Abstract
Background:
Cardiomyopathy is reflected in a deterioration of heart function, increased risk of developing arrhythmias, and the potential for sudden cardiac death. The use of enhanced external counterpulsation has been recommended for treating chronic stable angina in high-risk surgical patients. Furthermore, cells require adequate levels of adenosine triphosphate for the maintenance of integrity and function. Lower myocardial levels of adenosine triphosphate are commonly found with ischemia and heart failure.
Subject:
We present a patient with cardiomyopathy and marked reduced cardiac function.
Conclusions:
This patient underwent enhanced external counterpulsation and metabolic supplementation, including
Introduction
Case Report
This 73-year-old white man had always been active in sports, maintaining a rigorous weekly exercise program until a hospitalization in 1999 due to shortness of breath and fatigue. During that admission, diagnoses of atrial fibrillation, hypertension, and congestive heart failure were discovered with an estimated ejection fraction of 35%. The patient underwent an initial cardioversion during that admission for his atrial fibrillation. He was discharged on oral medications of warfarin (7.5 mg, qd; alternating days with 5 mg, qd), carvedilol (6.25 mg, qd), and ramipril (5 mg, qd). This initial cardioconversion into normal sinus rhythm was not sustained. He underwent a subsequent conversion, which also did not have long-term success.
He was again admitted for therapeutic intervention for progressive heart failure and dilated cardiomyopathy in 2001 due to noncompliance of his medications. The patient elected to discontinue carvedilol due to severe vertigo. His body weight had increased to 179 lb. During that hospitalization, echocardiograms revealed a dilated left ventricle with global hypokinesis, an estimated ejection fraction of 30% with severe left ventricular systolic dysfunction, severe mitral regurgitation, and moderate to severe tricuspid regurgitation. The patient and his wife elected to try an alternative treatment approach for this heart failure, such as acupuncture, biofeedback, and herbal therapy in place of conventional pharmaceuticals. At discharge, the patient elected to remain only on warfarin.
The patient's heart failure progressed, and in 2005 the patient was admitted for the potential placement of a pacemaker and defibrillator due to his progressing cardiomyopathy. The patient mainly had a sedentary lifestyle and his body weight upon admission was 172 lb. Echocardiograms revealed a moderately dilated left ventricle, severe left ventricular global hypokinesis, moderately reduced right ventricular systolic function, moderate mitral regurgitation, moderate tricuspid regurgitation, and severely reduced left ventricular systolic function with an estimated ejection fraction of 20%. The patient elected to not have a pacemaker and defibrillator placed. Health care professionals recommended to the patient that he should then consider transplantation. The patient refused to be a candidate for transplantation. Oral medications included furosemide (20 mg, qd), warfarin (7.5 mg, qd; alternating days with 5 mg, qd), lisinopril (10 mg, qd), and digoxin (0.25 mg, qd). The patient was also experiencing at this time episodes of sleep apnea, for which he was treated with a nocturnal continuous positive airway pressure (CPAP) device. Upon using the CPAP mask, the patient experienced increased nasal congestion, for which the CPAP mask was abandoned, and presently the patient uses an oral inserted device for his sleep apnea.
The patient had always adhered to a healthy diet with a negative history of smoking or alcohol use. Due to the nature of his underlying heart disease, it was recommended that an oral daily supplementation of magnesium citrate (600 mg, qd), CoQ10 (300 mg, qd),
Discussion
Acquired cardiomyopathy affects many individuals, and the exact cause is unknown; however, a viral etiology, producing myocarditis, commonly is thought to be the cause. Other less common causes can include other infectious organisms, diseases affecting the immune system (i.e., human immunodeficiency virus), nutritional deficiencies, obesity, exposure to toxins (such as alcohol), and pregnancy. Symptomatically, most adult patients present with difficulty in breathing, poor appetite, a decrease or decline in physical activity, weight reduction, and predominant fatigue. Following diagnosis, therapeutic options center commonly on pharmaceuticals, implantation of a pacemaker or defibrillator, surgical intervention, and lastly heart transplantation. 3 The use of EECP has been recommended for treating chronic stable angina in patients deemed a higher surgical risk or for inoperable anatomy. 4 The use of EECP has not been universally accepted as a therapy for cardiomyopathy, but interest for its use continues to grow.
Studies on using EECP have reported symptomatic improvements in angina and exercise tolerance in patients with ischemic coronary disease.
5,6
Physicians have also urged the use of metabolic substrates to further enhance these benefits with EECP. Adequate levels of high-energy phosphate compounds are necessary to maintain normal cardiac function. Ischemic cardiac disease decreases energy levels, where supply does not meet demand. The use of a metabolic combination of CoQ10,
Footnotes
Acknowledgments
The authors would like to thank the patient in this case report for reviewing the history of events in his care described in this article.
Disclosure Statement
Dr. Brookman has no commercial associations that might create a conflict of interest in connection with the article. Dr. St. Cyr has acquired stock options/warrants from Bioenergy, Inc.