meurin a story of heart failure
DESCRIPTION
the evolution of a patient suffering from chronic heart failureTRANSCRIPT
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A story of heart failure
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April 2006. Mr C, 35 year-old, executive
No significant medical history Hystory of the disease :
– progressive tiredness during last 6 months
– Dry cough during 3 days
– Paroxysmal nocturnal dyspnoea :
• Dyspnoea/orthopnoea/sensation of imminent death Ambulance:
– BP : 140/90 ; HR : 120 ; Oxygen saturation : 75 %
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Acute management Acute management
Emergency room:
• Non-invasive ventilation with O2
• ECG : sinusal rhythm 120 bpm ; no sign of myocardial infarction
• IV line:
- Lasilix : 80 mg IVD
- TNT : 1 follow by 2 mg/h
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After stabilizationAfter stabilization
Intensive care unit : D1-D2
O2 : 3 liters/min during 24 h
Lasilix : 40 mg x 4 IVD only during first 24 h
Per-os :
- Coversyl 5 mg/day
- Kardegic 75 mg : 1/day
- Lasilix 80 mg per-os D2 and D3 follow by 40 mg/day
- Aldactone : 25 mg/d
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ECG : 2 times/day : nothing new
Monitoring : HR/BP/ø/SaO2
Chest X-ray
Echocardiography
Laboratory tests:
• BNP : 2350
• Enzymes (troponine, CPK) : normal
• Routine laboratory tests (ionogramme, blood count, thyroïd) : normal
Monitoring in Intensive Monitoring in Intensive care unitcare unit
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Chest X-ray: pulmonary oedema, Chest X-ray: pulmonary oedema, cardiomegalycardiomegaly
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0
200
400
600
800
1000
1200
Normal Class I Class II Class III Class IV
12.3 95.4 221.5 459.1 1006.3
BNP (pg/mL)
Corelation between BNP levels Corelation between BNP levels /NYHA class /NYHA class
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Survival probability according with BNP levelsSurvival probability according with BNP levels
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A normal A normal echocardiographyechocardiography
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Our Patient:
• LV dilatation, hypokinesis ; LVEF = 20 %
• H-sPAP
• Normal valves, no sign of myocardial infarction
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Armchair, no need for perfusion
Drugs: Per-os :
Lasilix 40 mg, aldactone 25 mg, coversyl 5mg, kardegic 75 mg
Start cardensiel 1.25 mg/D on D5
Discharge from intensive care Discharge from intensive care unitunit: D3: D3
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Check up• EKG
• Chest X Ray
• Echocardiography
• Blood tests
• Coronaro-angiography
• Holter
• Sleep apnea detection (polygraphy)
• Exercise test
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Coronaro angiography
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Other posibility: CT
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Family history: the patient had an uncle who died from HF at 50 years
MRI does not show any specific etiology
Idiopathic DMCIdiopathic DMC
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Sustained Sinus rythm: 80 bpm No bradycardia, no pause Rare PVC :
• 300 in 24 h and 5 bigeminy
Holter Holter
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SAS quite severe
• AHI = 35/hour (every episode > 10 sec)
• Central (typically for HF) Indication for device by bi-pap
Detection of sleep apnoeaDetection of sleep apnoea
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Exercise test: bicycle protocol 10w/min
• Performed up to 120 watts
• Exercise duration : 6 min 40 sec
• HR: at rest : 85 bpm, max : 131 bpm
• SBP : at rest : 85 mmHg, max : 100 mmHg Peak VO2 = 12 ml/kg/mn
VO 2 Exercise test (D13) : a very VO 2 Exercise test (D13) : a very poor performancepoor performance
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Rehabilitation program in CRC (D7-D 20) Medical treatment :
• Lasilix 40, Aldactone 25, Coversyl 7,5
• Bisoprolol 3,75 mg, Procoralan 10 mg bi-pap device (D40) Go back to work part-time on D30
And then…And then…
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Evolution
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Echography : no change, no complication • LV dilatation , hypokinetic (LVEF : 25 %) ; no thrombus
Mitral insufficiency grade 1• No H-sPAP
Blood tests: • BNP = 350 ; normal renal fuction
Exercise test• Performed up to 150 watts• Peak VO2 : 14,2 ml/kg/min
Clinical evaluation :• Pauci-symptomatic (NYHA = 2)• SBP : 90 mmHg ; HR : 69 bpm
Re-evaluation at D60: a patient Re-evaluation at D60: a patient stable and well treatedstable and well treated
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Pharmacological treatment :no need to change• Lasilix 40, aldactone 25, coversyl 10, cardensiel 5, procoralan 15
Recommendation for defibrillator• LVEF < 35 %
No indication for transplantation Close monitoring: 3 times / year by the physician and 1time /y in
Ambulatory center at University Hospital
ConclusionConclusion
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battery
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Overdrive to reboot the heart
The heart starts up again normally
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Normal activity Nothing new during 18 months Hospitalisation 10 days for APO on the 28th of December, 2007
• due to bronchitis (infection) and Christmas diner ( salty food)
Therapeutical education ++
Rehabilitation (exercise training) ++
Evolution (1)Evolution (1)
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Nothing new from January to August 2008 During holidays :
• Fatigue, dyspnoea (NYHA class 3), weight gain (4 kg in 1 month) Check after holidays :
- ECG : sinus rhythm, reveals a Left Bundle Branch Block : sign of myocardial deterioration
- Echo : LVEF : 20 %, hypokinesia of LV and RV
- SBP : 90 mmHg, HR : 65 bpm, BNP : 890
Evolution (2)Evolution (2)
Reinforce the medical treatment (diuretics)Indication for Pacemaker: Cardiac resynchronization therapy
15 /09/2008
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Wide QRS
Narrower QRS
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Moderate improvement in symptoms
• NYHA Class 2-3 ; dyspnoea at 2 levels
• No inferior limbs oedema Go back to work on D30 (15 octobre 2008)
• Stops again on 01/11/08 for tiredness
Evolution (1)Evolution (1)
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Nov 2008- sept 2009 : he is slowly going downhill
• Dyspnoea at only one floor (37 years old)
• 2 moderate acute HF episodes with no need for hospitalisation but requirement for treatment modifications:
- Cardensiel 3.75, Procoralan 15, Coversyl 10, Aldactone 50, Lasilix 160, Hémigoxine: 1 cp
Mental depression ,Fatigue, anorexia, loss of weight (muscle atrophy)
Evolution (2)Evolution (2)
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Clinical description :• Cachexia : weight loss : 8 kg
- Muscles atrophy (legs +++)• Fatigue : stays at home, dyspnoea class NYHA 3 < first floor• SPB = 85 mmHg
Blood tests : • BNP = 1000, moderate anemia, normal kidney function
ECG : • sinus rhythm 62 bpm
Echocardiography :• LVEF : 17 %
Medical treatment: maximal treatment
Outpatient check-up – December Outpatient check-up – December 2009 (3 years after the beginning 2009 (3 years after the beginning of the disease)of the disease)
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Muscle-MRI : healthy subject vs Muscle-MRI : healthy subject vs heart failure patientheart failure patient
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VO2 = 14 VO2 = 8
June 2006 September 2009
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How does heart failure patient die?
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Total mortalityTotal mortality
PlaceboPlacebo BêtabloquantBêtabloquant
17 %17 %17 %17 % 12 %12 %12 %12 %
IDMIDM
12,2 % 12,2 %
6,3 %6,3 % 3,6 %3,6 %
3,5 %3,5 % 2,7 %2,7 %
RRRR pp
0,660,660,660,66 < 0,0001< 0,0001< 0,0001< 0,0001
0,710,71 0,00490,0049
0,560,56
0,740,74
0,00110,0011
0,170,17
0,6 %0,6 % 0,5 %0,5 % 0,850,85 0,750,75
CIBIS II. Lancet 1999;353:9-13;suivi 15 mois.
9 %9 %
Heart failure: mortality causesHeart failure: mortality causes
Cardiac deathCardiac death
HF deathHF death
Sudden deathSudden death
Others...Others... -------- -------- -------- --------
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Relative mortality :HF mortality/total mortality
0%
10%
20%
30%
40%
50%
60%
pas de betabloquant (CIBIS 2)
bêta bloquant(CIBIS 2)
DAI ( EVADEF) GISSI HF
Icard
morts subites
How does heart failure patient die?
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Definition Definition : :
Death during the first hour following the symptoms: oficial definition Death during the first hour following the symptoms: oficial definition CIBIS 2CIBIS 2
Around 1/3 of total mortality Around 1/3 of total mortality MechanismsMechanisms (sometimes unknown): (sometimes unknown):
• • ArrhythmiasArrhythmias- Mainly ventricular fibrilation
• • SStroketroke- - Ischemic or haemoragic (VKA)
• • Pulmonary embolismPulmonary embolism, cardiac tamponade…, cardiac tamponade…
Sudden deathSudden death
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BetablockersBetablockers ICD : Implantable Cardioverter Defibrillator ICD : Implantable Cardioverter Defibrillator • • Ex : the study SCD–HeFT Ex : the study SCD–HeFT
- Without ICD : 29 %
- With ICD : 22 % (p = 0,007)
follow-up 45 months
Prevention of sudden deathPrevention of sudden death
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Around ¼ of total mortalityAround ¼ of total mortality MecanismsMecanisms::
• • Dilation of the 4 cardiac chambers Dilation of the 4 cardiac chambers
• Low cardiac outputLow cardiac output
End-stage heart failureEnd-stage heart failure
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Pulmonary congestionPulmonary congestion : :
• Sub-PO persistent
Low cardiac output : :• • Kidney: renal insufficiencyKidney: renal insufficiency• • Brain : encephalopathyBrain : encephalopathy• • Muscle : amyotrophyMuscle : amyotrophy• • Skin : Pale skinSkin : Pale skin
……………………....
Clinical : painful death (1)Clinical : painful death (1)
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High pressure in the right heart High pressure in the right heart ::
••Painful Painful hepatomegalia hepatomegalia
• • Generalized oedema : Generalized oedema :
- pleural effusion , ascite
- Interstitial peripheral edema , lombal, face…
The death : :• commonly happens by electrical disorders : progressively widening of QRS till the cardiac contraction is inefficient.
• Other causes : renal failure, acute respiratory insufficiency…
Clinical : painful death (2)Clinical : painful death (2)
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Proposed for transplantation 03/01/2010Transplantation in 10/05/2010
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Survival: average : 10 years Survival: average : 10 years
(http://www.agence-biomedecine.fr)
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Slightly improvement of functional status No improvement in peak VO2 : 8,5 ml/kg/min
Hospitalization for readaptationHospitalization for readaptation
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3 événements CV (4%)
24 événements CV (31%)
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BNP BNP (et ANP)(et ANP)BNP BNP (et ANP)(et ANP)
Endopeptidase neutre
Clairance
NatriurieVasodilatation
Beneficial trophic effect
Inhibitionof RAA and cathecolamine
proBNPproBNP
Secretion
N-BNP
Cardiac wall stretch (heart failure)
Cardiaque myocyte
The BNP (Brain Natriuretic The BNP (Brain Natriuretic Peptides)Peptides)
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Coronarographie in the D4: Coronarographie in the D4: normale coronariesnormale coronaries