the evolution of a patient suffering from chronic heart failure

1. A story of heart failure

2. 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 %

3. AAccuuttee mmaannaaggeemmeenntt
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

4. AAfftteerr ssttaabbiilliizzaattiioonn
 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

5. MMoonniittoorriinngg iinn IInntteennssiivvee ccaarree uunniitt
 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

6. CChheesstt XX--rraayy:: ppuullmmoonnaarryy ooeeddeemmaa,, ccaarrddiioommeeggaallyy

7. Corelation between BBNNPP lleevveellss //NNYYHHAA ccllaassss
BNP (pg/mL)
1200
1000
800
600
400
200
0
Normal Class I Class II Class III Class IV
12.3 95.4 221.5 459.1
1006.3

8. Survival probability according wwiitthh BBNNPP lleevveellss

9. AA nnoorrmmaall eecchhooccaarrddiiooggrraapphhyy

10.  Our Patient:
• LV dilatation, hypokinesis ; LVEF = 20 %
• H-sPAP
• Normal valves, no sign of myocardial infarction

11. DDiisscchhaarrggee ffrroomm iinntteennssiivvee ccaarree uunniitt:: DD33
 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

12. Check up
• EKG
• Chest X Ray
• Echocardiography
• Blood tests
• Coronaro-angiography
• Holter
• Sleep apnea detection (polygraphy)
• Exercise test

13. Coronaro angiography

16. Other posibility: CT

17. IIddiiooppaatthhiicc DDMMCC
 Family history: the patient had an uncle who died from HF at 50
years
 MRI does not show any specific etiology

18. HHoolltteerr
 Sustained Sinus rythm: 80 bpm
 No bradycardia, no pause
 Rare PVC :
• 300 in 24 h and 5 bigeminy

19. DDeetteeccttiioonn ooff sslleeeepp aappnnooeeaa
 SAS quite severe
• AHI = 35/hour (every episode > 10 sec)
• Central (typically for HF)
 Indication for device by bi-pap

21. VO 2 Exercise tteesstt ((DD1133)) :: aa vveerryy ppoooorr
ppeerrffoorrmmaannccee
 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

22. AAnndd tthheenn……
 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

23. Evolution

24. Re-evaluation at D60: a ppaattiieenntt ssttaabbllee aanndd wweellll
ttrreeaatteedd
 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

25. CCoonncclluussiioonn
 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

26. battery

27. Overdrive to reboot the heart
The heart starts up again normally

28. EEvvoolluuttiioonn ((11))
 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) ++

29. EEvvoolluuttiioonn ((22))
 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
Reinforce the medical treatment (diuretics)
Indication for Pacemaker: Cardiac resynchronization therapy
15 /09/2008

32. Wide QRS
Narrower QRS

33. EEvvoolluuttiioonn ((11))
 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

34. EEvvoolluuttiioonn ((22))
 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)

35. Outpatient cchheecckk--uupp –– DDeecceemmbbeerr 22000099 ((33 yyeeaarrss
aafftteerr tthhee bbeeggiinnnniinngg ooff tthhee ddiisseeaassee))
 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

36. Muscle-MRI : healthy ssuubbjjeecctt vvss hheeaarrtt ffaaiilluurree
ppaattiieenntt

37. June 2006 September 2009
VO2 = 14 VO2 = 8

38. How does heart failure patient die?

39. HHeeaarrtt ffaaiilluurree:: mmoorrttaalliittyy ccaauusseess
TToottaall mmoorrttaalliittyy
PPllaacceebboo BBêêttaabbllooqquuaanntt
1177 %% 1122 %%
SSuuddddeenn ddeeaatthh
IIDDMM
1122,,22 %%
66,,33 %% 33,,66 %%
33,,55 %% 22,,77 %%
RRRR pp
00,,6666 << 00,,00000011
00,,7711 00,,00004499
00,,5566
00,,00001111
00,,7744
00,,1177
00,,66 %% 00,,55 %% 00,,8855 00,,7755
CIBIS II. Lancet 1999;353:9-13;suivi 15 mois.
99 %%
CCaarrddiiaacc ddeeaatthh
HHFF ddeeaatthh
OOtthheerrss... -------- -------- -------- --------

40. How does heart failure patient die?
Relative mortality :
HF mortality/total mortality
60%
50%
40%
30%
20%
10%
0%
pas de beta
bloquant (CIBIS 2)
bêta bloquant
(CIBIS 2)
DAI ( EVADEF) GISSI HF
Icard
morts subites

41. SSuuddddeenn ddeeaatthh
 DDeeffiinniittiioonn ::
DDeeaatthh dduurriinngg tthhee ffiirrsstt hhoouurr ffoolllloowwiinngg tthhee ssyymmppttoommss:: ooffiicciiaall ddeeffiinniittiioonn
CCIIBBIISS 22
 AArroouunndd 11//33 ooff ttoottaall mmoorrttaalliittyy
 MMeecchhaanniissmmss ((ssoommeettiimmeess uunnkknnoowwnn))::
•• AArrrrhhyytthhmmiiaass
- Mainly ventricular fibrilation
•• SSttrrookkee
-- Ischemic or haemoragic (VKA)
•• PPuullmmoonnaarryy eemmbboolliissmm,, ccaarrddiiaacc ttaammppoonnaaddee……

42. PPrreevveennttiioonn ooff ssuuddddeenn ddeeaatthh
 BBeettaabblloocckkeerrss
 IICCDD :: IImmppllaannttaabbllee CCaarrddiioovveerrtteerr DDeeffiibbrriillllaattoorr
 •• EExx :: tthhee ssttuuddyy SSCCDD––HHeeFFTT
- Without ICD : 29 %
- With ICD : 22 % (p = 0,007)
follow-up 45 months

43. EEnndd--ssttaaggee hheeaarrtt ffaaiilluurree
 Around ¼ ooff ttoottaall mmoorrttaalliittyy
 MMeeccaanniissmmss::
•• DDiillaattiioonn ooff tthhee 44 ccaarrddiiaacc cchhaammbbeerrss
• LLooww ccaarrddiiaacc oouuttppuutt

44. CClliinniiccaall :: ppaaiinnffuull ddeeaatthh ((11))
 PPuullmmoonnaarryy ccoonnggeessttiioonn ::
• Sub-PO persistent
Low cardiac output ::
•• KKiiddnneeyy:: rreennaall iinnssuuffffiicciieennccyy
•• BBrraaiinn :: eenncceepphhaallooppaatthhyy
•• MMuussccllee :: aammyyoottrroopphhyy
•• SSkkiinn :: PPaallee sskkiinn
……………………....

45. CClliinniiccaall :: ppaaiinnffuull ddeeaatthh ((22))
 High pressure iinn tthhee rriigghhtt hheeaarrtt ::
••PPaaiinnffuull hheeppaattoommeeggaalliiaa
•• GGeenneerraalliizzeedd ooeeddeemmaa ::
- 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…

46. Proposed for transplantation 03/01/2010
Transplantation in 10/05/2010

47. Survival: aavveerraaggee :: 1100 yyeeaarrss
(http://www.agence-biomedecine.fr)

50. Hospitalization ffoorr rreeaaddaappttaattiioonn
 Slightly improvement of functional status
 No improvement in peak VO2 : 8,5 ml/kg/min

51. 3 événements CV
(4%)
24 événements CV (31%)

52. TThhee BBNNPP ((BBrraaiinn NNaattrriiuurreettiicc PPeeppttiiddeess))
BBBBNNNNPPPP ((((eeeetttt AAAANNNNPPPP))))
Endopeptidase neutre
Clairance
Beneficial trophic effect
Vasodilatation Natriurie
Inhibition
of RAA and cathecolamine
pprrooBBNNPP
Secretion
N-BNP
Cardiac wall stretch
(heart failure)
Cardiaque
myocyte

53. Coronarographie iinn tthhee DD44:: nnoorrmmaallee ccoorroonnaarriieess