What could cause a decreased ejection fraction?

Question

Hello doctor,

I had an anterior myocardial infarction five years ago, and I was on medications until the angiogram and angioplasty were performed last year. My echo report from last month indicates that the mid-anterior septum, anterior wall, and anterolateral wall are thinned and hypokinetic.

The apical septum and LV apex are thinned and akinetic. There is a dilated LV with moderate LV dysfunction, no LV clot, 2+ tricuspid regurgitation, moderate pulmonary artery hypertension, mild mitral regurgitation, and impaired RV function (TAPSE 0.55 inch). The right and left atria are dilated, and the EF is 40 percent.

Does this indicate any significant issues?

Please advise.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern.

These changes are due to an anterior wall myocardial infarction (AWMI). You are experiencing moderate heart dysfunction, which is significant but manageable. Normal heart function is above 55 percent, and yours is currently at 40 percent.

Survival chances are considerably low with heart function below 15 percent, so you have a sufficient reserve. The priority now is to prevent further damage to your heart, which can be achieved through a healthy lifestyle and medication.

You should visit a hospital if you experience any recurrence of chest pain, chest heaviness, or sudden onset of sweating. To maintain a healthy lifestyle, consider the following recommendations:

Avoid fatty, oily, and high-calorie foods.
Follow a low-salt diet.
Monitor your blood pressure regularly, ensuring it does not persistently exceed 140/90 mmHg.
Engage in regular exercise, such as brisk walking or walking according to your capacity, for at least 30 minutes a day, five days a week.
Consume plenty of green leafy vegetables, fruits, and fish once or twice a week, while avoiding meat.
Additionally, refrain from smoking and alcohol if applicable.
You will also need to be on medications such as Atorvastatin or Rosuvastatin, Aspirin, Clopidogrel, Ramipril, and beta blockers like Metoprolol and Spironolactone, which I assume you are already taking.
Furthermore, your lungs need to be evaluated; you may require a chest X-ray and, if necessary, a high-resolution computed tomography (HRCT) scan if it has not been done earlier.

I hope this information helps, and feel free to reach out if you have any questions.

Thank you.

Answer 2

Hello,

Welcome back to icliniq.com.

I understand your concern.

Firstly, there are two reasons for the decreased ejection fraction. One reason is the presence of a blockage, which is not complete but is 95 percent. This results in a continuous decrease in blood supply to the heart tissue, causing the heart tissue to become less functional but not dead. This reduced function is referred to as 'hibernation of the heart.' As a result, overall heart function declines, but it may improve after the vessel is opened, which was the basis for your angioplasty and the subsequent slight improvement in function. Some heart tissue was already dead, while other parts were hibernating, so the angioplasty likely led to some improvement in heart function.

The second cause is that once the heart is damaged, a vicious cycle begins, and various internal factors continue to damage the heart. To prevent this, we keep patients on medications such as beta-blockers, ACE (angiotensin-converting enzyme) inhibitors, and Spironolactone, which help slow down the damage process. The likely cause of the dilated right heart is the AV fistula; if it is not necessary, it should be closed. It is possible that the right side was only slightly dilated at the time of angioplasty but was overlooked because it was minimal, and over the years, this dilation has progressed to a more noticeable extent.

Additionally, an echocardiogram is a highly observer-dependent investigation, meaning it can vary based on the observer and their interpretation of what is considered abnormal.

I hope this clarifies your doubts.

Thank you.