ICG Case Studies

INITIAL VISIT:

Patient: 67 year old male

Diagnosis: Ischemic cardiomyopathy with coronary artery disease.

History: Two 'light' heart attacks in the past. Echo showed EF 15% with diastolic dysfunction and moderate mitral regurgitation. Last seen six months ago, failed to appear for scheduled appointments until now.

Current Status: Abdominal swelling and dyspnea worsening over last 3 months.

Current Meds: Lanoxin 0.125 mg q.d., Coumadin as directed, nitroglycerin spray, Lasix 80 mg b.i.d., Aldactone 25 mg q.d., K-Dur 20 mEq b.i.d., Coreg 25 mg b.i.d., and Vasotec 5 mg t.i.d.

Exam: Weight is 164 lbs., up 8 lbs. from last visit. BP 138/81, apical pulse 100. No jugular venous distension while sitting or at 30 degrees, but there was a Kussmaul's sign at 30 degrees. Lungs with coarse rales halfway up on the left, and 1/3 of the way up on the right. Cardiac examination revealed diminished S1, with a normal S2, and a loud S3 gallop at the apex. There was 3 to 3.5/6 MR murmur at the apex with radiation to the axilla. There was definite hepatomegaly and I could feel the edge of the liver on inspiration. There was no pedal edema.

EKG: Sinus tachycardia with a right bundle branch block, left anterior hemiblock, high lateral Q-waves, nonspecific ST-T changes, left ventricular hypertrophy, and poor R-wave progression.

LABS: Unremarkable CBC with diff, BUN and creatinine were 27 and 1.0 respectively, and the potassium was 4.1. Normal liver function tests.

Initial Plan: Treat with intravenous Lasix.

ICG: Impedance cardiography revealed a low cardiac output/index of 3.8/2.1. The systemic vascular resistance (SVR) was increased at 1962. Thoracic fluid content was 35.1.

Revised Plan: Reduce afterload by increasing dose of Vasotec from 5 mg t.i.d. to 20 mg b.i.d.

Schedule follow up visit in 3 days

VISIT 3 DAYS LATER:

Exam: Symptoms have completely subsided with dramatic improvement in hemodynamic profile (cardiac output 5.0 and SVR 997).

Weight is 163.5 lbs., down 0.5 lbs. from last visit three days ago. BP 111/55, apical pulse 72. No jugular venous distension. Lungs are clear to auscultation and percussion except for some decreased breath sounds at the left base. This was clearly an improvement and there were no rales today. Cardiac examination was also improved with a normal S1 and S2, although they were distant. There was a probably S4, but no S3 gallop today and on a 1.5/6 MR murmur at the apex with radiation to the axilla. Liver edge still palpable, no pedal edema.

EKG: His EKG is also improved with sinus rhythm at a heart rate of 86, which is 20 beats per minute decreased compared to the last visit. There is a right bundle branch block, left anterior hemiblock, nonspecific ST-T changes, left atrial enlargement, and left ventricular hypertrophy.

LABS: Pending at time of this dictation.

ICG: Impedance cardiography much improved with a systemic vascular resistance (SVR) now of 997 with a cardiac output/index of 5.0/2.7 and thoracic fluid content of 30.8.

Plan: Patient shows much improvement on the increased dosage of Vasotec. Continue with present medications and see him at the heart failure clinic in one week.

Summary:
I thought some of you might find this case interesting in the use of impedance cardiography. As you can see, I saw this patient in our Heart Failure Clinic on Monday, 3/25/02. He had been lost to our follow-up for awhile and came in with significantly worsening symptoms. He really didn't have a lot of evidence of volume overload, although he did have hepatomegaly and he had abdominal discomfort most likely from this along with some abdominal bloating. He did not have any jugular venous distention, but he had a new loud mitral regurgitation murmur. Without the data from the impedance cardiography, I probably would have treated this patient with intravenous Lasix. As it were, because of his increased systemic vascular resistance and MR murmur, I felt that afterload reduction would be more appropriate. He had previously not been able to tolerate the Vasotec because of dizziness, but his hemodynamic status at that time may have been different. He was on Vasotec 5 mg b.i.d. or t.i.d. and I just increased the Vasotec to 20 mg b.i.d. I brought him back today, Thursday, 3/28/02. His symptoms had completely gone away and, as you can see, his hemodynamic profile improved dramatically with the cardiac output now 5.0 and a systemic vascular resistance of 997. His heart rate was also 105 when I saw him on 3/25/02 and he had an S3 gallop. His heart rate decreased to 85. I certainly think that this technology helped direct me and I do not think that my physical exam or assessment would have been as accurate without impedance cardiography.

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