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What Is The Ideal Dosage Of Amlodipine While Suffering From Heart Failure?
Question: I have just been changed from amlodipine 2.5 mg daily to 5 mg daily. I weigh 95 lbs, and am in left ventricular heart failure with respiratory alkalosis and compensatory metabolic acidosis. This is a result of too high a dose of RF during an ablation for atrial flutter a year ago. The flutter is gone, but it left me w/ pericarditis, severe dyspnea. All pulmonary function tests are normal, PO2 is 100%, but ABG's are very abnormal. I have angina---they think from cardiac syndrome X, which is most likely just concurrent w/ the ablation complications.
What do I need to be concerned about with the new double dose of amlodipine? I know this is a normal dose for most adults, but I am 5'6" and 95 lbs. WOB burns up lots of calories. I am a critical care nurse, 64 years old, and basically very fit. I have had to give up many physical endeavors as I hit an anaerobic threshold very easily. I am a former Olympic athlete, and now just try to keep as fit as my heart allows.
Any other thoughts would be greatly appreciated. I am traveling from NC to CO (10,000 ft elevation) in a week. My Duke cardiologist told me to go, because he doesn't know how long I can live in my present state, unless my body heals itself. The ablation was NOT done at Duke.
Thank you! XXXXXXX ( YYYY@YYYY )
What do I need to be concerned about with the new double dose of amlodipine? I know this is a normal dose for most adults, but I am 5'6" and 95 lbs. WOB burns up lots of calories. I am a critical care nurse, 64 years old, and basically very fit. I have had to give up many physical endeavors as I hit an anaerobic threshold very easily. I am a former Olympic athlete, and now just try to keep as fit as my heart allows.
Any other thoughts would be greatly appreciated. I am traveling from NC to CO (10,000 ft elevation) in a week. My Duke cardiologist told me to go, because he doesn't know how long I can live in my present state, unless my body heals itself. The ablation was NOT done at Duke.
Thank you! XXXXXXX ( YYYY@YYYY )
Brief Answer:
I would explain as follows:
Detailed Answer:
Hello XXXXXXX
Welcome and thank you for asking on HCM!
First, I would like to tell you that I am glad to discuss with a critical care nurse, as it happened your question is answered by me, a cardiologist in intensive cardiac care unit.
I carefully passed through your medical history and I would like to explain you that there are some topics to be clarified:
-I would like to know the precise appearance of your heart failure symptomatology. Did it start before your cardiac ablation procedure and worsened after that, or your initial complaints appeared only after ablation?
As you have experienced pericarditis after cardiac ablation, it seems that this procedure has not lead to important complications.
The fact that your arterial blood gas analysis is abnormal, means that you may have pulmonary or renal dysfunction.
a-Pulmonary disorders may have been present before or just caused by cardiac ablation.
A well-known complication of cardiac ablation is phrenic nerve injury, which may lead to respiratory failure, expressed with dyspnea, increased breath working, and consequent acid-base disorders (respiratory acidosis) with compensatory metabolic alkalosis.
b-Renal dysfunction related to a primary renal disorder, or secondary to heart failure pathophysiology, could lead to acid-base disorders as well.
So, do you really have primary respiratory alkalosis?! With compensatory metabolic acidosis?!
Coming to this point, I would like to directly review your ABG test results. Please could you upload them for a direct review?
Also I would like to know whether your attending doctor has suspected or confirmed a possible post procedural phrenic nerve injury.
In addition, I would like to know your recent cardiac ultrasound report and any other available tests.
Only after reviewing the above mentioned tests, I could give a more professional opinion.
Regarding amlodipine, I would like to explain that 5mg could not be harmful to you, a long as you haven’t liver dysfunction or any known hypersensitivity to its active ingredients. Though, you have a low body weight, it can be well tolerated.
But meanwhile, I recommend you to closely monitor your blood pressure (to avoid possible excessive antihypertensive effect, leading to hypotension), and monitor for possible limb edema or any other new disturbances (amlodipine side effects).
I would like to be more helpful with my professional opinions. So please upload your available tests!
Hope to have been helpful!
Feel free to ask any other questions, whenever you need!
Kind regards,
Dr. Iliri
I would explain as follows:
Detailed Answer:
Hello XXXXXXX
Welcome and thank you for asking on HCM!
First, I would like to tell you that I am glad to discuss with a critical care nurse, as it happened your question is answered by me, a cardiologist in intensive cardiac care unit.
I carefully passed through your medical history and I would like to explain you that there are some topics to be clarified:
-I would like to know the precise appearance of your heart failure symptomatology. Did it start before your cardiac ablation procedure and worsened after that, or your initial complaints appeared only after ablation?
As you have experienced pericarditis after cardiac ablation, it seems that this procedure has not lead to important complications.
The fact that your arterial blood gas analysis is abnormal, means that you may have pulmonary or renal dysfunction.
a-Pulmonary disorders may have been present before or just caused by cardiac ablation.
A well-known complication of cardiac ablation is phrenic nerve injury, which may lead to respiratory failure, expressed with dyspnea, increased breath working, and consequent acid-base disorders (respiratory acidosis) with compensatory metabolic alkalosis.
b-Renal dysfunction related to a primary renal disorder, or secondary to heart failure pathophysiology, could lead to acid-base disorders as well.
So, do you really have primary respiratory alkalosis?! With compensatory metabolic acidosis?!
Coming to this point, I would like to directly review your ABG test results. Please could you upload them for a direct review?
Also I would like to know whether your attending doctor has suspected or confirmed a possible post procedural phrenic nerve injury.
In addition, I would like to know your recent cardiac ultrasound report and any other available tests.
Only after reviewing the above mentioned tests, I could give a more professional opinion.
Regarding amlodipine, I would like to explain that 5mg could not be harmful to you, a long as you haven’t liver dysfunction or any known hypersensitivity to its active ingredients. Though, you have a low body weight, it can be well tolerated.
But meanwhile, I recommend you to closely monitor your blood pressure (to avoid possible excessive antihypertensive effect, leading to hypotension), and monitor for possible limb edema or any other new disturbances (amlodipine side effects).
I would like to be more helpful with my professional opinions. So please upload your available tests!
Hope to have been helpful!
Feel free to ask any other questions, whenever you need!
Kind regards,
Dr. Iliri
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
I had normal pulmonary CPET pre and post ablation--all indications were cardiac dysfunction. The ablation is the cause of my current problems. Resting room air blood gases indicate chronic respiratory alkalosis w/ compensatory metabolic acidosis due to chronic hyperventilation. With exercise, pH falls due to the generation of lactic acid and absence of sufficient buffering capacity. This started suddenly immediately after the atrial ablation a year ago. The most likely hypothesis at this point is that the increase in respiratory rate and hypocapnia could have been initiated by injury to the irritant receptors of the lung or J-receptors or C fibers of the lung by high RF, which are carried by the afferent sensory vagal nerves from the lungs to the respiratory center in the brainstem. The phrenic nerve has not been injured--no diaphragm dysfunction. HTN is not well controlled, atypical chest pain--CRO microvascular disease/syndrome X suspected. Echo shows no abnormalities or shunting. Cardiac XXXXXXX shows left ventricular dysfunction w/ nmL EF.
I am in 2nd degree AV block on 12 lead ECG. ABG x2 is 7.48 pH, PCO2 25, PO2 129, bicarb, arterial 19, total CO2, arterial 19.
I am in 2nd degree AV block on 12 lead ECG. ABG x2 is 7.48 pH, PCO2 25, PO2 129, bicarb, arterial 19, total CO2, arterial 19.
Brief Answer:
My opinion as follows:
Detailed Answer:
Hi again, dear XXXXXXX
As you insist that respiratory alkalosis is the primary event of your ABG disorders and metabolic acidosis is just a compensatory consequence, I could say that once defining the exact reason of hyperventilation, your acid-base disorder could be controlled.
I would like to explain you, it is true that high RF during cardiac ablation may lead to neural endings injury inside the mediastinal space (structures surrounding the heart), but this is generally reversible after 9-12 months. So, ablation could not be a reliable cause for your persisting hyperventilation.
Coming to this point, as you refer that PH is 7.45; PCO2 25 mmHg and PO2 is 129 mmHg there is no chemo-stimulating reason for triggering hyperventilation (no acidosis, no hypercapnia, no hypoxemia), so the only reason to over–stimulate lung J receptors remain an abnormally elevated pulmonary arterial pressure.
This abnormally pulmonary pressure that could easily be detected by Doppler cardiac ultrasound or in the XXXXXXX lab (please upload you cardiac ultrasound report and ABG tests) may have two obvious reasons in your case:
(1) Heart failure; in this situation a properly controlled symptomatology by the adequate medical treatment would diminish this responsible cause. But, from the other side, heart failure is commonly associated with pulmonary acidosis (when acute severe pulmonary congestion is present) or metabolic acidosis when cardio-renal syndrome appears.
(2) Possible obstruction in pulmonary vein drainage. In such case pulmonary vein stenosis may be the reason. Cardiac ablation may also be complicated with pulmonary vein stenosis because of inflammation and fibrosis around pulmonary veins (consequence of RF procedures on site). At this point chest magnetic resonance imaging would be helpful in excluding this potential complication of cardiac ablation..
Regarding your actual therapy, it seems that there are some conflicting evidence: you declare the presence of second degree of AV block and meantime your maintaining therapy includes a beta-blocker??!! (Propranolol ER). Please could you explain better why this therapeutic attitude?
I insist for a direct review of your available medical tests (ECHO, ABG tests, other pulmonary tests, renal and liver function tests.
If nothing of the above alternatives on hyperventilation causes results rationale (true), then other reasons should be sought (liver disease, anxiety mediated hyperventilation, etc).
I hope my explanations will be of some help in providing you some more opinions.
I am sorry about my delayed response, because of some professional engagements.
Wishing you a pleasant weekend.
Regards,
Dr. Iliri
My opinion as follows:
Detailed Answer:
Hi again, dear XXXXXXX
As you insist that respiratory alkalosis is the primary event of your ABG disorders and metabolic acidosis is just a compensatory consequence, I could say that once defining the exact reason of hyperventilation, your acid-base disorder could be controlled.
I would like to explain you, it is true that high RF during cardiac ablation may lead to neural endings injury inside the mediastinal space (structures surrounding the heart), but this is generally reversible after 9-12 months. So, ablation could not be a reliable cause for your persisting hyperventilation.
Coming to this point, as you refer that PH is 7.45; PCO2 25 mmHg and PO2 is 129 mmHg there is no chemo-stimulating reason for triggering hyperventilation (no acidosis, no hypercapnia, no hypoxemia), so the only reason to over–stimulate lung J receptors remain an abnormally elevated pulmonary arterial pressure.
This abnormally pulmonary pressure that could easily be detected by Doppler cardiac ultrasound or in the XXXXXXX lab (please upload you cardiac ultrasound report and ABG tests) may have two obvious reasons in your case:
(1) Heart failure; in this situation a properly controlled symptomatology by the adequate medical treatment would diminish this responsible cause. But, from the other side, heart failure is commonly associated with pulmonary acidosis (when acute severe pulmonary congestion is present) or metabolic acidosis when cardio-renal syndrome appears.
(2) Possible obstruction in pulmonary vein drainage. In such case pulmonary vein stenosis may be the reason. Cardiac ablation may also be complicated with pulmonary vein stenosis because of inflammation and fibrosis around pulmonary veins (consequence of RF procedures on site). At this point chest magnetic resonance imaging would be helpful in excluding this potential complication of cardiac ablation..
Regarding your actual therapy, it seems that there are some conflicting evidence: you declare the presence of second degree of AV block and meantime your maintaining therapy includes a beta-blocker??!! (Propranolol ER). Please could you explain better why this therapeutic attitude?
I insist for a direct review of your available medical tests (ECHO, ABG tests, other pulmonary tests, renal and liver function tests.
If nothing of the above alternatives on hyperventilation causes results rationale (true), then other reasons should be sought (liver disease, anxiety mediated hyperventilation, etc).
I hope my explanations will be of some help in providing you some more opinions.
I am sorry about my delayed response, because of some professional engagements.
Wishing you a pleasant weekend.
Regards,
Dr. Iliri
Note: For further queries related to coronary artery disease and prevention, click here.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Answered by
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