Question

Subjective:

Medical History: Mr. XN, a 60 yr old SE Asian male, was referred via dialysis unit for cardiac rehabilitation after PCI. He had severe dyspnea and chest pain on mild exertion. He had a 6 mo dialysis history. Body mass was 70 kg. Resting echo revealed left ventricular ejection fraction of 12%. Hemoglobin was 10g · dL–1.

Medications: Carvedilol 25 mg daily, enalnopril 20 mg once daily, aspirin, Plavix, and atorvastatin.

Objective and Laboratory Data:

Stress Echo:

Baseline: Cycled at 60 rpm starting at 10 W, increasing 10 W min–1. Finished after 6.15 min at 70 W. Peak V̇O2 12.9 mL · kg–1 · min–1.

Baseline: Severe LV dysfunction 12.1%, Diastology E/A 0.66, DT 355 ms, E/e’ 19.1

Assessment and Plan:

Exercise Prescription and Interventions: Exercise rehabilitation, EPO administration to address anemia due to renal failure, revascularization (PCI).

• We know that mean peak V̇O2 (for a 70 kg person this is only a peak of 840 mL O2!) of heart failure patients in exercise studies is around 12-13 mL · kg–1 · min–1 or 3.7- 4.0 METs* (Smart 2004 AJM).

• So moderate intensity @40-60% would require the patient to exercise at 5.0-7.2 mL · kg–1 · min–1 or 1.4-2.1 METs, which for a 70 kg person is equivalent to cycling at a low wattage of 25 W. However to obtain benefits we would like the person to cycling continually for 15-20 min, building over several weeks to perhaps 30 min. Mr. XN, however, could only manage 5-6 min continuous cycling at the outset so we adopted another approach.

• High intensity@ 85-95% would be 10.9 mL · kg–1 · min–1 (85% peak V̇O2) or 3.1 METs, this is equivalent to cycling at 42 W (illustrating the importance of having cycling equipment that can be titrated to within 2 W accuracy).

• Difference between moderate and high intensity is approximately 1.0 MET (which is relatively small).

• With recovery between intervals in HIT—to attenuate physical stress of 3 min at rest or preferably recovery at about 30-40% peak V̇O2 (initially), as Mr. XN improves we would challenge them to recover at 40-60% peak V̇O2.

• Easily below the requirements of independent living (5.5 METs) so training at high intensity will not likely expose people (with chronic disease) to efforts they are not already routinely experiencing multiple times daily.

Patient Progress:

Base 8 wk 16 wk 52 wk EDV (mL) 232 201 166 193 ESV (mL) 204 153 89 102 LVEF (%) 12.1 24.3 46.7 47.2 Peak V̇O2 12.9 15.8 17.8 16.2 Minnesota Living with Heart Failure Total Score Max 30 27 23 20 21

Case Study Discussion Questions:

1. Do you think Mr. XN would be eligible for a heart transplant? Please justify your answer.

2. Do you think Mr. XN should have had CABS? Please justify your answer.

3. With respect to his change in cardiac function baseline to 52 wk, do you think this is typical?

4. What might explain why relative change in peak V̇O2 at 52 wk was much less than the relative change in cardiac function?

5. Was the change in Minnesota score clinically significant?

please help me with this case study, this is all the information that is provided and is enough information to answer the questions, thank you!!

Answer 1

Poor prognosis of heart transpoant patients with renal faillulre,Chronic kidney diasease and end stage renal failure are major complication after heart transplant.The aim of this study is to compare survival in heart transplant vs non heart transplant patient starting dialysis,

The impact of the degree of renal dysfunction in patient undergoing coronory artery bypass grafting ranging form normal to dialysis depends is not well defined, THe preoperative RD is common in the CABG population and is assocciated with diminnished long term survival improved early outcomes in patient with RD undergoing opcab diminished with RD.

Change in Minnesota living with heart faioure a five point change in MLHFQ is considered clinically with significant worse survival, A change of 5 point is considered clinically significant.