Dott C Mazzone

Centro Cardiovascolare

ASS 1 “Triestina”

• Donna di 78 anni• Casalinga, mai fumato, allergia ASA• Ipertensione art. controllata in terapia (dal

1983)• Diabete mellito NID (dal 2002),• Dislipidemia controllata con statine (dal 2004)• Obesità (BMI 1984: 30.7; 2001: 35.9, 2002:

32.2) • Familiarità per ipertensione art ed ictus

(madre) e cardiopatia non precisata nel padre

• Dal 1992 (62 aa) brevi episodi di FAP;

• 1999 (69 aa) diagnosi di SCC in corso di FA ad elevata FC

• ECO: IVS, dil VSn+, FE conservata, dil ASn + CVE profilassi con amiodarone

• Dal 2000 multiple recidive di FA trattate con CVE

• Terapia AA: amiodarone (sospeso per ipertiroidismo); propafenone inefficace; sotatolo fino a dosaggi 80+120+80mg

• FA cronica + dispnea da sforzo (NYHA II-III)• PA e DM in (probabile) discreto controllo,

ipotiroidismo subclinico (TSH 6.81 FT4 10.9), gonartrosi importante

• Terapia: Sotalolo 280 mg, Irbesartan 300 1cp, Furosemide 25 mg, Spironolattone 37.5 mg, Acenocumarolo, atorvastatina 20 mg;

• EO BMI 35.9; PA 130/80 mmHg; non SCC• Rx torace: interstiziopatia bibasale, ispessimenti

pleurici bilaterali, non cardiomegalia

• Obesità, FA, betabloccanti, interstiziopatia -ispess pleuriciDISPNEA!........però……

• Abbiamo fatto ecocardiogramma

• “Grossolanamente” normale cinetica biventricolare

• pattern restrittivo (E 1msec, TdecM 100-120msec)

• Dieta ipocalorica, terapia ipoglicemizzante

• (Sotalolo 280 mg/die)*

• Digossina 0.25 mg/die

• Irbesartan 300mg/die

• Lasitone 1cp/die

• Sintrom sec INR seguito dal MMG

• atorvastatina 20mg la sera– *NB Suggerita sostituzione sotalolo -> verapamil non

attuata dalla pz

Gestione MMG• BMI da 35.928.7 (4-05)30.5(2-06)• HbA1C 8.8% (3-04)7 (10-04)7.4 (4-05)7.9

(2-06) • Ipotiroidismo subclinico• Normale funzione renale e Hb• “Intolleranza” a metformina >850mg x 2 e

glitazoni, levotiroxina (FA ad elevata frequenza) • Coxartrosi e gonartrosi importante talora con

uso di FANS; polimialgia reumatica (2-2006)

• Dispnea da sforzo nuovamente peggiorata (NYHA II-III)

• EO: BMI 29,76, PA 135/85mmHg, non SC• ECG FA 80 bpm, BBDx, EAS• Rx torace invariato• Terapia: sostituzione sotalolo 280 mg/die

con verapamile 80 mg x3 ,aggiunto HCTZ,resto invariata

• dispnea peggiorata NYHA III, nega DPN (transitorio miglioramento dopo sostituzione dei betabloccanti con verapamile)

• EO: BMI 37, PA 130/80mmHg,

• IM lieve, non segni SC

• Ematochimici: creat 0.93, CT 174, TG 174, HDL 52, Hb 13.8, glic 164*, HBbA1C 8.7%*, VES 54*, TSH 6.31*, FT4 8.4, microalbuminuria 0.58mgdl,

• BNP: 358pg/ml*

• 6MWT: 280m

• PFR: VC 1.81(69%) , FVC 1.77(68%) , FEV1 1.50 (69%) , FEV1/VC 83.03% (112%) : quadro restrittivo

ECG

• IVS lieve (1.3cm setto),• DTD/DTS 5.7/3.8cm, • Area Asn 30cmq, Adx 25cmq.• E 1,2m/sec, T dec169 msec,

E/E’ 17, • IT gr1, vel IT 2.8m/sec PAPS

36mmHg

• La diagnosi è certa?• Possiamo migliorare la terapia?

– Verapamile 240, irbesartan, 300, furosemide 25, spironolattone 37.5, idroclorotiazide (aggiunto), sintrom?

• Quanto una terapia aggressiva delle comorbidità – diabete, obesità, ipotiroidismo - può influenzare l’evoluzione dello SC?

• E’ (o sarebbe stato) indicato cercare una ischemia coronarica – FR ++, BMI ++?

LUNG DISEASE 53%

< EF 9%AF 8%

VALVE DISEASE 8%

OBESITY 32%

> PAP 17%

DIASTOLIC DYSFUNCTION 3%

MYOCARDIAL ISCHEMIA

DISPNEA da SFORZO con EF NORMALE

DISFUNZIONEDIASTOLICA

E’ SOLO UNAdelle VARIE CAUSE !!!!

““Patients with diastolic heart failure Patients with diastolic heart failure likely represent the likely represent the largest grouplargest group of of patients with a cardiovascular patients with a cardiovascular disorder of substantial public health disorder of substantial public health impact who have not been impact who have not been systematically studied.”systematically studied.”

Am J Med, 2000Am J Med, 2000

““Diastolic Heart Failure: Diastolic Heart Failure: Miles to Go Before We Sleep”Miles to Go Before We Sleep”

Lynne W. StevensonLynne W. Stevenson

Clinical characteristics

AgeSexHypertensionDiabetes mellitusPrior MIObesitàCOPDGallopAtrial fibrillationCardiomegaly

DHF

ElderlyFemale

+ + + + + +

+ + + +

+ +S4 + ++

SHF

All ages(tipically 50 - 70 y)

Male+ ++ +

+ + + + 0S3 +

+ +

““Utility of Utility of HistoryHistory, , Physical ExaminationPhysical Examination, , ElectrocardiogramElectrocardiogram, , and and Chest RadiographChest Radiograph for Differentiating Normal from for Differentiating Normal from

Decreased Systolic Function in Patients with Heart Failure”Decreased Systolic Function in Patients with Heart Failure”

Segni e sintomi: SC Sistolico Vs. Diastolico

Scompenso cardiaco Sistolico vs Diastolico

0 20 40 60 80 100

Disp.Sforzo

Disp.Paross.

Ortopnea

Dist. Giug.

Rantoli

Itto Apicale

S4

S3

Percentuale di pazienti

SC Diast

SC Sist

Nessun segno e nessun sintomo è specifico di SC Sist. O SC Diast.

Zile et al, Circulation.2002;105:1387-93

CHF vs. Non CHF and CHF Systol.vs Non-Systol. In CHF vs. Non CHF and CHF Systol.vs Non-Systol. In 452 Pts.with CHF: B-Type Natriuretic Peptide 452 Pts.with CHF: B-Type Natriuretic Peptide

0.0 0.5 1.0

0.5

1.0

0.0 0.5

0.5

1.0

AUC = 0.66;P<0.001

0.0 0.5 1.0

0.5

1.0

300300AUC = 0.90;P<0.001

1-SPEC.1-SPEC.1-SPEC.1-SPEC.0.0 0.5

0.5

1.0

400

200

100

300200

100CHF vs. Non-CHF vs. Non-CHFCHF

CHF Systol. vs. Non-Syst

SENS.SENS.SENS.SENS.

1) BNP is accurate in distinguishing CHF and Non-CHF (BNP=100 pg/ml: Sens 90, Spec 73, Accur. 81)

2) BNP is not accurate in distinguishing Systol. Vs Non-Systol. CHF (BNP=100 pg/ml: Sens 95, Spec 14, Accur. 66)

BNP pg/ml

Maisel et al., JACC.2003

The Natural History of Diastolic Function and LV Filling

AbnormalAbnormalrelaxationrelaxation

Pseudo-Pseudo-normalizationnormalization

RestrictionRestriction(reversible)(reversible)

RestrictionRestriction(irreversible)(irreversible)

Treatment of cardiac Treatment of cardiac pathophysiologicalpathophysiologicalmechanismsmechanisms

• Maintain atrial contraction Cardioversion for A FibSequential A-V Pacemaker

• Prevent or reduce LVH Antihypertensive drugs

Surgery (AVR for AS)• Prevent/treat ischemia -blocker, Ca++ entry blocker

Nitrates• Reduce HR/increase -blocker, Ca++ entry blocker

filling time Digitalis (AF)• Avoid LVOT obstruction Avoid arterial vasodilatators• Reduce interstitial fibrosis Ace-i/ARBs, antialdosterone

Goal of therapy Methods of treatment

• Nessun trattamento ha mostrato convincentemente di ridurre la mortalità e la morbidità

• Diuretici: riducono edema e dispnea

• Terapia aggressiva per il controllo della PA (ACEI/ARB 1a scelta)

• Terapia aggressiva per il controllo dell’ischemia

• Controllo della FC nei pazienti in FA (verapamil)

• Terapia aggressiva del diabete

ESC Guidelines 2008

EHJ 2007; 28: 2539-2550

by dr Carmine Mazzone

In absence of a comprehensive diastolic assessment

Simple echocardiographic criteria

- left atrial enlargement- normal LV dimension- left ventricular hypertrophy- wall motion abnormalities- elevated pulmonary pressures

Considerazioni

• Tipico paziente con SC diastolico vedi dia andrea da inserire eventualmente anche dia su FP dispnea cardiaca

• Mai ricoveri ospedalieri per sc almeno negli ultimi 7 anni (in precedenza comunque solo ricoveri per FA da cardiovertire eccetto uno dei primi episodi di FA associati ad

importante sintomatologiaSC) prognosi favorevole• Gestione integrata MMG-Cardiologo• Poteva essere proponibile ablazione FA in

passato almeno?

Si poteva fare di meglio?

• Forse si, forse no……credo di no

• Chiudere con dia filosofica da andrea

Trends in Prevalence and Outcome of Heart Failure with Preserved Ejection Fraction

Theophilus E. Owan, M.D., David O. Hodge, M.S., Regina M. Herges, B.S., Steven J. Jacobsen, M.D., Ph.D., Veronique L.

Roger, M.D., M.P.H., and Margaret M. Redfield, M.D.

Volume 355:251-259      July 20, 2006      Number 3

EF “CUT-OFF” : 40% or 50%EF “CUT-OFF” : 40% or 50% ?1) Some studies report a EF cut-off 40% and others 50%

2) The frequency of EF among 40-50% is approximately 10%

3) When preserved EF was defined as >50% the results of mortality, readmission and functional decline remained similar to the group of EF 40-50% (Smith GL et al, JACC 2003)

The predominant pathophysiological cause of heart failure in these patients is abnormal diastolic function (Zile MR)

““EF CUT-OFF” seem to be EF CUT-OFF” seem to be >> 40% 40%

The Natural History of Diastolic Function and LV Filling

4040

00

NormalNormalAbnormalAbnormalrelaxationrelaxation

Pseudo-Pseudo-normalizationnormalization

RestrictionRestriction(reversible)(reversible)

RestrictionRestriction(irreversible)(irreversible)

Mean LAPMean LAP

TAUTAU

NYHANYHA I-III-II II-IIIII-III III-IVIII-IV IVIV

GradeGrade II IIII IIIIII IVIV

Mean LAPMean LAP

TAUTAU

NYHANYHA I-III-II II-IIIII-III III-IVIII-IV IVIV

GradeGrade II IIII IIIIII IVIV

N-N-

The PREVALENCE of CHF with NORMAL EF INCREASES with AGE

5 yrs

1 yr

Pooled study from Circulation 2002;105;1387

Among the elderly CHF portends a grim prognosis independent of the level of measured EF. Michele Senni JACC 2001;38:1277

Metabolic syndrome and risk of development of atrial fibrillation

The Niigata preventive Medicine Study

• Prospective community-based observational cohort study with annual checkup

• To study the risk of development of AF• 28449pts without baseline AF• The metabolic syndrome was present 13%-16%• FU 4.5 y• In pt with MS: obesity HR 1.64, elev BP HR

1.69, low HDL HR 1.52, impaired insulin tolerance HR 1.44-1.35risk for AF

Circulation 2008; 117: 1255-1260