Transcript 2007_05_31-Bromley - Calgary Emergency Medicine

Congestive Heart Failure
and
Cardiomyopathy
Mark Bromley
PGY-1
Case 1
• A 63-year-old male presents with breathlessness x 3 days.
?Approach, ?Hx
PMHx: MI 3 years ago
• 4-vessel CABG
• asymptomatic since surgery with no complaints of CP
HPI: Over the last 3 months, the patient notes onset of shortness of breath
while unloading groceries, and walking stairs.
– 2 weeks ago, he was unable to complete his daily one-mile walk at the high
school track. He noted swelling in his feet and ankles.
– 4 days ago he woke at 2 am short of breath and had to sleep in his recliner
the rest of the night. He has been unable to lay flat in bed at night since
then and has slept on 3 pillows.
– Yesterday, he became breathless walking from one room to another
– He presents today with extreme shortness of breath
– He denies chest pain
BP 108/52
P 140, irreg.
R 30 and labored
Temp 99°F
Ht: 5'8"
Wt: 210.
General: Breathless, moderately obese male in acute distress sitting
upright complaining "I am going to die. Please help me."
Chest: Scattered rhonchi throughout, rales bilateral one third lower bases.
Cough is productive and frothy.
CVS: Tachycardia and irreg. Grade 3/6 systolic murmur at LSB, S3 gallop
noted. JVP to jaw
Abd: Liver palpable three centimeters below right costal margin. HJR.
Extremities: 4+ pitting edema of lower extremities to the knees. Pulses
intact.
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Organization of CHF
Importance
Pathophysiology
Diagnosis
Etiologies – Decompensation
Management
Cardiomyopathy
Importance
• Increasing burden
• Aging population Improved survival
(Hypertension/CAD)
• Nationwide, heart failure affects more
than 400 000 Canadians1
• (10% of those >75)
• >50 000 new cases are diagnosed /yr1
Bad Disease
• Mortality
• 1 year – 10-20%
• 6 year – 60-80%
• ED visits
• 20% new diagnosis
• 80% repeat visit (decompensation)
Definition
• CHF
– Inability of the heart to maintain adequate vital
organ perfusion at normal filling pressures
• Decreased exercise capacity
• Associated neurohumoral-endocrine changes, initially
compensatory but ultimately maladaptive
• Pulmonary Edema
– A condition associated with increased loss of fluid
from the pulmonary capillaries into the pulmonary
interstitium and alveoli
The heart is a pump that works
together with the lungs. It pumps blood
in 2 ways
1. It pumps blood from the heart to the lungs to pick up
oxygen. The oxygenated blood returns to the heart
2. It then pumps blood out into the circulatory system of
blood vessels that carry blood through the body
• In HF the pumping action of the heart
becomes less and less efficient/powerful
• The heart does not pump blood as well as it
should
• When this happens, blood does not move
efficiently through the circulatory system
• It starts to back up, increasing the pressure in
the blood vessels, forcing fluid from the blood
vessels into body tissues.
Physiology
• ↓ CO = HR X Stroke Volume
• SV = preload + contractility - afterload
• Preload
– initial stretching of the cardiac myocytes
prior to contraction
• Afterload
– the "load" that the heart must eject blood
against
– Aortic pressure
Stroke Volume
– Hypertrophy is a mechanism that allows more
muscle fibers to share the work
• Contractility
– ability of a cardiac muscle fiber to contract
at a given fiber length
• catecholamines (norepi and epi)
• sympathetic stimulation
• Ca++
Neurohormonal Activation
Jackson, G et al. BMJ 2000;320:167-170
Copyright ©2000 BMJ Publishing Group Ltd.
[Nor-epi] and Mortality
Jackson, G et al. BMJ 2000;320:167-170
Copyright ©2000 BMJ Publishing Group Ltd.
Sympathetic Activation
Jackson, G et al. BMJ 2000;320:167-170
Copyright ©2000 BMJ Publishing Group Ltd.
Remodelling Post MI
Jackson, G et al. BMJ 2000;320:167-170
Copyright ©2000 BMJ Publishing Group Ltd.
Classification of Heart Failure
• Low Output
• Cardiac output is low, but demand for blood flow is normal
• The heart is unable to meet this demand and fails
• Dx: IHD, HTN, dilated cardiomyopathy, valvular and pericardial dz
• High Output
• High-output heart failure Cardiac output is normal or a little bit
high
• Demand for blood flow is abnormally high
• (hyperthyroidism, anemia, severe infections)
• The heart is unable to deliver the increased amount of blood and
fails
• Dx: hyperthyroidism, anemia, pregnancy, AV fistulas, beriberi, &
Paget’s
• Rx: ↓volume overload and correct the underlying disorder
Classification of Heart Failure
• Acute
• MI, Acute Valve Dysfunction
• largely systolic
• sudden reduction in cardiac output often results in
systemic hypotension without peripheral edema
• Chronic
• Cardiomyopathy
• arterial pressure tends to be well maintained until
very late in the course
• there is often accumulation of peripheral edema
Classification of Heart Failure
• Right Sided (right ventricle)
•
(pulmonic stenosis or pulmonary hypertension)
• When the right side of the heart starts to fail, fluid collects in the
feet and lower legs
• As the heart failure becomes worse, the legs swell and eventually
the abdomen collects fluid (ascites, hepatic congestion)
• Weight gain accompanies the fluid retention and is an excellent
measure of how much fluid is being retained.
• Left Sided (left ventricle)
• left ventricle is mechanically overloaded (aortic stenosis) or
weakened (post MI)
• When the left side of the heart starts to fail, fluid collects in the
lungs (Orthopnea/PND)
• Breathing becomes more difficult, and the patient may feel short of
breath, particularly with activity or lying down
• This extra fluid in the lungs makes it more difficult for the airways to
expand on inhalation
• ↓O2 diffusion
Classification of Heart Failure
• Systolic
– The heart has difficulty contracting and pumping out enough
blood
• weakness, fatigue and decreased ability to exercise
↓Ejection fraction = (stroke volume)/(end diastolic volume)
– A normal ejection fraction is greater than 50%
– Systolic heart failure has a ↓EF < 50%.
• Diastolic
– The heart is unable to fill properly during diastole
– ↑ filling pressure
– This impedes blood filling into the heart → backup into the
lungs → CHF symptoms
– ↑ in patients > 75 years; women; HTN
– Ejection fraction is normal
Classification of Heart Failure
Directional Heart Failure
• Backwards heart failure
– The ventricle is not pumping out all the blood that
comes into it. ↑ ventricular filling pressure and systemic
or pulmonary edema
– In fact, the heart can only meet the needs of the body if
the ventricular filling pressure is high
• Forward heart failure
– The heart is not pumping out enough blood to meet the
needs of the body
– ↓ blood reaches the kidneys, they conserve salt and
water, which contributes to excess fluid retention and
edema
– Forward failure also decreases the blood flow to various
organs, causing weakness and fatigue
Diagnosis
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History
Phsyical
EKG
CXR
History
• Prior Heart Dz, Dyspnea, PND,
Orthopnea, Fatigue, Cough, Bloating,
Angina, ↑Wt/↑Girth, Nocturia
• Precipitants
– ↑salt, non-compliance, new meds, NSAIDs,
palpitations, angina
• Comorbidities
• (COPD, Renal Dz, DM)
PE
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↑HR ↑RR
JVP
HJR
Precordial exam:
– Apical impulse
• Location, Size, Sustained
• (45’ LLD position – exp)
– Loud P2
– S3 (ventricular vibration with rapid filling)
• Low pitched (bell) 45’ LLD position
• Lungs:
– Cracks / Wheezes
• Peripheral Edema
Case 2
58 F with known Idiopathic Dilated Cardiomyopathy
•Cardiac Cath (05): N coronaries LVEF 35%
•Meds: ACE-I, Diuretics, Digoxin
•↑SOBOE x 3weeks
•OE: Displaced MPI
•Soft S3
•Pre-sacral edema
Case 3
70 M – Obese
•SOBOE and fatigue x 3 months
•No Orthopnea/PND
•PMHx: Smoke x 40 pack-years, HTN (poorly
controlled) DMII
•OE: BP 180/100
•Sustained MPI
•Bilateral Rales
•Mild/Moderate Pretib Edema
X-ray
• Cardiomegally
– ↑LV or hypertrophied ventricular wall
– Cardiothoracic Ratio > 50%
• Redistribution (cephalization)
– Systolic dys-fxn → ↑filling pressure
– Upper lobe vessels > Lower lobe vessels
• Blunting of costophrenic Angle
• Peribronchial cuffing
• Kerly-B lines
Peri-Bronchial Cuffing
“First, strike for the jugular and let the rest go!”
• Oliver W. Holmes Jr.
Etiology
• Dysrhythmia
– Tachy
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↓Diastolic filling time +/- atrial kick
↓CO
↓Coronary perfusion
↑ Myocardial O2 demand
– Brady
• ↓HR
• ↓CO = SV x ↓HR
• Infection
• ↑ systemic met demands
• Pulm infection = ↓O2
• Tachycardia
• Anemia
• Isovolumic hemodilution
• ↑CO meet O2 demands
• ↓Coronary O2 delivery
• Pregnancy
• ↑ demand for CO
• Acute Myocarditis
• ↓ contactility
• Acute valvular dysfunction
• 2o to MI
• ↑preload or ↑↑afterload
• PE
• ↓O2 supply
• ↑ Pulmonary Hypertension
• Pharmacologic
• ↓ inotropic effects
• ↑ Na / H2O retention
Etiology
• Decompensation/Causes of exacerbation
• FAILURE:
Forgot medication25%
Arrhythmia/ Anemia
10%
Ischemia/ Infarction/ Infection (Pneumonia)
25%
Lifestyle: taken too much salt
Up-regulation of CO: pregnancy, hyperthyroidism
Renal failure
Embolism: pulmonary
10%
Inappropriate treatment
20%
Failure to seek care
Case 1 Management
• A 63-year-old male presents with breathlessness x 3 days.
?Approach, ?Hx
PMHx: MI 3 years ago
• 4-vessel CABG
• asymptomatic since surgery with no complaints of CP
HPI: Over the last 3 months, the patient notes onset of shortness of breath
while unloading groceries, and walking stairs.
– 2 weeks ago, he was unable to complete his daily one-mile walk at the high
school track. He noted swelling in his feet and ankles.
– 4 days ago he woke at 2 am short of breath and had to sleep in his recliner
the rest of the night. He has been unable to lay flat in bed at night since
then and has slept on 3 pillows.
– Yesterday, he became breathless walking from one room to another
– He presents today with extreme shortness of breath
– He denies chest pain
Management
• Treat the maladaptation
• ↑ Vascular resistance
• ↑ Sympathetic tone
• ↑ Total blood volume
• ? LMNOP
Management
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Nitrates
Nitrates
Nitrates
O2
Ventilation Assist Devices
ACE I
Diuretics
Morphine
Inotropes
Airway/Breathing
• Non-rebreather facemask delivering
100% O2
• Once initial therapy has begun, oxygen
supplementation can be titrated in order
to keep the patient comfortable and
arterial oxygen saturation above 90
percent.
NIPPV
• If respiratory distress and/or hypoxia persist, consider
non-invasive PPV
– ↓ preload, ↓ afterload, and ↑ left ventricular performance
– Meta-analysis of 15 clinical trials: ↓mortality and ↓intubation
with NPPV compared to conventional therapy
– Patients who fail/do not tolerate/have contraindications to
NPPV should be intubated
– Positive end-expiratory pressure is often useful for improving
oxygenation
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Multi-centre RCT
130 pts
Cardiogenic Pulmonary Edema
Emergency Department
Medical therapy+O2 (65 pts)
non-invasive pressure support ventilation (65 pts)
Primary outcome – need for intubation
Loop Diuretics
• ↑Na & H2O excretion
• Useful in volume overload
• Rapid onset
– Mild vasodilator
• ↑1/2 life in CHF …be careful
• Depletion of K + and Mg++
Loop Diuretics
• Dosing – not well established
• High dose Lasix and low dose Nitro has
worse outcomes than low dose Lasix
and high dose Nitro
Morphine
• Controversial
• Weak vasodilator / ↓ Resp Drive
• ↑ ICU admisssions (OR = 3) Sacchetti
• ?Anxiolytic
Nitrates
• ↓preload @ low dose
• ↓afterload @ high dose
Nitrates - Route
• SL/Spray (0.1 - 0.4mg / 5 min) x3
– 50-100ug/min
• IV Drip (5-10ug/min)
– titrate to effect
– (100-200ug)
• Transdermal
– Peripherally shut down
– Unreliable absorption
• Contraindications / Cautions
– Viagra
– RV MI
– Fixed Aortic Lesions
Case 4
• 67 M ↑SOB Visibly Distressed
96 28 200/110 75% ORA
• PMHx: HTN, DM II
• EKG:
Nitroprusside
• Direct smooth muscle relaxant
• Balanced reduction of pre/after load
• Continuous pressure monitoring – good
– Avoid hypotension
Case 5
• 67 M ↑SOB Visibly Distressed
96 28 140/90 75% ORA
• PMHx: HTN, DM II
• Meds: Inconsistent
Natriuretic Peptide
Jackson, G et al. BMJ 2000;320:167-170
Copyright ©2000 BMJ Publishing Group Ltd.
Nesiritide
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Recombinant BNP
↓ Aldosterone
↓ Endothelin
↑ Na & H2O excretion – no reflex tachy
Good for Nitro contraindications
VMAC
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Randomized, Double Blind
489 inpatients
IV Nisiritide vs IV Nitrates vs Placebo
PCWP and Dyspnea
– Improvement in PCWP – 2mm HG @ 6h
– No change in Dyspnea
• Problems:
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↓Nitro dosing
Prolonged Hypotension
Not ED patients
Industry sponsored
Vosodilator Therapy:
Nesiritide
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Efficacy Phase
– 432 patients
– In the efficacy phase, 127 patients underwent hemodynamic monitoring with
a pulmonary artery catheter
– A six hour infusion of nesiritide (0.015 and 0.03 µg/kg per min) decreased
pulmonary capillary wedge pressure
– (6 and 10 mmHg versus an ↑ of 2 mmHg for placebo)
– Improved the clinical status in a greater number of patients (60% and 67%
versus 14%)
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Comparative phase
– 305 patients
– Randomly assigned to nesiritide or standard vasoactive agents for seven
days without hemodynamic monitoring
– Compared to standard treatment with a single vasoactive agent
(dobutamine, milrinone, nitroglycerin, or nitroprusside)
– nesiritide produced a similar significant improvement in clinical status and
reduction in dyspnea and fatigue that persisted during the entire infusion
period.
– Asymptomatic, dose-related hypotension was the most common side effect
• Death within 30 days tended to occur more
often among patients randomized to nesiritide
therapy
– 35 [7.2%] of 485 vs 15 [4.0%] of 377 patients
• RR from meta-analysis: 1.74
– (95% confidence interval [CI], 0.97-3.12; P = .059)
• Hazard ratio after adjusting for study, 1.80
– (95% CI, 0.98-3.31; P = .057)
Vasodilator Therapy
• Nitroglycerin: ↓preload ↓afterload
• Nitroprusside: ↓ ↓ afterload
• Nesiritide - BNP
ACE Inhibitors
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Clear longterm benefits
1.
2.
3.
4.
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Vasodilate
Block Aldosterone
Bradykinin System
↓ Remodeling
Take longer to work than nitrates
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(peak effect 45min)
Effect of ACE-I
Jackson, G et al. BMJ 2000;320:167-170
Copyright ©2000 BMJ Publishing Group Ltd.
Placebo-Controlled, Randomized, Double-Blind Study of
Intravenous Enalaprilat Efficacy and Safety in Acute
Cardiogenic Pulmonary Edema
• The purpose of this study was to evaluate the efficacy and safety of a
single IV 2-hour infusion of enalaprilat (1 mg)
• placebo-controlled, randomized, double-blind study
– 20 CHF patients (NYHA class III or IV)
• Compared with placebo, enalaprilat
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↓ pulmonary capillary wedge pressure (-37% versus -10%, P=.001),
↓ diastolic and mean systemic blood pressures (-21% vs 0%, P=.009, and -18% vs -1%, P=.026)
↓ diastolic and mean pulmonary blood pressures (-21% vs -8%, P=.040; -18% vs -9%, P=.046)
↓ brachial and renal resistances (-44% versus -14%, P=.017, and -22% versus -2%, P=.014)
↑ brachial and renal blood flows (+77% versus +8%, P=.036, and +12% versus 0%, P=.043)
↑ arterial oxygen tension (+2% versus -16%, P=.041)
↑ arterial oxygen saturation (+1% versus -2%, P=.045)
• Enalaprilat did not affect CO or carotid or hepatosplanchnic
hemodynamics
• Excluded those already on ACE I
BNP
• Why do we need another diagnostic
test?
– Diagnostic uncertainty
• How uncertain are we?
• How uncertain should we be?
– ER docs are rarely wrong when they rate
the probability of HF as very high or very
low2
– ER docs are uncertain of the diagnosis in
the in-betweeners (30%)2
BNP
• ↑Ventricular pressure & ↑Stretch
– Pro-BNP → Nt-BNP(↑spec) & BNP(↑sens)
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Prospective, Blinded
1586 pts presenting with acute dyspnea
ED Study
Bedside assay
“Gold Standard” = 2 cardiologists
Breathing Not Properly
Breathing Not Properly
• ad
Breathing Not Properly
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Prospective diagnostic test evaluation
7 centers
1586 patients
BNP – blinded
Gold Standard – Cardiology Chart Review
97% certainty by ED physician
At “80%” EP certainty
• Sens: 49% Specificity: 96%
• At 100 pg/ml
• Sens: 90% Specificity: 73%
• adf
Breathing Not Properly - Analysis
• BNP brings us closer to the “gold standard”
• Low Prob -EP
• 17% had CHF
• 90% would have been corrected by BNP
• High Prob -EP
• 4% did not have CHF
• 80% would have been corrected by BNP
• Uncertain -EP
• BNP correctly classified 74%
• Misclassified 7%
BNP
• Levels < 100 pg/ml may prompt clinician
to focus on alternative diagnosis
(COPD)
• Reasonable neg pred value
• Prognostic Value
• ?Variation with Age/Gender/Kidney fxn
Prospective, Randomized, Controlled
Single blind
452 Pts with dyspnea
Diagnostic Strategy (BNP) vrs Standard Assessment
Told EP if <100 CHF unlikely, >500 CHF likely, 100-500
indeterminate
End Points: Time to D/C & Total Cost
Safety: Similar
Conclusion: BNP improved evaluation thereby improving
and cost – no change in safety
time to D/C
• BNP strong prognostic indicator in
symptomatic and asymptomatic individuals
• Death or Cardiac Death
• Additive to LVEF
Cardiomyopathy
• http://www.medmovie.com/mmdatabase
/MedMovieRedirect.aspx?ClientID=27
Case
• Previously well 10 year old girl presents with 2 weeks of
progressive right sided ABD pain. General malaise. Mild fatigue
on exertion.
• Parents report mild lethargy, pallor and decreased PO intake
over same period. Shallow rapid breathing, worse when
reclining at night.
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37.8oC 123 24 94/54
Pale irritable
HEENT: MMM. No adenopathy
CVS: regular S1S2, no murmer, PPPx4, no edema
CHEST: AE=AE slight decrease at bases
ABD: palpable liver edge below umbilicus
• EKG: sinus tach, LAD, flattened T-waves, decreased voltages.
Post Myocarditis
Dilated Cardiomyopathy
• Most common CM
– 30% idiopathic
– Hereditary
• X-linked (dystrophin gene)
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Booze
Heavy Metal
Drugs
Infectious
• Viral
• Chagas
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Post partum
Collagen vascular disease
Glycogen storage disease
Thiamine, PO4, zinc deficiency
Amyloidosis
Neuromuscular disorders
Dilated Cardiomyopathy
• Biopsy helpful for etiology
• Rx same as other CHF
• MDC (Metoprolol in Dilated CM)
– 34% reduction in Death
• Multicenter Myocarditis Treatment Trial
– no benefit of corticosteroids and azathioprine for
Rx of biopsy-proven inflammation in dilated CM
HCM
• Inappropriate hypertrophy w/o stimulus
• Usually asymmetric
• 4% mortality per year (sudden death)
HCM
• 50% familial (Dominant Inheritance)
• Mechanism
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Abn Ca++ kinetics
Abn sympathetic stim
Abn Coronaries
Subendocardial ischemia
Structural abn
HCM
• 25% 1st relatives of HCM
• Usually 3rd decade – not always
• M>F
HCM - Presentation
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Sudden Death
Dysrhythmia
CHF
Presyncope / Syncope
Angina
HCM
• CHF Sx
OE:
• ↑JVP – prominent “a” wave
• Double impulse pulse
• PMI laterally displaced and increased
• SEM / HSM
• Split S2
HCM
• Genetic Studies
• ECG
• Echo
– LV outflow gradient >50mmHg
– Diastolic dysfunction
– HOCM: septum >1.4:1 ratio to post wall
HCM – Approach/Mgmt
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ABCD
Normal CHF / CAD Rx
Myomectomy
Catheter septal ablation
MV replacement
ICD
B-blockade
CCB
Anti-arrhythmias
Restrictive
• Least common CM
• Incidence – likely under diagnosed
• Poor prognosis
Cardiomyopathy
• http://www.medmovie.com/mmdatabase
/MedMovieRedirect.aspx?ClientID=27
Restrictive
• Idiopathic restrictive cardiomyopathy
– EndoMyocardial Fibrosis
– Loeffler eosinophilic endomyocardial disease
• Secondary restrictive cardiomyopathy
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Radiation
Hemochromatosis
Amyloidosis
Scleroderma
Carcinoid heart disease
Glycogen storage disease of the heart
Diagnosis
• Chest x-ray
– Absence of cardiomegaly, normal cardiac
silhouette
– CHF
• Electrocardiogram
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LBBB common, RBBB possible
Low voltage
Nonspecific ST-T changes
Various arrhythmias
Chamber enlargement
• Echocardiography
– Normal to symmetrically thickened walls
– Rapid early-diastolic filling, slow latediastolic filling
– Normal or slightly reduced ventricular
volume and systolic function
• Cardiac catheterization
– Elevated ventricular end-diastolic pressure
– Dip and plateau configuration of the diastolic
portion of the ventricular pressure pulse
– Normal to slightly decreased ejection fraction
– Prominent x and y descent
• Endomyocardial biopsy
– May detect typical eosinophil infiltration in the
inflammatory stage
– May detect myocardial fibrosis in later-stage cases
– Negative findings do not exclude diagnosis
• Treat underlying cause if possible
• Therapy similar for other causes of CHF
• Consider anticoagulation as prone to stasis
– thromboembolism
• Thanks Shawn for the resources!
References
1.
2.
Kostuk WJ. Congestive heart failure: what can we offer our patients? CMAJ
2001;165(8):1053-5
Schwam E. B-type natriuretic peptide for diagnosis of heart failure in emergency
department patients: a critical appraisal. Acad Emerg Med 2004;11:686-91.
Risk of HF after AMI
Jackson, G et al. BMJ 2000;320:167-170
Copyright ©2000 BMJ Publishing Group Ltd.
• 20 pts Pulmonary Edema
• Looked like needed intubation
• 2 intubated
• Also had COPD
• Mean Treatment Duration 2 ½ h