Transcript Slide 1
A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA The Time Line BC 500 Socrates (470-399 BC) Hippocrates (460-377 BC) AD 0 500 Galen (180) 1000 1500 dropsy Harvey (1616) Laënnec (1700) 2000 CHF ~400 B.C. – SOB, edema, rales First described by Hippocrates Ear directly on chest How to drain effusions caused by excess of “phlegm” (cold humor) Moving from brain to chest ~180 AD -- Galen – the heart as a source of heat 1616 – Harvey and circulation 1700 – Laënnec’s stethoscope CHF - Dropsy A morbid condition characterized by the accumulation of watery fluid in the serous cavities or the connective tissue of the body. Hydrops, Idropsie First use in 1290 – “Some fullen in-to be dropesie” OED CHF - Dropsy A woman, 50 years of age, had been affected for twelve years with all the symptoms of disease of the heart, in a very high degree, viz. strong and frequent palpitations, habitual dyspnoea, breathlessness on using the least exercise, sudden startings from sleep, almost constant endema of the lower extremitites, and lividity of the cheeks, nose and lips. Laennec “A Treatise on the Diseases of the Chest” 1821 CHF - Dropsy Oedema of the Lungs The symptoms of this affection are extremely equivocal. Impeded respiration, slight cough and a watery expectoration are the only signs of it. Laennec “A Treatise on the Diseases of the Chest” 1821 CHF - Dropsy Dilatation and feebleness of the heart… The heart’s action permanently irregular, with an extended, but not a strong impulse; the sounds so rapid and equal that their analysis is difficult…It occurs in gouty and debilitated habits, and is almost always attended with chronic bronchitis and enlargement of the liver. Stokes “Diseases of the Heart and the Aorta” 1853 CHF - Dropsy Treatment of the Weak and probably Dilated Heart… …we next proceed to examine that of the weakened hearts, of which the two most common forms are dilatation of the cavities, associated with pulmonary and hepatic disease; and again, the fatty degeneration. It is remarkable, that although the beneficial action of mercury in the affection is known to may practical physicians, but little practical information can be found on the subject…it is impossible to speak too highly of the efficacy of this treatment… Stokes “Diseases of the Heart and the Aorta” 1853 CHF - Dropsy Treatment of the Weak and probably Dilated Heart… During this treatment, and especially when free diuresis is established, it is necessary that wine or some other diffusible stimulus should be carefully administered, and the system supported by a proper aliment… Stokes “Diseases of the Heart and the Aorta” 1853 William Harvey 1578-1657 1639: De Motu Cordis Groucho on the Circulation “We then come to the bloodstream. The blood rushes from the head, down to the feet… gets a look at those feet, and rushes back to the head again.” from “Horse Feathers” (Julius Henry Marx) William Withering Born: 1741 - 1799 1775: Obtained first “tea” from gypsy Foxglove From German: Fingerhut (finger hat or thimble) Mid-1500’s: Latinized to “digitalis” – finger (digitus) Digitalis purpurea – a common variety 1775 – William Withering CHF It’s a hemodynamic disease ! Afterload Preload Contractility Preload • William Stokes (1804-1878) uses Mercury to treat CHF • Southey’s tubes • 1919 - Organomercurial diuretics • Rotating tourniquets • 1958 – thiazide diuretics • Oral nitrates improve hemodynamics AHJ 1975;90:346 CHF Southey’s Tubes Used into the late 1950’s CHF It’s a hemodynamic disease ! Afterload Preload Contractility Contractility • Digoxin • Epinephrine • Dopamine • Dobutamine CHF It’s a hemodynamic disease ! Afterload Preload Contractility Afterload • Lowered afterload improves hemodynamics in MR (Ann Int Med 1975;83:312) • Vasodilator therapy in heart failure (Ann Int Med 1975;83:421) • Hydralazine / Minoxidil in refractory CHF (Ann Int Med 1976;85:467) • Lowered afterload improves hemodynamics in AI (Circulation 1976;53:879) • Lowered afterload improves hemodynamics in CHF (Ann Rev Physiology 1977;39:277 • 1987 - CONSENSUS I CHF It’s a neurohormonal disease ! • 1963 – Plasma norepinephrine elevated in CHF (NEJM 1963;269:653) • 1970’s digoxin reduces plasma renin and norepinephrine levels CHF • It’s a hemodynamic disease Preload Contractility Afterload • It’s a neurohormonal disease CHF Systolic vs Diastolic Failure Systolic 55% 45% Diastolic *No valvular or mechanical causes Kitzman,et al., Am J Cardiol, 2001;87:413-419 CHF Systole = contraction (inotropy) Diastole = relaxation (lusitropy) CHF What is diastolic dysfunction? CHF Dilated Normal Hypertrophic CHF Normal Heart Enlarged Heart CHF Diagnosis • Clinical SOB, DOE, Cough Orthopnea Edema • CxR • BNP • Echo (or equivalent) CHF Diagnosis What is the EF? Low Normal High CHF Diagnosis Is there ischemia? Yes PTCA CABG EECP No CHF (systolic dysfunction) • Preload • Contractility • Afterload • Neurohormonal • Dysrhythmia • Dysynchrony Emergency Rx CHF Preload Lasix Nesiritide Contractility Inotropes Digoxin Afterload Nipride Neurohormonal N/A Dysrhythmia Antiarrhythmics Dysynchrony N/A Chronic Rx CHF Preload + Lasix + Ultrafiltration + Nitrates Contractility Digoxin Transplant evaluation / LVAD Afterload ACE / ARB Hydralazine Neurohormonal Beta blocker ACE / ARB Spironolactone / eplerinone Dysrhythmia ICD + Antiarrhythmics Dysynchrony BiV Pacing Preload IV diuretics Lasix (20,40,80,160,320) Lasix drip Combination (Lasix / zaroxolyn) Naturetic peptic (nesiritide) Dialysis / Ultrafiltration Nitrates Dialysis / Ultrafiltration Ultrafiltration CHF Solutions, Inc. Contractility • Dobutamine • Milrinone • Epinephrine • Dopamine • LVAD • Heart transplantation Ambulatory Infusion Pumps • Dobutamine • Milrinone Afterload • ACE inhibitors • ARB’s • Hydralazine Neurohormonal • Beta blocker • Spironolactone / eplerenone • ACE inhibitors • ARB’s Is there a BEST Beta Blocker? 17% Reduction Dysrhythmia • ICD • Antiarrhythmics • Beta blockers Dysynchrony • Bi-V pacing Therapy of CHF Systolic Dysfunction Diastolic Dysfunction Normal 0 10 20 30 40 50 60 Ejection Fraction 70 80 90 100 Therapy of CHF • ICD • BiV pacer • Heart transplant • Aggressive MedRx Systolic Dysfunction Diastolic Dysfunction Normal Range 0 10 20 30 40 50 60 Ejection Fraction 70 80 90 100 Therapy of CHF N Y H A C L A S S I +ACE, Beta, +ARB ACE, Beta, ARB, dig II ICD, BiV III Transplant IV 0 10 20 30 40 50 60 Ejection Fraction 70 80 90 100 End CHF Diagnosis CHF Diagnosis • Clinical • CxR • BNP • Echo