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Is There A Direct Relationship Between Daily Fluid Intake And Urine Output?
Question: Dear Dr. Iliri,
I am in need of reassurance, yet again, as I am having trouble convincing myself that I don't need to go to the ER for testing. It's this continuing feeling that I am retaining fluid and going into heart failure while feeling quite normal. My only "symptom" is that while drinking quite a bit, about 2.5 L, I feel that my urine output is low. Actually upon measurement, it was not low, but as I've told you, I feel like I rarely have the urge to empty my bladder unless I press down on my abdomen. I feel very damaged and broken and like I will never be normal again.
One doctor in the ER told me if I had fluid retention, my weight would quickly go up 10-15 lbs and my feet/legs/ankles would be swollen. My morning weight is stable and I don't have visible edema or breathing issues but I didn't even when I was diagnosed last year with an EF of 25 and ProBNP of 8000. It has now been 2 months since last echo and complete blood work. Are you quite certain nothing could have changed? I am not scheduled for tests for many months and am finding it difficult not to go to ER for reassurance. My regular cardio and EP both say I need no tests. I am just so frightened because I felt OK a year ago,yet was admitted into the hospital in critical condition. How can I trust I am still ok when I felt ok even when very sick?
Thank you so much, dear Dr Iliri. I hope you are well and that your patients are less hard-headed and anxious than I am.
Many many thanks,
XXXX
I am in need of reassurance, yet again, as I am having trouble convincing myself that I don't need to go to the ER for testing. It's this continuing feeling that I am retaining fluid and going into heart failure while feeling quite normal. My only "symptom" is that while drinking quite a bit, about 2.5 L, I feel that my urine output is low. Actually upon measurement, it was not low, but as I've told you, I feel like I rarely have the urge to empty my bladder unless I press down on my abdomen. I feel very damaged and broken and like I will never be normal again.
One doctor in the ER told me if I had fluid retention, my weight would quickly go up 10-15 lbs and my feet/legs/ankles would be swollen. My morning weight is stable and I don't have visible edema or breathing issues but I didn't even when I was diagnosed last year with an EF of 25 and ProBNP of 8000. It has now been 2 months since last echo and complete blood work. Are you quite certain nothing could have changed? I am not scheduled for tests for many months and am finding it difficult not to go to ER for reassurance. My regular cardio and EP both say I need no tests. I am just so frightened because I felt OK a year ago,yet was admitted into the hospital in critical condition. How can I trust I am still ok when I felt ok even when very sick?
Thank you so much, dear Dr Iliri. I hope you are well and that your patients are less hard-headed and anxious than I am.
Many many thanks,
XXXX
Brief Answer:
My opinion as follows:
Detailed Answer:
Dear XXXX,
I would like to explain you again that, there is not such a direct relationship between daily fluid intake and urine output, as several other factors interfere in non-visible fluid losses contribution.
So, I strongly encourage you to disregard such an erroneous method of checking your body fluid form comparing strictly water drinking with urine output.
That bladder compression ritual is not acceptable for such an intelligent and sensible person you are.
Your previous cardiomyopathy (which in fact was completely reversible) wasn't so silent as you think. It was the arrhythmia, general body discomfort, decrease physical performance, etc. which signify a real symptomatology. Only acute heart decompensation may be expressed with a more severe clinical picture; while your cardiomyopathy has been configured for a much longer time (permitting arrhythmia to produce such adverse effects).
Regarding fluid retention, I would explain that human body may retain around 4 - 5 liters of fluids without overt edema.
But, that is not your case.
With a normal functioning heart, without clinically obvious heart failure, and without any precipitating factors for such a scenario, such a pessimistic hypothesis is quite impossible.
So relax my dear!
You are completely healthy and your heart is perfectly normal!
I believe with a little help you will be able to get stronger mind, and suppress your fears and unpleasant thoughts.
Wishing you a pleasant weekend!
Kind regards,
Dr. Iliri
My opinion as follows:
Detailed Answer:
Dear XXXX,
I would like to explain you again that, there is not such a direct relationship between daily fluid intake and urine output, as several other factors interfere in non-visible fluid losses contribution.
So, I strongly encourage you to disregard such an erroneous method of checking your body fluid form comparing strictly water drinking with urine output.
That bladder compression ritual is not acceptable for such an intelligent and sensible person you are.
Your previous cardiomyopathy (which in fact was completely reversible) wasn't so silent as you think. It was the arrhythmia, general body discomfort, decrease physical performance, etc. which signify a real symptomatology. Only acute heart decompensation may be expressed with a more severe clinical picture; while your cardiomyopathy has been configured for a much longer time (permitting arrhythmia to produce such adverse effects).
Regarding fluid retention, I would explain that human body may retain around 4 - 5 liters of fluids without overt edema.
But, that is not your case.
With a normal functioning heart, without clinically obvious heart failure, and without any precipitating factors for such a scenario, such a pessimistic hypothesis is quite impossible.
So relax my dear!
You are completely healthy and your heart is perfectly normal!
I believe with a little help you will be able to get stronger mind, and suppress your fears and unpleasant thoughts.
Wishing you a pleasant weekend!
Kind regards,
Dr. Iliri
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you so much dear Dr. Iliri,
Your words and knowledge are so reassuring and despite my continuing anxiety, are helping me more than you can know.
On one level, I trust and believe my doctors, but there is a part of my brain which just feels fear on a primal level which doesn't respond to rational explanations. I am in therapy and medications but I have limited success when I am told such cliched notions as "loving myself" will cure my PTSD.
So it is quite impossible that my heart would be weak just 7 weeks after echo measured EF at 65-70? I worry so much because just three weeks before that echo, echo was 55-60. I think then that it could easily change downwards and 50-55 or 45-50. Is that not possible? So many worries just swim through my head and only tests can reassure me and only briefly. I wish there was home echo like there is home blood pressure measuring. You are quite sure more frequent testing is not necessary?
Thank you for everything, Dr. Iliri. You are helping me so much. I haven't been to the ER in two months and before talking to you, I was going every week in a panic.
Thank you so much,
XXXX
Your words and knowledge are so reassuring and despite my continuing anxiety, are helping me more than you can know.
On one level, I trust and believe my doctors, but there is a part of my brain which just feels fear on a primal level which doesn't respond to rational explanations. I am in therapy and medications but I have limited success when I am told such cliched notions as "loving myself" will cure my PTSD.
So it is quite impossible that my heart would be weak just 7 weeks after echo measured EF at 65-70? I worry so much because just three weeks before that echo, echo was 55-60. I think then that it could easily change downwards and 50-55 or 45-50. Is that not possible? So many worries just swim through my head and only tests can reassure me and only briefly. I wish there was home echo like there is home blood pressure measuring. You are quite sure more frequent testing is not necessary?
Thank you for everything, Dr. Iliri. You are helping me so much. I haven't been to the ER in two months and before talking to you, I was going every week in a panic.
Thank you so much,
XXXX
Brief Answer:
I will be happy offering the necessary support to you.
Detailed Answer:
Dear XXXX,
I know it’s difficult to deal with irrational thoughts and persisting fears, as they are part of a strong obsession and needs compulsive actions to be released (like frequent echos and several lab tests).
But, you have to try and disrupt this persisting chain, which is conditioning your daily activity.
You are on the right way of dealing with your anxiety. Almost another couple of weeks out of ER and I believe you are done.
As such hypothetical echo results deviations (as you fear) couldn’t be possible on a completely limpid blue sky (without a minimal warning sign), there is no need to have those tests so frequently.
You need to decondition yourself from those useless tests.
Having echo equipment at home wouldn’t yield a better result than you are actually experiencing, as cardiac physiology is more stable than could be imagined.
No pathological process, other than heart attack or a severe acute heart inflammation (infection) could change your cardiac function so abruptly.
But, fortunately that is not your case. You are a young woman, free of those adverse heart implications.
The only compulsion you are advised to follow is just to relax, and remember that you are stronger than you feel.
Probably you need further reassurance and I will be happy offering the necessary support to you.
But, meanwhile you encourage you to review our discussions and try to practice meditation as a powerful tool to clear up you mind.
Hope you are heaving a relaxing weekend!
Kind regards,
Dr. Iliri
I will be happy offering the necessary support to you.
Detailed Answer:
Dear XXXX,
I know it’s difficult to deal with irrational thoughts and persisting fears, as they are part of a strong obsession and needs compulsive actions to be released (like frequent echos and several lab tests).
But, you have to try and disrupt this persisting chain, which is conditioning your daily activity.
You are on the right way of dealing with your anxiety. Almost another couple of weeks out of ER and I believe you are done.
As such hypothetical echo results deviations (as you fear) couldn’t be possible on a completely limpid blue sky (without a minimal warning sign), there is no need to have those tests so frequently.
You need to decondition yourself from those useless tests.
Having echo equipment at home wouldn’t yield a better result than you are actually experiencing, as cardiac physiology is more stable than could be imagined.
No pathological process, other than heart attack or a severe acute heart inflammation (infection) could change your cardiac function so abruptly.
But, fortunately that is not your case. You are a young woman, free of those adverse heart implications.
The only compulsion you are advised to follow is just to relax, and remember that you are stronger than you feel.
Probably you need further reassurance and I will be happy offering the necessary support to you.
But, meanwhile you encourage you to review our discussions and try to practice meditation as a powerful tool to clear up you mind.
Hope you are heaving a relaxing weekend!
Kind regards,
Dr. Iliri
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you Dr Iliri. I am so anxious(as you well know) but something you said was very interesting. Because I was young and healthy, it seemed the cardiomyopathy came out of the blue and I feel so fragile like heart can instantly just fail- from healthy one day to heart failure the next. My pre-ablation holter showed 65,000 PVCs over 24 hours which I had been having for 5 months. Without such an extreme level of PVCs, is my heart stable? I am terrified if I feel a single PVC or my pulse feels faint or of course the crazy fluid obsession. I am trying to absorb what you have said about the heart being resilient and strong and not as changeable and fragile as I seem to think.
I have been on lowered carvedilol for 2 weeks and heart rate remains below 60 most of the time. Is this definitely my increased exercise and not a sign of trouble? before I was exercising, heart rate was under 60 at rest but would quickly go up to 70-80 with just mild exertion. I was very fit before cardiomyopathy and Coreg and typically HR was about 60.
Perhaps I should volunteer to become a cyborg as my research is in this area of robotics. Perhaps even a computerized heart could fail, though. I am just looking for certainty in a body and world which will never be able to make promises.
Hope you are having a good weekend. Thank you so much for all of your help.
Best to you, wonderful doctor.
XXXX
I have been on lowered carvedilol for 2 weeks and heart rate remains below 60 most of the time. Is this definitely my increased exercise and not a sign of trouble? before I was exercising, heart rate was under 60 at rest but would quickly go up to 70-80 with just mild exertion. I was very fit before cardiomyopathy and Coreg and typically HR was about 60.
Perhaps I should volunteer to become a cyborg as my research is in this area of robotics. Perhaps even a computerized heart could fail, though. I am just looking for certainty in a body and world which will never be able to make promises.
Hope you are having a good weekend. Thank you so much for all of your help.
Best to you, wonderful doctor.
XXXX
Brief Answer:
You are going to be much better.
Detailed Answer:
Dear XXXX!
Your previous arrhythmia and the underlying cardiomyopathy is a faraway history now.
Nothing but just some persisting unpleasant memories would link your actual clinical status to what you previously experienced.
Arrhythmia is no more a matter of discussion in your case.
Those scarce, solitary PVCs are just physiological findings frequently seen in every normal individual.
And your heart rate is perfect at around 60 bpm; just like a physically well trained person.
I believe that your fluid obsession will gradually vanish, and you will be OK after that.
At the end I would like to give my opinion that being human is much more complicated than a cyborg, and at the same time much better, as you could find the willing to improve your actual condition infinitely.
This is called natural adaptation, and no cyborg could be able to realize it.
Best wishes,
Dr. Iliri
You are going to be much better.
Detailed Answer:
Dear XXXX!
Your previous arrhythmia and the underlying cardiomyopathy is a faraway history now.
Nothing but just some persisting unpleasant memories would link your actual clinical status to what you previously experienced.
Arrhythmia is no more a matter of discussion in your case.
Those scarce, solitary PVCs are just physiological findings frequently seen in every normal individual.
And your heart rate is perfect at around 60 bpm; just like a physically well trained person.
I believe that your fluid obsession will gradually vanish, and you will be OK after that.
At the end I would like to give my opinion that being human is much more complicated than a cyborg, and at the same time much better, as you could find the willing to improve your actual condition infinitely.
This is called natural adaptation, and no cyborg could be able to realize it.
Best wishes,
Dr. Iliri
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you Dr Iliri,
I can track so much of my anxiety to a single dr appointment. My cardiologist had told me that 65,000 PVCs could not damage my heart and as I did my own research and read about PVC mediated cardiomyopathy, it seemed more and more likely so I made an appointment with an EP on my own. It turns out my cardiologist was part of the same large practice of my EP and he harassed my EP, telling him and me that I would not survive ablation and he even repeatedly called EP lab during my surgery, interrupting my EP multiple times. By this time, I was no longer seeing the cardiologist, of course.
What would cause a highly regarded cardiologist to behave this way? He was so angry that I saw EP that he told me I was surely on the path to an early death. He told me I would not survive ablation, that I would never be cured. He said I needed to be on 100mg of Coreg to even start to improve and if I lowered or stopped medication, I would quickly overload with fluid and die because I wrongly believed I was fixed.
I had no personal relationship or connection with this doctor, nor even a long professional one. I can only think professional ego or perhaps a financial issue with an ablation procedure must have made him angry. He continued to leave me messages after my ablation to tell me I was in danger. He had told me to keep taking the Coreg in the days right before ablation, directly against my EP's instructions. I didn't, of course, but he badly wanted my ablation to fail. His voice, repeatedly telling me cardiomyopathy is a permanent condition, and I will never be cured, is the voice of my fear. "Fluid will flood around you and kill you off medication." Ironically, I was never on diuretics.
That is another mystery. At diagnosis, proBNP was over 8000 but my chest xray didnt show pleural effusion, my feet and ankles were not swollen. I did have a cough, and my shins were taut and shiny though no pitting edema. I am just confused at feeling and looking normal yet being admitted to the critical cardiac unit. It seems important because I need to believe I would know if I was again sick.
Thank you so much, Dr Iliri- your eloquence and compassion for seeing the emotional side of my problems is helping as much as your deep clinical knowledge.
XXXX
I can track so much of my anxiety to a single dr appointment. My cardiologist had told me that 65,000 PVCs could not damage my heart and as I did my own research and read about PVC mediated cardiomyopathy, it seemed more and more likely so I made an appointment with an EP on my own. It turns out my cardiologist was part of the same large practice of my EP and he harassed my EP, telling him and me that I would not survive ablation and he even repeatedly called EP lab during my surgery, interrupting my EP multiple times. By this time, I was no longer seeing the cardiologist, of course.
What would cause a highly regarded cardiologist to behave this way? He was so angry that I saw EP that he told me I was surely on the path to an early death. He told me I would not survive ablation, that I would never be cured. He said I needed to be on 100mg of Coreg to even start to improve and if I lowered or stopped medication, I would quickly overload with fluid and die because I wrongly believed I was fixed.
I had no personal relationship or connection with this doctor, nor even a long professional one. I can only think professional ego or perhaps a financial issue with an ablation procedure must have made him angry. He continued to leave me messages after my ablation to tell me I was in danger. He had told me to keep taking the Coreg in the days right before ablation, directly against my EP's instructions. I didn't, of course, but he badly wanted my ablation to fail. His voice, repeatedly telling me cardiomyopathy is a permanent condition, and I will never be cured, is the voice of my fear. "Fluid will flood around you and kill you off medication." Ironically, I was never on diuretics.
That is another mystery. At diagnosis, proBNP was over 8000 but my chest xray didnt show pleural effusion, my feet and ankles were not swollen. I did have a cough, and my shins were taut and shiny though no pitting edema. I am just confused at feeling and looking normal yet being admitted to the critical cardiac unit. It seems important because I need to believe I would know if I was again sick.
Thank you so much, Dr Iliri- your eloquence and compassion for seeing the emotional side of my problems is helping as much as your deep clinical knowledge.
XXXX
Brief Answer:
You are actually on perfectly good conditions.
Detailed Answer:
Dear XXXX,
The fact you improved successfully after the cardiac ablation procedure confirmed that your consulting cardiologist wasn't right.
So, you don't have to mention his suggestions any more.
Regarding you NT-pro BNP rise, I would explain that it perfectly correlated with your heart failure symptoms and signs.
Coughing, your shiny and taut shins are a significant expression of pulmonary and systemic congestion respectively. A careful physical exam and patient interview can reveal such
You couldn't have overt edema, as your cardiomyopathy was not allowed to follow its chronic course and the right heart has been on fairly good conditions (to express with right heart failure).
So, no reasonable explanations can be found for a generalized edema scenario.
So, you can understand from the above explanations that a clinical symptomatology of your previous cardiomyopathy has been present.
But, actually you are on perfectly good conditions. Nothing to worry about any more!
Kind regards,
Dr. Iliri
You are actually on perfectly good conditions.
Detailed Answer:
Dear XXXX,
The fact you improved successfully after the cardiac ablation procedure confirmed that your consulting cardiologist wasn't right.
So, you don't have to mention his suggestions any more.
Regarding you NT-pro BNP rise, I would explain that it perfectly correlated with your heart failure symptoms and signs.
Coughing, your shiny and taut shins are a significant expression of pulmonary and systemic congestion respectively. A careful physical exam and patient interview can reveal such
You couldn't have overt edema, as your cardiomyopathy was not allowed to follow its chronic course and the right heart has been on fairly good conditions (to express with right heart failure).
So, no reasonable explanations can be found for a generalized edema scenario.
So, you can understand from the above explanations that a clinical symptomatology of your previous cardiomyopathy has been present.
But, actually you are on perfectly good conditions. Nothing to worry about any more!
Kind regards,
Dr. Iliri
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you Dr Iliri,
Do you mean my right ventricle was not enlarged and failing yet when I had cardiomyopathy, not that there is issue with right heart now?
Do you believe I would have symptoms as before if I were having any problem now?
You think it would be detrimental to seek reassurance from an ER? I feel better when I do so, although for a very brief time. I dont know how I will wait so long for next tests.
Thank you so much, dr Iliri.
XXXX
Do you mean my right ventricle was not enlarged and failing yet when I had cardiomyopathy, not that there is issue with right heart now?
Do you believe I would have symptoms as before if I were having any problem now?
You think it would be detrimental to seek reassurance from an ER? I feel better when I do so, although for a very brief time. I dont know how I will wait so long for next tests.
Thank you so much, dr Iliri.
XXXX
Brief Answer:
My opinion:
Detailed Answer:
Hi XXXX!
Luckily your right heart has always been unaffected by any specific disorders. And it keeps functioning perfectly.
Surely you would have similar symptomatology, if a hypothetical cardiomyopathy relapse would occur.
I would like to explain that ER environment would never be the perfect place to give you the psychological reassurance, as you actually haven't any specific matters to be considered by their field of expertise.
If fact you are just a normal healthy person (with some persisting fears!!!)
But, this is not for too long, as you are going to feel OK again.
That's my opinion!
Best wishes,
Dr. Iliri
My opinion:
Detailed Answer:
Hi XXXX!
Luckily your right heart has always been unaffected by any specific disorders. And it keeps functioning perfectly.
Surely you would have similar symptomatology, if a hypothetical cardiomyopathy relapse would occur.
I would like to explain that ER environment would never be the perfect place to give you the psychological reassurance, as you actually haven't any specific matters to be considered by their field of expertise.
If fact you are just a normal healthy person (with some persisting fears!!!)
But, this is not for too long, as you are going to feel OK again.
That's my opinion!
Best wishes,
Dr. Iliri
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Dear dr Iliri,
Thank you again for all your knowledge and your endless kindness and patience. I think you're a great doctor, a rare one who understands the complicated human emotional state that goes along with the physical condition. I believe it's been difficult for me because I was seeing a cardio weekly, considered seriously ill, and then recovered quickly after my ablation, and then was told I was cured and considered a very low priority patient.
So, in dealing with this continued fluid obsession, would you say that I would have all the symptoms I had before, such as taut skin on shins, before anything like renal dysfunction which would cause low urine output? I am so obsessed now, but of course before old cardio told me to beware of fluids, I like any normal person did not keep track of fluid intake or output and just drank when I was thirsty. I hope I can be like that again soon. I keep looking for the facts that would prove that there's no way I'm having a recurrence and retaining fluid. For me, it seems only echo can provide that certainty. When I first started coughing, chest x-ray and physical exam were considered normal when I went to the clinic. A week later, I was in the critical cardiac unit.
I keep your words in my head as I am tempted each day to drive into the ER.
Thank you so much,
XXXX
Thank you again for all your knowledge and your endless kindness and patience. I think you're a great doctor, a rare one who understands the complicated human emotional state that goes along with the physical condition. I believe it's been difficult for me because I was seeing a cardio weekly, considered seriously ill, and then recovered quickly after my ablation, and then was told I was cured and considered a very low priority patient.
So, in dealing with this continued fluid obsession, would you say that I would have all the symptoms I had before, such as taut skin on shins, before anything like renal dysfunction which would cause low urine output? I am so obsessed now, but of course before old cardio told me to beware of fluids, I like any normal person did not keep track of fluid intake or output and just drank when I was thirsty. I hope I can be like that again soon. I keep looking for the facts that would prove that there's no way I'm having a recurrence and retaining fluid. For me, it seems only echo can provide that certainty. When I first started coughing, chest x-ray and physical exam were considered normal when I went to the clinic. A week later, I was in the critical cardiac unit.
I keep your words in my head as I am tempted each day to drive into the ER.
Thank you so much,
XXXX
Brief Answer:
I would explain as follows:
Detailed Answer:
Dear XXXX!
I would like to repeat that in a healthy individual with a normal cardiac function a new onset heart failure may be presented with coughing and dyspnea without obvious evidence of peripheral edema and even without any preliminary abnormal changes of renal function.
So, it is useless to check your daily urine output as it would not be a suitable warning tool.
From the other side, a frequent cardiac ultrasound would not be helpful as far as no clinical cardiac symptomatology is present.
A routine scheduled cardiac testing check up every 6 months to one year would be rationale.
An exception from this rule would be a new emerging symptomatology.
Remember that heart failure is a clinical syndrome, and not just a systolic cardiac function degree.
Even in preserved systolic cardiac function patients heart failure may be present (heart failure with preserved ejection fraction).
I believe that your fears will disappear soon as your actual medical experience and knowledge is broadening, and you already know the real importance of certain issues.
Kind regards,
Dr. Iliri
I would explain as follows:
Detailed Answer:
Dear XXXX!
I would like to repeat that in a healthy individual with a normal cardiac function a new onset heart failure may be presented with coughing and dyspnea without obvious evidence of peripheral edema and even without any preliminary abnormal changes of renal function.
So, it is useless to check your daily urine output as it would not be a suitable warning tool.
From the other side, a frequent cardiac ultrasound would not be helpful as far as no clinical cardiac symptomatology is present.
A routine scheduled cardiac testing check up every 6 months to one year would be rationale.
An exception from this rule would be a new emerging symptomatology.
Remember that heart failure is a clinical syndrome, and not just a systolic cardiac function degree.
Even in preserved systolic cardiac function patients heart failure may be present (heart failure with preserved ejection fraction).
I believe that your fears will disappear soon as your actual medical experience and knowledge is broadening, and you already know the real importance of certain issues.
Kind regards,
Dr. Iliri
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Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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