaze my wife's heart.

#

Hi,

Welcome back to icliniq.com.

Tachycardia means a heart rate of more than 100 per minute. There are two types, basically ventricular and supraventricular. Supraventricular means any tachycardia that arises from above the level of the ventricle. Atrial fibrillation is one type of supraventricular tachycardia. It does not usually cause atrial enlargement; the reverse is true. However, if the atrium is enlarged due to any reason, atrial fibrillation may result. Atrial fibrillation is the most common rhythm problem in the heart. It can be caused by many non-cardiac causes, such as hypertension, pneumonia, overactive thyroid, and viral infections.

Whatever the cause, there are two management strategies. Prevent stroke and control heart rate. The third strategy is rhythm control which is indicated in only a few specific situations. For any patient with multiple comorbidities, only rate control is all that is needed, plus stroke prevention. The electrophysiologist will not ablate for AF (atrial fibrillation) as there is no need to revert rhythm.

Regards.


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