Hello Dr. Sanila,

You have a very appropriate question. A very logical one.

You are absolutely right that we aim to improve the preload by Snehan process which can create pressure on the heart.

There are two types of Heart failure.

1. Low Preload or End Diastolic Volume
2. High Preload or End Diastolic Volume

In the first category, Snehan will rectify the problem by improving the EDV and reversing failure.

In the second category, patients should be first given Mutra or Purisha Virechan to reduce the EDV or can be planned for 24 hour NBM or Langhana before you take the patients for these procedures.

If Snehan is performed in these High EDV high Preload patients blindly, it might create a load on the heart. But this is also kept in check by the next process called Swedan which helps in reducing the EDV or Preload.

Now let us understand the same in figures. This preload can be assessed on the ECHO by a parameter called EDV, End diastolic volume. Normally it should be ranging from 80 to 120 ml. Patients with high NT pro BNP and grade Grade 4 Failure in CHF have a very high EDV, may be above 180 or 200. Such patients are first to be given Mutra or Purisha virechan to lower the EDV significantly before taking him for any procedure. 24 hour NBM or Langhan can also be an effective procedure to reduce the EDV. Swedan also helps to control this EDV to a significant level.

Snehan does increase the EDV to a certain level transiently. This procedure is to be performed for patients who have normal EDV or till 180 to 200 ml. Usually Swedan, a process to control the raised EDV is to be performed post Snehan. If Swedan is not performed post snehan the raised EDV can create a pressure on heart in case of High EDV heart failure. In low EDV failure, Snehan will rectify the problem by improving the EDV.

I hope i have tried to answer your question. If any more doubts, please feel free to ask more questions.

Hello Dr. Archana,

First of all I will like to congratulate you for your confidence in tapering medications of a Low BMI DM patient keeping his sugar levels in control. Helping such a  patient to maintain his HbA1C levels in control without Insulin and OHA is a great task.

I would like to clarify one point here that GTT is not the target for such patients. You should consider Hba1C as the parameter of reversal in such patients.

As you rightly said, to grow the muscle mass you have advised your patient for strength training and you should be aware that growing muscle bulk is a time consuming process.

According to me, you should conduct his GTT after a year of maintaining his HbA1C under 6 and growing his muscle bulk considerably so that the consumed sugars can be well utilized by his muscles.