Dr. Isaac Gana
Cardiology
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Patient's Query
Hello doctor,
I am a 57 year old male, and I had episodes of shortness of breath and tachycardia, six months back. I take high doses of Statin and ACE inhibitors from ten years, and my lipid profile is excellent. EKG showed slight ST depression, an echocardiogram showed WMA (wall motion abnormalities), and the angiogram showed moderate coronary artery disease (CAD) in LAD, about 50% at first septal branch. LVEDP is 4 mmHg, no aortic pullback, and no mitral gradient. The diagnosis is nonobstructive coronary artery disease, and when I pressed for the etiology of symptoms, I was told it was due to a mild developmental disorder. After six months of weight loss, diet changes, exercise, etc., my symptoms have improved, but are still evident. How is LVEDP of 4 mmHg concordant with diastolic dysfunction? What else could be causing the symptoms, since CAD is nonhemodynamic?
Hello,
Welcome to icliniq.com.
Thanks for providing a detailed explanation. In my practice, normal LVEDP (left ventricular end-diastolic pressure) is considered between 4 to 12 mmHg. I would love to know when you last went for any of these tests, that is EKG (electrocardiography), echocardiogram, and lipid profile tests? Is your present weight 229 pounds? These questions are important because nonobstructive CAD (coronary artery disease) progresses very fast to cause cardiac events because most physicians do not aggressively tackle it due to the absence of significant obstruction. Symptoms most times do not disappear immediately, especially if our BMI (body mass index) is presently at 31, that puts you at stage 1 obesity. So, I advise that you redo EKG, echocardiogram, lipid profile test that might give an insight.
Patient's Query
Hello doctor,
Thank you for the quick reply. EKG, echo and cardiopulmonary tests were done six months ago. My present weight is 230 lbs, down from 285 lbs. My LDL was 70 mg/dL, HDL was 57 mg/dL, non-HDL was 112 mg/dL, and TG 185 mg?dl. But, now my LDL is 35 mg/dL, HDL is 50 mg/dL, TG is 75 mg/dL, non-HDL is 51 mg/dL, and hs-CRP is 6 mg/dL. Unfortunately, I do not know LDL-P or ApoB. I added Ezetimibe 10 mg to 20 mg Crestor plus and stopped eating carbohydrates. I am still confused about how the LVEDP can be 4 mmHg, with diastolic dysfunction? Would not a non-compliant LV, typically cause preload to be higher rather than lower? And LVEF is 60 %. My cardiologist does not want to see me for another year and does not explain anything.
Hello,
Welcome back to icliniq.com.
Your lipid profile test shows significant improvement, which is good. I certainly do not know why he would not want to see you this year. Not to scare you, but a situation where you have diastolic dysfunction with a normal ejection fraction is known as heart failure with preserved ejection fraction (HFpEF). This situation could be caused by obesity, ischemia, aging, etc. Your EKG result as of six months ago showed ST depression, which indicated ischemia. This could be the cause in your case. There is a study, that shows the prevalence of diastolic dysfunction occurring for a longer time after an event of ischemia. I will advise that you go for a stress echocardiography, this will give a clear picture of your diastolic function. If the test comes back and shows that you have traces of diastolic dysfunction, then I will advise you approach your cardiologist and explain the situation to him. It is necessary to do the test because six months is quite some time, there might no longer be a trace of diastolic dysfunction, which will be good news. I sincerely hope you get better soon.
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