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Shot Through the Heart & You’re to Blame,You Give Love a Bad Name: CHF & Cardiomyopathy

Shot Through the Heart & You’re to Blame,You Give Love a Bad Name: CHF & Cardiomyopathy. Resident Rounds Nov 28/02 A.F. Chad, MD, CCFP. Heartbreak Hotel. Failure to maintain adequate circulation of blood Left versus Right sided CHF Systolic versus Diastolic CHF High versus Low Output CHF.

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Shot Through the Heart & You’re to Blame,You Give Love a Bad Name: CHF & Cardiomyopathy

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  1. Shot Through the Heart & You’re to Blame,You Give Love a Bad Name: CHF & Cardiomyopathy Resident Rounds Nov 28/02 A.F. Chad, MD, CCFP

  2. Heartbreak Hotel • Failure to maintain adequate circulation of blood • Left versus Right sided CHF • Systolic versus Diastolic CHF • High versus Low Output CHF

  3. What is Love, if not Neurohormonal Mechanism • 1. Sympathetic system activation • 2. Activation of the Renin-Angiotensin Aldosterone system (RAAS) • 3. Increased naturetic peptides • 4. Increased Antidiuretic hormone • 5. Increased Endothelins

  4. Getting in the Mood: Sympathetic Activation • Causes increased cardiac output, increased heart rate, and peripheral vasoconstriction • If sustained activates the RAAS which increases both preload and afterload • Stimulation of alpha and beta receptors leads to myocardial hypertrophy and fibroblast hyperplasia which lead to decreased compliance • Increased norepinephrine levels lead to myocardial cell death and areas of focal necrosis further impairing LV function

  5. Feeling “RAAS”NDYYeah Baby! • Stimulation leads to increased Angiotensin II which leads to : • 1. Increased aldosterone • 2. Increased norepinephrine • 3.Inhibition of vagal tone

  6. The Male Love Hormone (Kind of): Aldosterone • Shown to be elevated up to 20 times in patients with CHF • Causes growth promoting activity in nonepithelial cells • Stimulates fibroblasts which leads to interstitial and perivascular fibrosis which increases LV stiffness • Produced in nonrenal sites such as the vessels and heart • Up to 40% of patients will have elevated levels despite being on ACE inhibitors

  7. Some like it hot & wet: Antidiuretic Hormone • Is elevated in severe heart failure • Higher levels have been reported in patients on diuretics • Can lead to hyponatremia

  8. More than an Endothelin • Secreted by vascular endothelial cells • Potent vasoconstrictor peptide which leads to sodium retention • Increases in proportion to the hemodynamic severity of heart failure • Interest in developing endothelin receptor antagonists

  9. Naturetic Peptides by Nature • 3 types • 1. Atrial Naturetic Peptide (ANP) – released from the atria in response to stretch. Is very sensitive and will be released even with exercise. Causes naturesis and vasodilatation • 2. Brain Naturetic Peptide (BNP) – release from the venticles in response to elevated LVEDP. Has the same effect as ANP

  10. Naturetic Peptides by Nature cont’d • 3. C-type naturetic peptide – limited to the vascular endothelium and has limited effects on naturesis and vasodilatation

  11. From the Bottom of my heart (filling my lungs) • Capillary pressure (12-15mmHg) • Plasma oncotic pressure (25mmHg) • Cardiac (Hi PCWP) • ARDS • Low oncotic P • Negative P • Lymphatic insufficiency • Other

  12. Where does my heart go now? • 3.2 million in USA • 400,000 new per year • 1-2% prevalence • High 5-yr mortality: 60% M, 45% W • Median survival: 3.2 yr M, 5.4 yr W • Progressive CHF vs sudden death

  13. Why you Wanna Break My Heart? • ISCHEMIA!!!!!! • Non-compliance • Valvular • HTN • CM • Infectious • Thyrotoxicosis, anemia

  14. To Find My Heart • Exertional Dyspnea: most sensitive (Spec<60%) • PND / Othopnea (sens<30%) • Cough • Edema • Anxiety • Non-specific stuff

  15. Piece of My Heart? • COPD • Asthma • PE • Tamponade • Pneumonia • ARDS

  16. Heart and Soul: CCS • I - ordinary activity = no angina, +++ activity = angina • II - slight limitations, angina >2 blocks level (+/- stress) • III - marked limitations, angina <2 blocks level • IV - no activity w/o discomfort +/- angina at rest • 59% Validity, 73% reproducible

  17. Heart and Soul: NYHA • I - ordinary activity = no Sx • II - slight limitations, ok at rest, ordinary activity = S • III - marked limitations, less than ordinary activity = Sx • IV - no activity w/o discomfort, Sx at rest • 51% Validity, 56% reproducible

  18. Sea of Love • Physical exam • 90% specific • 20-30% sensitive

  19. Love Shack . . . Left’s where it’s at!!! • Tachypnea / tachycardia • S3, gallup • Diaphoresis • Crackles / wheezes • Pulsus Alternans • PMI laterally displaced

  20. Love Shack . . . Right’s where it’s at!!! • JVD • Edema • Hepatomegaly / HJR

  21. Heart and Soul: Killip • I - No CHF - 5% mortality • II - Mild CHF (bibasilar rales and S3) - 15-25% mortality • III - Frank pulmonary edema - 40% mortality • IV - Cardiogenic shock - 80% mortality

  22. Find My Heart • CBC • Lytes • Creatinine • LFT’s • TNT? • TSH? • BNP?

  23. You Down with BNP? Yeah, you know me! • New polypeptide that is produced in the ventricles • Released in proportion to LV expansion reflecting the LVEDP • Levels rise with age (due to increased LV stiffness) • Levels are elevated with pulmonary disease (due to increased RVEDP) • Levels are elevated in end-stage renal disease reflecting decreased excretion

  24. You Down with BNP? Yeah, you know me! • There is a bedside test that is FDA approved, but it costs $25 - $40 per test. • Cut off has been determined retrospectively in studies • Levels below 75 – 100 pg/ml correlate with fairly normal LV function • The higher the level the worse the LV function • If a patient presented with acute worsening, one would expect a level > 300 pg/ml

  25. You Down with BNP? Yeah, you know me! • This test will probably be used to also follow therapy for patients. Studies have shown that better optimization of ACE therapy can be instituted. • It may reduce the need for repeat ECHO’s • Levels rise acutely and decline with effective treatment within hours – the ½ life is 22 minutes in patients without renal disease

  26. You Down with BNP? Yeah, you know me! • The best use is in patients with multiple medical problems who present with increased dyspnea. • If patients have COPD, are at risk for PE and have a history of CHF then BNP can help separate cardiac from other causes of dyspnea • Maisel AS, Krishnaswamy P, Nowak RM, McCord J, Hollander JE, Duc P, Omland T, Storrow AB, Abraham WT, Wu AH, Clopton P, Steg PG, Westheim A, Knudsen CW, Perez A, Kazanegra R, Herrmann HC, McCullough PA. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med. 2002 Jul 18;347(3):161-7.

  27. Find My Heart • ECG • Ischemia • Hypertrophy • Dysrhythmias • CXR • Cardiomegaly (lots of love) • Redistribution (PCWP12-18mmHg) • Kerley B lines(PCWP 25mmHg) • Pulmonary edema (PCWP >25mmHg)

  28. Find My Heart, Find My Heart • ECHO • WMA • EF • Cardiac FNC • Valves • Tamponade • Size • Dimensions

  29. Find My Heart • Cath? • ?definitive Rx • MUGA? • ?echo good enough • Swan? • No benefit with mortality • ?helpful clinically

  30. How do You mend a Broken Heart? • Acute emergency therapy • Chronic maintenance therapy

  31. How do You mend a Broken Heart? • ABCD!!!! • O2, IV’s, Monitors • CPAP / BiPAP for Edema (more MI with BiPAP) • Sacchetti A. Effectiveness of BiPAP for congestive heart failure. J Am Coll Cardiol. 2001 May;37(6):1754-5. • Elevate head & Lower legs • Cheesy Poetry

  32. How do You mend a Broken Heart? • What is the cause? • TREAT THE CAUSE!!!!! • Nitrates • ACE • Diuretics • Morphine • hBNP • Inotropes

  33. Sex Bomb: Nitrates • Decreases preload and afterload (slightly) • Shown to be effective in reducing mortality and improving symptoms • Can be given sublingual, IV, or as a patch • Dose is 10mcg/min and can be titrated up every 3 – 5 minutes until desired effect. • Can cause hypotension

  34. Sex Bomb: Nitrates • Can switch to a patch from IV nitrates, however this switch worked only when patients were on lower doses (< 50 mcg/ml) • Topical patches have an onset in decreasing PCWP at 20 – 30 minutes with peak effect at 120 minutes. Therefore, their use in an acute severe decompensation is not warranted as first line therapy

  35. Sex Bomb: Nitrates • Sublingual NTG tabs decreased PCWP by 36%. Onset was 4 minutes with peak effect at 9 minutes • The spray had an onset of 1-2 minutes with peak effect at 5 minutes

  36. Ace of the Heart • Haude M, Steffen W, Erbel R, Meyer J. Sublingual administration of captopril versus nitroglycerin in patients with severe congestive heart failure. Int J Cardiol. 1990 Jun;27(3):351-9

  37. Ace of the Heart • Captopril sublingually decreased PCWP after 10 minutes with a peak effect seen at 30 minutes. • Sacchetti et al showed that it decreased the admissions to ICU – odds ration 0.29 • Haude M, Steffen W, Erbel R, Tschollar W, Belz GG, Meyer J. [Hemodynamics after sublingual administration of captopril in severe heart failure. A pilot study] Dtsch Med Wochenschr. 1989 Jul 14;114(28-29):1095-100.

  38. IV Ace of the Heart • Annane D, Bellissant E, Pussard E, Asmar R, Lacombe F, Lanata E, Madonna O, Safar M, Giudicelli JF, Gajdos P. Placebo-controlled, randomized, double-blind study of intravenous enalaprilat efficacy and safety in acute cardiogenic pulmonary edema. Circulation. 1996 Sep 15;94(6):1316-24

  39. Hot &Wet: Diuretics • Have venodilatory properties as well as decreasing intravascular volume through diuresis. • Causes increased plasma renin and Norepinephrine levels leading to Increased SVR • A study comparing high dose NTG and low dose diuretics showed lower mortality than high dose diuretic and low dose NTG

  40. Fool for Love: Morphine • Causes venodilation through histamine release (lasts around 10 minutes) • Causes sedation and respiratory depression • Sacchetti et al showed it increased ICU admissions – odds ratio 3.0

  41. Nesiritide (human recombinant BNP): New Love • Increases cyclic GMP->second messenger ->dilate veins and arteries • Decreases PCWP & Dyspnea • 2 mcg/kg IV bolus over 60 s; follow by 0.01 mcg/kg/min continuous infusion • Elkayam U, Akhter MW, Tummala P, Khan S, Singh H. Nesiritide: a new drug for the treatment of decompensated heart failure. J Cardiovasc Pharmacol Ther. 2002 Jul;7(3):181-94.

  42. Acute treatment – conclusions • 1. Nitrates are first line therapy and should be given intravenously if the patient is sick • 2. Ace inhibitors are beneficial in acute CHF • 3. Diuretics should be used in moderation • 4. Morphine should be used with extreme caution

  43. Chronic Therapy • 1. Ace Inhibitors/ ARB’s • 2. Betablockers - • 3. Spironolactone • 4. Diuretics • 5. Digoxin

  44. Ace of the Heart • Considered first line therapy for CHF. • Recommended for all stages of CHF • Absolute mortality reduction is around 15% at one year for class III/IV patients with a NTT of 6 (relative risk reduction is 30 – 35%) • The effect on mortality was dose related and the higher the dose till the target range was reached ;the lower the mortality

  45. Ace of the Heart • These results were based on the CONSENSUS I/II, SOLVD, AND SAVE trials • Note the effect of ace inhibitors is reduced on patients who are on NSAIDS as well as ASA

  46. Angiotensin Receptor Blockers (of love) • Were thought to be better because angiotensin II was still produced in patients on Ace inhibitors. • These drugs block the Angiotensin II receptor. • Also they do not produce Bradykinens which Ace inhibitors do. These Bradykinens lead to S/E such as cough and angioedema

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