heart failure challenges · heart failure challenges: when optimal therapy is not an option afonso...
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HeartFailurechallenges:whenoptimaltherapyisnotanoption
AfonsoNunesFerreiraRafaelSantos
2019
CardiologyDepartment,SantaMariaUniversityHospital(CHULN),CAML, CCUL,LisbonSchoolofMedicine,Universidade deLisboa,Portugal
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
♂,82yearsSyncope &chest pain while having breakfast
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
♂,82yearsSyncope &chest pain while having breakfast
• ECGMedicalService
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
♂,82yearsSyncope &chest pain while having breakfast
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
♂,82yearsSyncope &chest pain while having breakfast
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
♂,82yearsSyncope &chest pain while having breakfast
• ECGà sick sinus syndrome+LBBB
• Refractory tomedicalTx(atropine 2mg)
MedicalService
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
♂,82yearsSyncope &chest pain while having breakfast
• ECGà sick sinussyndrome +LBBB
• Refractory tomedicalTx(atropine 2mg)
MedicalService
Transcutaneouspacing system
OTI
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
• HeartFailurewithreducedEjectionFraction• Ischemicheartdiseasewithunknowncoronaryanatomy• Peripheral arterydisease
• Rightaorto-femoralbypass• Cerebrovascular disease• Chronickidneydisease; anemia• CVriskfactors:Hypertension, dyslipidemia, diabetes• Medication: Perindopril 4mg,Bisoprolol 2.5mg,spironolactone25mg,furosemide 40mg,
clopidogrel 75mg,rosuvastatin 10mg,metformin 850mgbid,linagliptine 5mg,alopurinol 300mg
Medicalhistory
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
• External pacing system• Summary echocardiography
• Apicaland anteriorwall akinesia,LVEF25-30%• ABG
• pH7.14,O2127mmHg,CO2 24mmHg,Lact 62mg/dL,K+7.5mmol/L,Na+ 135mmol/L,Hb 8g/dL
Hospitaladmission
Metabolic iatrogenic sick sinus syndrome
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
Metabolic iatrogenic sick sinus syndrome
• Clinical andhemodynamicstabilisation
• Extubation
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
• Blood samples
Cardiology wardParameters Day1
Hemoglobin(g/dL) 8.5
C-reactiveprotein
(mg/dL)
4.7
Creatinine(mg/dL) 3.2
CKD-EPI(mL/min/1.73) 17.1
Potassium(mmol/L) 7.4
Sodium(mmol/L) 129
ALT(U/L) 865
LDH(U/L) 982
NT-proBNP (pg/mL) 14021
Troponin T(ng/L) 222
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
• Echocardiography
Cardiology ward
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
• Echocardiography
Cardiology ward
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
• Blood samples• Echocardiography
• DilatedLV,withapicalakinesiaanddifuse hypokinesiamainlyintheseptumandanteriorwall;
• LVEF28%;• Severesecondarymitralregurgitation
• Coronariography
Cardiology ward
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
• Coronariography
Cardiology ward
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
• Coronariography
Cardiology ward
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
• Bloodsamples• Echocardiography• Coronariography
• LM– significantdistalcalcifiedlesion• LAD– longcalcifiedirregularities,70%lesioninmidsegment• Cx withoutsignificantlesions• RCAcalcifiedproximalocclusion,distalsegmentretrogradeperfusion
• Stressechocardiography• Ø viabilityinLADandARDterritories• Ischemiainmidlateralsegment
Cardiology ward
Clinical Case
• Blood samples
Cardiology ward
Parameters Day1 Day2 Day7
Hemoglobin(g/dL) 8.5 10.0 9.9
C-reactiveprotein
(mg/dL)
4.7 5.1 3.07
Creatinine(mg/dL) 3.2 4.1 1.4
CKD-EPI(mL/min/1.73) 17 12.2 47.8
Potassium(mmol/L) 7.4 4.9 4.2
Sodium(mmol/L) 129 136
ALT(U/L) 865 1299 84
LDH(U/L) 982 1020 63
NT-proBNP(pg/mL) 14021 8675
Troponin T(ng/L) 222 348 57
Clinical Case
• Blood samples
Cardiology ward
Parameters Day1 Day2 Day7
Hemoglobin(g/dL) 8.5 10.0 9.9
C-reactiveprotein
(mg/dL)
4.7 5.1 3.07
Creatinine(mg/dL) 3.2 4.1 1.4
CKD-EPI(mL/min/1.73) 17 12.2 47.8
Potassium(mmol/L) 7.4 4.9 4.2
Sodium(mmol/L) 129 136
ALT(U/L) 865 1299 84
LDH(U/L) 982 1020 63
NT-proBNP(pg/mL) 14021 8675
Troponin T(ng/L) 222 348 57
• Re-introduction ofperindopril 2mg/dayàHiperK+ 6.2mmol/L
• Fast normalization after ACEisuspension
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
• Metabolic and iatrogenic sick sinus syndrome• HFrEF of ischemic etiology (LVEF28%)• CKDKDIGOIIIà AKIAKINIII• PAD
Clinical summary
Metabolic iatrogenic sick sinus syndrome
Pre-discharge?
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
Triplechallenge
OralTherapy Coronary intervention Pacingintervention
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
Triplechallenge
OralTherapy
HFrEF optimizedtherapy Vs Suspensionof
RASi andMRA
Coronary intervention
PCILMSà Cx Vs ConservativeTx
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
Triplechallenge
OralTherapy
HFrEF optimizedtherapy Vs Suspensionof
RASi andMRA
Coronary intervention
Vs ConservativeTx
Pacingintervention
Nointervention Vs PacemakerDDDR Vs CRT-P
PCILMSà Cx
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
Triplechallenge
OralTherapy
HFrEF optimizedtherapy Vs Suspensionof
RASi andMRA
Coronary intervention
Vs ConservativeTx
Pacingintervention
Nointervention Vs PacemakerDDDR Vs CRT-P
PCILMSà Cx
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
Triplechallenge
Pacingintervention
Nointervention Vs PacemakerDDDR Vs CRT-P
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
• Asymptomatic, SR• PMDDDR• Medicaltherapy
• Bisoprolol 2.5mg,furosemide 40mg,clopidogrel 75mg,rosuvastatin 10mg,metformin 850mgbid,linagliptine5mg,alopurinol 300mg
Discharge
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
♂,82yearsSyncope&chest painwhile having breakfast
MedicalService
FatigueNYHAIII,atypicalchestpain
2monthslater
Decompensated chronic heart failure
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
• Optimized medicaltherapy• Spironolactone 12.5mg/day,isossorbide dinitrate 20mg,
Bisoprolol 2.5mg,furosemide 40mg,clopidogrel 75mg,rosuvastatin 10mg,metformin 850mgbid,linagliptine5mg,alopurinol 300mg
Discharge
HeartFailurechallenges:whenoptimaltherapyisnotanoption
AfonsoNunesFerreiraRafaelSantos
2019
CardiologyDepartment,SantaMariaUniversityHospital(CHULN),CAML, CCUL,LisbonSchoolofMedicine,Universidade deLisboa,Portugal
@A_NunesFerreira