CHF, BNP & cardiac ?s

sharona97, BSN, RN · Feb 25, 2008

I had a pt this week who was diagnosed with chronic CHF and dilated cardiomyopathi about 3 years ago. He was a heavy smoker for some time and quit about 10 months ago. When he quit smoking his SOB with activity lessened considerably. Now several months later he has become simptomatic againg with increased SOB, increased BP, and decreased activity intolerance. He recently had a weight gain of 10lbs in one week and had his lasix increased. At the same time his labs show a BNP of 85 and a CXRAY that showed no evidence of CHF or the dilated cardiomyopathi.
My questions are:
1. Do cardiac meds work well enough that a pt with chonic CHF would have a normal BNP and no evidence of CHF on a chest x-ray? (pts I've had in clinical in LTC all still had elevated BNP)
2. Is it possible that dilated cardiomypathi can be 'fixed'? I thought that was something that couldn't be 'cured' but the progression could be slowed.
3. If this pt's labs are all WNL and chest x-ray is neg for CHF and dilated cardiomyopathi, and a recent cardiogram showed an ejection fracture of 50% (when pt was diagnosed was only 26%!) why is this pt still so simptomatic?
Being a recent grad I kinda feel dumb because this doesn't make any sense to me! This probably should make sense - but it doesn't! I quess cardiac was always a weak subject for me. Any help would be appreciated! For some reason this is really bothering me and if I could get a clear explaination, well, that would help a lot!
Thanks in advance!!!

Has the patient only been worked up for cardiology related sx's for this problem? Any recent surgeries? Possible DVT possible? Full CBC done? Chem 12 or 24? Just a few thoughts.

leslie :-D · Feb 25, 2008

is there any renal disease involved?

lung disease?

myopathy is managed, not cured.

leslie

onyx77 · Feb 25, 2008

There is no diagnosed lung or kidney disease. BUN and Creat were both normal. I was pretty sure that myopathies aren't cured, but why would the chest x-ray show that there is no myopathies? That is what is really confusing me.

Kristiern1 · Feb 25, 2008

Non Ischemic Dilated cardiomyopathies CAN and often will improve with appropriate treatment. In my experience, especially hypertensive cardiomyopathies can improve significantly....not all...but a fair number.

What you don't mention is if this patient has an ischemic component to his cardiomyopathy. I would think at the time of his diagnosis he would have had a cath or at least a myoview.

The symptoms you describe can also be an angina equivalent and should be evaluated as such. Additionally since most cardiomyopathy patients are on B-blockers for treatment guidelines would want to make sure patient is not significantly bradycardic

Your proof is in the puddin' so to speak with his echo. EF improving from 26% to 50%. Remember though, people can still have CHF with normal systolic LV fxn. Diastolic dysfunction can also cause heart failure symptoms.

This patient does not sound like overt heart failure. Other info I would like to know is pulse ox? 6 minute walk. EKG etc. Is he on any new medications? Did he have a diuresis with his increased diuretics? Normal cxr and BNP of 80 is not consistent with CHF.

Would consider exercise cardiolite and perhaps pulm eval.

Kristie

Kristiern1 · Feb 25, 2008

is there any renal disease involved?
lung disease?
myopathy is managed, not cured.
leslie

Leslie, I respectfully disagree. Cardiomyopathy can be reversed. We have had many patietns in our practice who have had improvement in their cardiomyopathy with complete return to normal of their systolic function. Ischemic cardiomyopathies typically do not improve with treatment....but are managed like you said... The non-ischemics can "be cured" although I don't like that word so much.

Kristie

onyx77 · Feb 26, 2008

Non Ischemic Dilated cardiomyopathies CAN and often will improve with appropriate treatment. In my experience, especially hypertensive cardiomyopathies can improve significantly....not all...but a fair number.
What you don't mention is if this patient has an ischemic component to his cardiomyopathy. I would think at the time of his diagnosis he would have had a cath or at least a myoview.
The symptoms you describe can also be an angina equivalent and should be evaluated as such. Additionally since most cardiomyopathy patients are on B-blockers for treatment guidelines would want to make sure patient is not significantly bradycardic
Your proof is in the puddin' so to speak with his echo. EF improving from 26% to 50%. Remember though, people can still have CHF with normal systolic LV fxn. Diastolic dysfunction can also cause heart failure symptoms.
This patient does not sound like overt heart failure. Other info I would like to know is pulse ox? 6 minute walk. EKG etc. Is he on any new medications? Did he have a diuresis with his increased diuretics? Normal cxr and BNP of 80 is not consistent with CHF.
Would consider exercise cardiolite and perhaps pulm eval.
Kristie

Pt is on B-blockers and pulse is in the 70's. Last pulse ox was 97% and pt becomes SOB with less activity than in the past. Pt was able to walk 10 blocks without SOB in July and now is SOB in about 75 feet. LS are clear. No new meds were added - lasix was increased from 20mg to 40mg with pt diuresing and maintaining a pretty even wt since the increase.

The chest x-ray and BNP is what is really tripping up here. They way I understood it was that with chronic CHF the BNP will always be elevated, with acute CHF it will be very elevated but can go back to 'normal', and that the chest x-ray will always show some evidence of the CHF.

Maybe it is just me being a new nurse and still learning, but I really feel dumb about this. I feel that this I should have straight!

Kristiern1 · Feb 26, 2008

Don't confuse cardiomyopathy and congestive heart failure. People who have a cardiomyopathy can have CHF or not have CHF.

Chronic cardiomyopathy patients will typically find a baseline BNP that they will "live" at when well compensated. It may be different for every patient. Your patient's BNP was normal because likely he was not in heart failure and as you pointed out his EF has basically normalized to 50%.

onyx77 · Feb 26, 2008

Don't confuse cardiomyopathy and congestive heart failure. People who have a cardiomyopathy can have CHF or not have CHF.
Chronic cardiomyopathy patients will typically find a baseline BNP that they will "live" at when well compensated. It may be different for every patient. Your patient's BNP was normal because likely he was not in heart failure and as you pointed out his EF has basically normalized to 50%.

Pt has a diagnoses of chronic CHF AND dilate cardiomyopathy. Now my question is HOW does the EF go from 26% to 50% - I know that the meds will improve the EF, but THAT much?

By the way - I REALLY appreciate your help with this! It does help clear some things up.

onyx77 · Feb 26, 2008

Has the patient only been worked up for cardiology related sx's for this problem? Any recent surgeries? Possible DVT possible? Full CBC done? Chem 12 or 24? Just a few thoughts.

Pt did have liver and kidney labs drawn - all were normal. Other than that it was focused on the heart. Pt's main problems for the last 3 years has been with the diagnoses of dilated cardiomyopathy and CHF. Pt has had several meds adjusted in these past 3 years. No recent surgery.

Kristiern1 · Feb 26, 2008

Ejection fraction (EF)describes the pumping ability of the left ventricle. Basically each time the heart beats or the left ventricle "pumps" how much blood is pumped out. It is not like nursing school where 100% is the best :-) We typically say normal is anything above 50% or closer to 55%.

Also know there are different ways to quantitate the EF. Most commonly by echocardiogram. But also by stress cardiolite, MUGA scan or cardiac catheterization.

Medicare guideline now require us to classify...chronic or acute

systolic or diastolic heart failure

It can be misleading because we tend to use the term "heart failure" for someone who has acute volume overload or congestion. For someone who has a weak heart but no congestion I would say Ischemic or Non Ischemic (whichever the case) dilated cardiomyopathy with no overt s/s heart failure at this time.

But yes to answer your question EF can improve that much.

leslie :-D · Feb 26, 2008

thanks for clearing up managed vs cured myopathy, kristie.

i'm accustomed to seeing the ischemic events.

i can't help think that with a bnp of 85, this pt does not have chf.

also, have known many chf pts that have had neg cxr's and ecg's.

xrays, ecg's are not as reliable as we've been led to believe.

i still think he needs a pulm consult.

in the absence of any positive cardiac diagnostics, pe, asthma, copd, all need to be r/o.

leslie