OpenHealth Q&A

Understanding Severe Heart Failure and Ejection Fraction Decline

Greetings everyone, I am reaching out to gain insight into the underlying mechanisms and rationale regarding a concerning medical situation; I do not aim to supplant professional medical advice. Please bear with me, as the circumstances are dire and I am struggling to comprehend the necessary steps to advocate effectively. This inquiry involves my uncle, a 52-year-old man residing in Azerbaijan, who faces challenges due to limited availability of specialized medical services and private healthcare options, largely due to financial limitations. I am working diligently to organize donations and assess insurance options, but I am keen to understand the current situation better so that I might advocate more effectively on his behalf. ### Personal and Medical Background: - **Age:** 52 years - **Lifestyle:** Smoker with occasional alcohol use, notably sedentary and mostly bed-bound, with no regular physical activity. - **Dietary Concerns:** Historical lack of dietary management, likely resulting in elevated sodium intake. - **Mental Health:** Exhibits significant depressive symptoms and psychosocial stressors. ### Cardiac History: - Experienced four heart attacks. - Received four coronary stents. - Has an implanted ICD (defibrillator). - Diagnosed with Heart Failure with Reduced Ejection Fraction (HFrEF). - Ejection Fraction (EF) was around 40% post-heart attacks but has steadily declined to approximately 12% over two years. - Consistently low blood pressure. Initially, when his EF was around 40%, he began a medical regimen, though his cardiologist cautioned him, stating, "it’s only downhill from here." This statement has prompted my desire for further understanding. ### Current Medication Regimen (unchanged for about two years): - **Sacubitril/valsartan (Yuperio):** 24/26 mg - **Empagliflozin** - **Torasemide:** 10 mg - **Spironolactone:** 50 mg - **Atorvastatin:** 20 mg ⚠️ **Key Concern:** He has faced difficulties adhering to his medication regimen at times due to cost and availability, occasionally missing doses for up to four days until he can afford the scripts. ### Additional Medical Concerns: - Possible chronic kidney disease. - Suspected congestive hepatopathy with potential ascites. - Severe swelling in both legs accompanied by purple discoloration. - A vague history of leg thrombosis. - Can walk only about five minutes due to intense leg pain and fatigue. ### Recent Events: - Experienced acute nocturnal shortness of breath, prompting an ambulance call, administration of IV medications, significant hypotension, but no hospitalization. - Following day, he suffered from severe body aches and exhaustion, with an ambulance providing pain relief. ### Primary Inquiry: My main question centers around why, despite being treated with guideline-recommended pharmacotherapy (including ARNI, SGLT2i, MRA, and loop diuretics), his EF continues to deteriorate instead of stabilizing or showing any degree of improvement. I have several considerations that puzzle me: - Could this decline be attributed to irreversible myocardial damage or scarring from his repeated heart attacks? - Might the low dosing of ARNI and the lack of titration explain the absence of improvement? - How significantly does intermittent non-adherence affect cardiac remodeling and the trajectory of ejection fraction? - What is the impact of ongoing ischemia in conjunction with cardiomyopathy and cardiorenal syndrome? - Is it possible that any potential for EF improvement was unrealistic in his situation? I recognize that the prognosis may not be favorable — I am not seeking false reassurances. My goal is to glean a clearer understanding of the physiological dynamics at play and to assess whether expectations for improvement were misplaced from the beginning. Thank you to anyone who can provide clarification or highlight important considerations in this matter.

Answers (1)

2/5/2026, 3:10:47 PM

OpenHealth AI

I'm truly sorry to hear about your uncle's situation. It sounds very complex and challenging, especially given the limited access to healthcare. I'll help clarify some aspects of heart failure, especially regarding his declining ejection fraction (EF) and factors that could affect his condition.

Key Points:

1. Understanding Ejection Fraction Decline:

   • Ejection fraction (EF) measures how well the heart pumps blood. In heart failure patients, a decline in EF can indicate worsening heart function and is often linked to irreversible damage from previous heart attacks.

2. Factors Contributing to Decline:

   • Irreversible Myocardial Damage: His history of multiple heart attacks raises the likelihood of scarring, which can impact heart performance.
   • Medication Adherence: Intermittent non-adherence to prescribed medications can hinder effective management. Missing doses can destabilize heart function, exacerbating symptoms.
   • Low Dosage and Lack of Titration: Medications like sacubitril/valsartan often need to be titrated to effective doses to maximize benefits. The current dosing might not be sufficient for optimal results.

3. Physiological Challenges:

   • Ongoing Ischemia: Reduced blood flow due to coronary artery disease can lead to further heart muscle damage and prevent recovery.
   • Cardiorenal Syndrome: Issues with the kidneys can further complicate heart failure, impacting treatment outcomes.

Actionable Guidance:

1. Medication Adherence:

   • Prioritize Consistency: Advocate for a plan to ensure he can consistently access necessary medications, possibly including exploring generics or aid programs.
   • Track Medications: Keep a daily pill organizer to help manage doses.

2. Cardiac Monitoring:

   • Daily Symptom Check: Monitor for worsening symptoms like increased swelling, breathlessness, or fatigue. Note any changes in his condition.

3. Lifestyle Modifications:

   • Nutrition: Emphasize a low-sodium diet to help manage heart failure symptoms and reduce fluid retention. Engage family members to help him adhere to dietary changes.
   • Physical Activity: Encourage slight physical activities, even short walks as tolerated, to improve circulation, if possible.

4. Communication with Healthcare Providers:

   • Prepare for Appointments: List all concerns and observations regarding his health to discuss thoroughly with his healthcare provider, especially regarding medication adjustments and the possibility of changing or increasing doses.
   • Engage in Support Resources: Seek local or online support groups for heart failure to connect with others facing similar challenges.

5. Mental Health Support:

   • Psychosocial Needs: Addressing his depressive symptoms is crucial. Consider looking into support options or therapy that can assist him emotionally.

Conclusion:

While prognosis can be challenging in cases of severe heart failure, actively managing medication, lifestyle factors, and seeking consistent care will help advocate for your uncle’s needs. It’s evident you care deeply for him, and your efforts can make a meaningful difference in navigating this difficult journey. Please reach out for further clarification on any specific points, and I wish you all the best in supporting your uncle through this.