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Medical Forum / General / Cardiology / June 2009

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Chicken and Egg

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analog@logwell.com - 16 Jun 2009 10:34 GMT
I am trying to sort out what has happened to me over the last several weeks.
This is not purely an academic exercise, but an attempt to make sense out of the
direction treatment should go.

I have been a Type 2 diabetic for several years.  CAD has almost certainly been
present for many years (overweight diabetic 57 year old male), but no angiogram
has been performed.  BG was well controlled with Metformin and CAD was treated
with mild diuretic (originally Moduretic, later just HCTZ 50 mg bid), ACE
Inhibitor (Monopril 40 mg bid), and Beta Blocker (Toprol 100mg tid).  A local
cardiologist diagnosed CHF from a stress test with echocardiogram, however
Howard Wayne disputed diagnosis and said EF was actually around 60%.  Wayne
prescribed the medical treatment above.

Recently, I noticed both BP control and BG control were slipping.  Eventually, I
felt so bad I could not postpone a trip to the endo any longer.  Lab work
revealed a BUN of around 60, and a Creatinine of around 3.  All drugs except
Toprol were discontinued.  Insulin was started.  There was a immediate
improvement in the Creatinine to 1.7.

Peripheral edema immediately went nuts (it had flared previously during an
earlier attempt to halve the HCTZ dose).  Shortness of breathe and exhaustion
were already severe, but the ensuing pulmonary edema resulted in the inability
to sleep.  A week of hospitalization was imposed during which time  Lasix was
administered IV 80mg BID.  Over 40 pounds of fluid was shed in a week.  Demedex
(40 mg BID) has been continued for the two weeks since discharge, with about
another 10 pounds of fluid loss.

I am breathing 100% better and sleeping wonderfully, finally.  Dry weight has
likely been achieved or very nearly achieved.  BP is being well (or perhaps
over) controlled with average BP something like 100/70, but there have been a
couple of recent episodes of hypotension (I suspect I am so damn dry, the meds
are working too well at the present dose).  Present meds:  Demedex 40mg bid,
Spironolactone 25  mg (was bid, but cut back), Toprol 100 mg TID ( sometimes
BID). Digoxin 0.25 mg, ASA 81 mg, Hydrazaline 25 mg bid, and Isordil 20 mg tid
(have had to halve dose to 10 mg, and even skip some doses to avoid fainting).
Lisinopril could not be started at even 5 mg without severe low BP.

Now, here is the question:  Do I really have CHF or was the appearance of CHF
simply the result of  the acute renal failure and the additional fluid load the
has now been shed.  In other words, what disease am I treating?   Am I
over-medicated and on the CHF cocktail?  What is the best strategy (assuming
revascularization is out of the question).  This is somewhat of an academic
exercise, but it seems important to know if I am treating real CHF or if the CHF
was quasi-transitory and was just a consequence of renal failure.

Am I misunderstanding the entire presentation of the problem?
Andrew B. Chung, MD/PhD - 16 Jun 2009 11:32 GMT
Syd wrote:

> I am trying to sort out what has happened to me over the last several weeks.
> This is not purely an academic exercise, but an attempt to make sense out of the
[quoted text clipped - 3 lines]
> present for many years (overweight diabetic 57 year old male), but no angiogram
> has been performed.

It remains possible that you have no **occlusive** CAD.

> BG was well controlled with Metformin and CAD was treated
> with mild diuretic (originally Moduretic, later just HCTZ 50 mg bid), ACE
> Inhibitor (Monopril 40 mg bid), and Beta Blocker (Toprol 100mg tid).

Would change CAD to hypertension in the above.

>  A local
> cardiologist diagnosed CHF from a stress test with echocardiogram, however
> Howard Wayne disputed diagnosis and said EF was actually around 60%.  Wayne
> prescribed the medical treatment above.

CHF is a clinical diagnosis that does not directly involve EF.  Folks
can have the clinical diagnosis of CHF even with a normal EF (ie
EF>50%).

> Recently, I noticed both BP control and BG control were slipping.  Eventually, I
> felt so bad I could not postpone a trip to the endo any longer.  Lab work
> revealed a BUN of around 60, and a Creatinine of around 3.  All drugs except
> Toprol were discontinued.  Insulin was started.  There was a immediate
> improvement in the Creatinine to 1.7.

The latter is still not normal.

> Peripheral edema immediately went nuts (it had flared previously during an
> earlier attempt to halve the HCTZ dose).  Shortness of breathe and exhaustion
[quoted text clipped - 3 lines]
> (40 mg BID) has been continued for the two weeks since discharge, with about
> another 10 pounds of fluid loss.

It is the pulmonary edema that would secure the diagnosis of CHF here.

> I am breathing 100% better and sleeping wonderfully, finally.  Dry weight has
> likely been achieved or very nearly achieved.  BP is being well (or perhaps
[quoted text clipped - 9 lines]
> simply the result of  the acute renal failure and the additional fluid load the
> has now been shed.  In other words, what disease am I treating?

The diagnosis is CHF.

> Am I
> over-medicated and on the CHF cocktail?  What is the best strategy (assuming
> revascularization is out of the question).  This is somewhat of an academic
> exercise, but it seems important to know if I am treating real CHF or if the CHF
> was quasi-transitory and was just a consequence of renal failure.

It is likely the CHF, the renal failure, the poor blood pressure
control, and the worsening type-2 diabetes are all consequences of the
PIACs from VAT.

> Am I misunderstanding the entire presentation of the problem?

See above.

Be hungrier, which is truly healthier for mind, body, and soul:

http://groups.google.com/group/sci.med.cardiology/msg/991d4e30704307e7?

Marana tha

Prayerfully in the awesome name of our Messiah, LORD Jesus Christ,

Andrew <><
--
Andrew B. Chung, MD/PhD
Board-certified Heart Doctor
and Author of "Be Hungry"
http://NetCabal.com
"Don't be left behind as were Cleopas and Simon ...
... -----------------> be hungry ! ! !"

http://groups.google.com/group/sci.med.cardiology/msg/9642aafa0aad16eb?

Only the truth can cure the "hunger is starvation" delusion:
http://groups.google.com/group/sci.med.cardiology/msg/74281ab7d7ce78de?
analog@logwell.com - 16 Jun 2009 17:28 GMT
>It remains possible that you have no **occlusive** CAD.

*Wanna bet?  That would be nice, but not very likely.

>> BG was well controlled with Metformin and CAD was treated
>> with mild diuretic (originally Moduretic, later just HCTZ 50 mg bid), ACE
>> Inhibitor (Monopril 40 mg bid), and Beta Blocker (Toprol 100mg tid).
>
>Would change CAD to hypertension in the above.

*Yes, technically correct.  However, we can be pretty dern sure I have CAD
especially with the stable angina symptoms.  In defense of the notion CAD is not
present, I seldom had or have real pain, but rather what I have been calling
angina is a sort of discomfort that I suppose could be a manifestation of CHF
without CAD.  But I would bet heavily on some degree of CAD (what 57 year old
lazy overweight diabetic male will not have at least a trace of CAD?).


>> Recently, I noticed both BP control and BG control were slipping.  Eventually, I
>> felt so bad I could not postpone a trip to the endo any longer.  Lab work
[quoted text clipped - 3 lines]
>
>The latter is still not normal.
*Understood, of course.  1.7 is taken to be around 50% kidney function.  I am
getting ready to do a true 24 hour Creatinine elimination test in the next few
days to find out for sure where the kidneys stand.  When I was at 1.3 some years
ago, the 24 four elimination rate was 124, so I may nit be quite as bad as it
sounds (I hope).

>It is the pulmonary edema that would secure the diagnosis of CHF here.  

*Also understood.  But can CHF be transitory?  The essence of my dilemma is I do
not understand exactly what I am now trying to treat with drug therapy.  Before,
I always assumed I was dealing with CAD and followed Howard's philosophy.
However if I am now treating CHF, then I need to deal with the Digoxin, the
Sporonolactone, etc, etc.  And of course, the more aggressive the drug therapy,
the more risk to the kidneys.

>The diagnosis is CHF.

*Once a victim of CHF, always a CHF sufferer?  Is CHF always a disease in and of
itself, or can it merely be the consequence of some other underlying condition
like renal failure.  Philosophically, do doctors always use the CHF drug
cocktail long term?

>It is likely the CHF, the renal failure, the poor blood pressure
>control, and the worsening type-2 diabetes are all consequences of the
>PIACs from VAT.

*PIACs?
Andrew B. Chung, MD/PhD - 16 Jun 2009 18:37 GMT
Syd wrote:
> Andrew, in the Holy Spirit, boldly wrote:
>
>>It remains possible that you have no **occlusive** CAD.
>
>*Wanna bet?  That would be nice, but not very likely.

"... with GOD all things are possible." -- LORD Jesus Christ (Matthew
19:26)

Amen.

>>> BG was well controlled with Metformin and CAD was treated
>>> with mild diuretic (originally Moduretic, later just HCTZ 50 mg bid), ACE
[quoted text clipped - 7 lines]
>angina is a sort of discomfort that I suppose could be a manifestation of CHF
>without CAD.

Chest discomfort also happens with high blood pressure in the setting
of hypertensive heart disease especially when significant concentric
left ventricular hypertrophy is present.

>  But I would bet heavily on some degree of CAD (what 57 year old
> lazy overweight diabetic male will not have at least a trace of CAD?).

Trace of CAD is not the same as **occlusive** CAD.

>>> Recently, I noticed both BP control and BG control were slipping.  Eventually, I
>>> felt so bad I could not postpone a trip to the endo any longer.  Lab work
[quoted text clipped - 9 lines]
>ago, the 24 four elimination rate was 124, so I may nit be quite as bad as it
>sounds (I hope).

(share that hope with you)

>>It is the pulmonary edema that would secure the diagnosis of CHF here.  
>
[quoted text clipped - 4 lines]
>Sporonolactone, etc, etc.  And of course, the more aggressive the drug therapy,
>the more risk to the kidneys.

The brain and lungs are typically less tolerant of aggressive CHF
therapy than the kidneys.

>>The diagnosis is CHF.
>
>*Once a victim of CHF, always a CHF sufferer?  Is CHF always a disease in and of
>itself, or can it merely be the consequence of some other underlying condition
>like renal failure.  Philosophically, do doctors always use the CHF drug
>cocktail long term?

Practically, doctors prescribe CHF drug regimens long term.

>>It is likely the CHF, the renal failure, the poor blood pressure
>>control, and the worsening type-2 diabetes are all consequences of the
>>PIACs from VAT.
>
>*PIACs?

*P*ro-*i*nflammatory *a*dipo*c*ytokines

Suggested reading:

http://HeartMDPhD.com/BeHealthier

Love in the truth,

Andrew <><
--
Andrew B. Chung, MD/PhD
Board-certified Cardiologist
and Author of "Be Hungry"
http://NetCabal.com
"Don't be left behind as were Cleopas and Simon ...
... -----------------> be hungry ! ! !"

"... no one can say 'Jesus is LORD' except by the Holy Spirit." (1 Cor
12:3)
http://groups.google.com/group/sci.med.cardiology/msg/035c93540862751c?

What are the keys of the Kingdom of Heaven?
http://groups.google.com/group/sci.med.cardiology/msg/980b41e6999de315?

Only the truth can cure the "hunger is starvation" delusion:
http://groups.google.com/group/sci.med.cardiology/msg/74281ab7d7ce78de?
analog@logwell.com - 16 Jun 2009 19:08 GMT
>Syd wrote:
>> Andrew, in the Holy Spirit, boldly wrote:

>Chest discomfort also happens with high blood pressure in the setting
>of hypertensive heart disease especially when significant concentric
>left ventricular hypertrophy is present.

*That is exactly what Howard said was wrong with me.  Really, the basis of his
philosophy was that most angina-like symptoms were related to high blood
pressure, or at least exertional high blood pressure.

>The brain and lungs are typically less tolerant of aggressive CHF
>therapy than the kidneys.

*Interesting.  How are they affected?  Why has the endo harped on the HCTZ or
the ACE Inhibitor causing the original kidney failure?

>Practically, doctors prescribe CHF drug regimens long term.

*Is that always prudent, or just a matter of convention?

Sorry for so many questions, but I am not happy until I understand a problem.
Andrew B. Chung, MD/PhD - 16 Jun 2009 19:20 GMT
Syd wrote:
> Andrew, in the Holy Spirit, boldly wrote:
>> Syd wrote:
[quoted text clipped - 7 lines]
>philosophy was that most angina-like symptoms were related to high blood
>pressure, or at least exertional high blood pressure.

This would make it less likely that you truly have **occlusive** CAD.

>>The brain and lungs are typically less tolerant of aggressive CHF
>>therapy than the kidneys.
>
>*Interesting.  How are they affected?

The brain is **starved** by hypoperfusion.

The lungs have more airway dysfunction with beta blockade.

> Why has the endo harped on the HCTZ or
> the ACE Inhibitor causing the original kidney failure?

Your endocrinologist is not a nephrologist.

>>Practically, doctors prescribe CHF drug regimens long term.
>>
> *Is that always prudent, or just a matter of convention?

Matter of necessity.  Truly, the only time when we see people come off
of CHF medications is when people lose their VAT (visceral adipose
tissue).

>Sorry for so many questions, but I am not happy until I understand a problem.

It is GOD who has put the desire for knowledge and understanding in
your heart.

Be hungrier, which really is much healthier for the heart:

http://TheWellnessFoundation.com/BeHealthier

Love in the truth,

Andrew <><
--
Andrew B. Chung, MD/PhD
Board-certified Cardiologist
and Author of "Be Hungry"
http://NetCabal.com
"Don't be left behind as were Cleopas and Simon ...
... -----------------> be hungry ! ! !"

"... no one can say 'Jesus is LORD' except by the Holy Spirit." (1 Cor
12:3)
http://groups.google.com/group/sci.med.cardiology/msg/035c93540862751c?

What are the keys of the Kingdom of Heaven?
http://groups.google.com/group/sci.med.cardiology/msg/980b41e6999de315?

Only the truth can cure the "hunger is starvation" delusion:
http://groups.google.com/group/sci.med.cardiology/msg/74281ab7d7ce78de?
Sensei - 18 Jun 2009 00:25 GMT
Taking "Dr" Chung's advice is a oneway ticket to death:

Andrew Chung:

Is a frequent and proven liar (evidence archived forever on Google)

Has lost numerous NNTP accounts with supernews and others, has had many
Google accounts nuked, and his vanity domain heartmdphd.com is now
banned from setting up accounts. He is instead using multiple Google
sock accounts and email addresses in the format lo...@thetruth.com (#
being a number)

Is unemployed after being sacked with cause from his one and only job
after just over 80 days

Fled the state of Florida, and now claims to practice in Georgia despite
having no admission priveliges in the State's hospitals

Runs a phony foundation with a total declared income of circa $200, the
ownership and contact details of which are obfuscated on its website

Makes failed prophecies concerning earthquakes with areas and dates,
which don't happen (remember the bible quotes about false prophets)

Performed a public attempt at 'exorcising' a Malaysian sock on usenet,
then denied doing it. He has recently reversed position again and admits
to practicing exorcism by usenet, proving himself a liar in the process.

Promotes a dangerous diet, with a million dollar guarantee that he
demands thirty dollars to access details of. This despite being
unemployed. His soliciting and spamming for donations looks to be
similar to the Nigerian Advance Fee Fraud, where victims pay money
upfront in the hope of coming into riches but find they have merely
bought into a lie. Part of his advice is to pour nail polish remover onto
food.

Declares he has a cardiology practice despite posting night and day from
the same IP address (his home presumably) or a coffee shop internet cafe

Makes further false prophecies that we should now be all dying in a bird
flu pandemic. When these fail to happen, he does them all over again and
changes the dates. Nuclear war is another Chung spciality, which
naturally doesn't happen when he says it is going to.

Worships evil hatemonger Fred Phelps and will not denounce the acts of
Westboro's congregation. He even accuses someone with the name Phelps of
being Fred's son and refuses to accept he is completely wrong.

Uses the same patter as Pat Robertson, indicating his religious activity
is confined to watching cable TV. No evidence Chung has ever attended a
church.

Has a tendency to cyberstalk, particularly women. His wife fled some
time ago to another state, an act which Chung tries to pass off as "being
on vacation".

Frequently passes himself off as being qualified in areas such as
endocrinology, despite making incredibly fundamental blunders in his
'advice'. It is no wonder the Florida heart facility terminated him, and
has publicly denounced his version of events. Again archived on Google.

Don't forget the fake fast, where he didn't lose any weight, as well as
the infamous 666 stamping fiasco. His latest vile trick is spamming the
blogs of dying cancer patients and then crowing triumphantly when they
pass away.
Andrew B. Chung, MD/PhD - 19 Jun 2009 11:07 GMT
http://groups.google.com/group/sci.med.cardiology/msg/cd948ac59bc892fe?

<><

"The lot is cast into the lap,  but its every decision is from the
LORD." (Proverbs 16:33)

Amen.

A Spirit-guided exegesis of Proverbs 16:33 ...

http://groups.google.com/group/sci.med.cardiology/msg/085dcffcafb7e4e2?

Nothing happens by chance because everything happens only as GOD
allows it (Ecclesiastes 9:11):

http://groups.google.com/group/sci.med.cardiology/msg/21527d1832960109?

Sign that GOD can easily unleash an H5N1 Pandemic (Pan-Flu) at any
time:

http://groups.google.com/group/sci.med.cardiology/msg/a4581567229974c0?

What we are teaching to prepare folks for the eventuality of a
catastrophic Pan-Flu:

http://www.youtube.com/watch?v=jfmkax1wbRU

How to not be fearful:

Trust the truth, Who is Jesus !!!

http://T3WiJ.com

May dear neighbors, friends, and brethren have a blessedly wonderful
2009th year since the birth of our LORD Jesus Christ as our Messiah,
the Son of Man ...

... by being hungrier:

http://groups.google.com/group/sci.med.cardiology/msg/f891e617d10bd689?

Hunger is wonderful ! ! !

It's how we know the answer to the question "What does Jesus
want?" (WDJW):

http://WDJW.net

Yes, hunger is our knowledge of good versus evil that Adam and Eve
paid for with their and our immortal lives:

http://groups.google.com/group/sci.med.cardiology/msg/52a3db8576495806?

Hunger is the physical "hearts burning within us" feeling that unlocks
the 4 mysteries of the "Road to Emmaus" adventure described in Luke
24:

http://groups.google.com/group/sci.med.cardiology/msg/386f56c2f6d0b154?

Moreover, being hungrier is the key to being Jesus' disciples:

http://groups.google.com/group/sci.med.cardiology/msg/bd20d7c4fe878897?

Being physically hungrier is how we will physically recognize Jesus
when He physically returns for us to meet Him physically in the air:

http://groups.google.com/group/sci.med.cardiology/msg/ffa6609710ea9587?

"Blessed are you who hunger NOW...

... for you will be satisfied." -- LORD Jesus Christ (Luke 6:21)

Amen.

Here is a Spirit-guided exegesis of Luke 6:21 given in hopes of
promoting much greater understanding:

http://groups.google.com/group/sci.med.cardiology/msg/cc2aa8f8a4d41360?

Jesus is LORD, forever !!!

http://JiL4ever.net

Be hungrier, which is truly healthier for mind, body, and soul:

http://groups.google.com/group/sci.med.cardiology/msg/991d4e30704307e7?

Marana tha

Prayerfully in the awesome name of our Messiah, LORD Jesus Christ,

Andrew <><
--
Andrew B. Chung, MD/PhD
Board-certified Cardiologist
and Author of WDJW:
http://en.wikipedia.org/wiki/What_does_Jesus_want%3F

"... no one can say 'Jesus is LORD' except by the Holy Spirit." (1 Cor
12:3)
http://groups.google.com/group/sci.med.cardiology/msg/035c93540862751c?

What is the name of Jesus' church where Peter serves as its rock?
http://groups.google.com/group/sci.med.cardiology/msg/42a30476ef3925ec?

Only the truth can cure the "hunger is starvation" delusion:
http://groups.google.com/group/sci.med.cardiology/msg/74281ab7d7ce78de?
 
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