PROGRESSION OF CONGESTIVE HEART
AND ITS THERAPY AS DOCUMENTED BY THE HOTMAN SYSTEM
B. Bo Sramek, Ph.D.
The patient in this study is an 84-year old male, 167 cm tall, who has been treated for hypertension for two decades by a combination of ARB + diuretic (Losartan HCTZ 100/25). This combination therapy was determined in the past by the HOTMAN System (causes: 80% vasoconstriction & 40% hypervolemia) and has been successfully maintaining his normotension. Subsequently, he was diagnosed with atrial fibrillation (aFib) three years ago, had been treated by two heart ablations and three cardioversions, however, in spite of these aggressive therapies, he still undergoes episodes of normal sinus rhythm (NSR) and aFib.
The last aFib episode started over three weeks before he was admitted to the ER (Emergency Room) with clear signs of CHF: Sudden weight gain, tiredness, shortness of breath, swollen abdomen and legs, pleural effusion, and signs of pulmonary edema.
He was examined by the HOTMAN System two days before the ER admission. The hemodynamic status at that date is depicted by the following two HOTMAN System pages: The Monitoring Page and the Hemodynamic Management Page.
The Monitoring Page (above) lists the values of all processed hemodynamic parameters in the right column of yellow numbers and depicts in analog fashion, by position of yellow diamonds withis the blue bars, the relationship of their measured value to their normal ranges (white numbers in two columns within the blue bargraphs). Please note the infranormal values of CI = 1.9 (normal range 2.8 - 4.2) and SI = 26 (normal range 35 - 65). Having both the perfusion and hemodynamic blood flow parameters at the infranormal levels could be a possible cause of CHF, resulting in excess of fluids in thoracic cavity (TFC = 0.049). Note also the rhythm variation of the analog signals due to aFib.
The Hemodynamic Management Page (above) expresses the hemodynamic state of the patient as a yellow hexagon dot on a hemodynamic map with its coordinates of MAP and SI values, and listing verbally in the left column under the map the status of hemodynamic state (83% hypodynamic @ normotension), and in the right column under the map its hemodynamic causes. Though the patient is diagnosed here as hypovolemic in the intravascular space, the edema in the extravascular spaces will require administration of diuretics.
Since the conditions of the patient worsened since the recordings above were taken, and he gained additional weight, the patient was admitted to the ER two days later and was given intravenously a dose of 20 mg lasix (furosemide). Due to a positive response to the intravenous lasix therapy (excreting 750 ml of urine in 90 minutes), he was given two options to continue lasix therapy: (1) stay in the hospital overnight and continue with intravenous administration of lasix, or (2) be released to a homecare and continue with oral administration of 2 x 20 mg lasix/day for three days. He chose the option 2.
Unfortunately, after the evening oral dose of 2 x 20 mg lasix, the production of urine stopped. The patient was therefore re-admitted to ER the next morning, where it was confirmed that due to edema of abdomen, the pharmacokinetics of orally-taken lasix differ extensively from its intravenous counterpart and lasix excretion through kidneys is blocked. The patient was then given another 20 mg dose of intravenous lasix and oral diuretic prescription was changed to torsemide 20 mg. The majority of torsemide is excreted through the liver, and its diuretic action is, therefore, independent of edema.
The hemodynamic conditions of the patient after two days on the modified diuretic therapy are depicted on the next set of two HOTMAN System pages:
You can see on the Monitoring Page above the profound improvement of hemodynamics - all parameters are within their normal respective ranges. This improvement is confirmed also by the Hemodynamic Management page below.
From the onset of CHF cycle and its subsequent successful therapy, the patient first gained and then lost 15 lb (almost 7 kg) of weight. The atrial fibrillation - a possible cause of CHF - will have to be resolved separately.