a history of dropsy timothy a. denton, m.d. attending cardiologist high desert heart institute...

A History of Dropsy

Timothy A. Denton, M.D.Attending Cardiologist

High Desert Heart InstituteVictorville, CA

The Time Line

500 20000 500 1000 1500

Socrates (470-399 BC)Hippocrates (460-377 BC)

BC AD

Galen (180)

Harvey (1616)

Laënnec(1700)

dropsy

CHF~400 B.C. – SOB, edema, ralesFirst described by Hippocrates

Ear directly on chestHow to drain effusions

caused by excess of “phlegm” (cold humor)Moving from brain to chest

~180 AD -- Galen – the heart as a source of heat

1616 – Harvey and circulation

1700 – Laënnec’s stethoscope

CHF - Dropsy

A morbid condition characterized by the accumulationof watery fluid in the serous cavitiesor the connective tissue of the body.

Hydrops, Idropsie

First use in 1290 – “Some fullen in-to be dropesie”

OED

CHF - Dropsy

A woman, 50 years of age, had been affected for twelve years with all the symptoms of disease of the heart, in a very high

degree, viz. strong and frequent palpitations, habitual dyspnoea, breathlessness on using the least exercise, sudden startings from

sleep, almost constant endema of the lower extremitites, and lividity of the cheeks, nose and lips.

Laennec“A Treatise on the Diseases of the Chest”

1821

CHF - Dropsy

Oedema of the Lungs

The symptoms of this affection are extremely equivocal. Impeded respiration, slight cough and a watery expectoration are the only

signs of it.

Laennec“A Treatise on the Diseases of the Chest”

1821

CHF - DropsyDilatation and feebleness of the heart…

The heart’s action permanently irregular, with an extended, but not a strong impulse; the sounds so rapid and equal that their analysis is difficult…It occurs in gouty and debilitated habits, and is almost always attended with chronic bronchitis and enlargement of the

liver.

Stokes“Diseases of the Heart and the Aorta”

1853

CHF - DropsyTreatment of the Weak and probably Dilated Heart…

…we next proceed to examine that of the weakened hearts, of which the two most common forms are dilatation of the cavities, associated with pulmonary and hepatic disease; and again, the

fatty degeneration.

It is remarkable, that although the beneficial action of mercury in the affection is known to may practical physicians, but little

practical information can be found on the subject…it is impossible to speak too highly of the efficacy of this treatment…

Stokes“Diseases of the Heart and the Aorta”

1853

CHF - DropsyTreatment of the Weak and probably Dilated Heart…

During this treatment, and especially when free diuresis is established, it is necessary that wine or some other diffusible

stimulus should be carefully administered, and the system supported by a proper aliment…

Stokes“Diseases of the Heart and the Aorta”

1853

William Harvey

1578-16571639: De Motu Cordis

“We then come to the bloodstream.The blood rushes from the head, down to the feet…gets a look at those feet,and rushes back to the head again.”

Groucho on the Circulation

from “Horse Feathers”(Julius Henry Marx)

William Withering

Born: 1741 - 17991775: Obtained first “tea” from gypsy

Foxglove

From German: Fingerhut (finger hat or thimble)Mid-1500’s: Latinized to “digitalis” – finger (digitus)Digitalis purpurea – a common variety1775 – William Withering

CHFIt’s a hemodynamic disease !

Preload

Afterload

Contractility

Preload

• William Stokes (1804-1878) uses Mercuryto treat CHF

• Southey’s tubes• 1919 - Organomercurial diuretics• Rotating tourniquets• 1958 – thiazide diuretics• Oral nitrates improve hemodynamics

AHJ 1975;90:346

CHF

Used into the late 1950’s

Southey’s Tubes

CHFIt’s a hemodynamic disease !

Preload

Afterload

Contractility

Contractility

• Digoxin• Epinephrine• Dopamine• Dobutamine

CHFIt’s a hemodynamic disease !

Preload

Afterload

Contractility

Afterload• Lowered afterload improves hemodynamics in MR

(Ann Int Med 1975;83:312)• Vasodilator therapy in heart failure

(Ann Int Med 1975;83:421)• Hydralazine / Minoxidil in refractory CHF

(Ann Int Med 1976;85:467)• Lowered afterload improves hemodynamics in AI

(Circulation 1976;53:879)• Lowered afterload improves hemodynamics in CHF

(Ann Rev Physiology 1977;39:277• 1987 - CONSENSUS I

CHF

It’s a neurohormonal disease !

• 1963 – Plasma norepinephrine elevated in CHF(NEJM 1963;269:653)

• 1970’s digoxin reduces plasma renin and norepinephrine levels

CHF

• It’s a hemodynamic diseasePreloadContractilityAfterload

• It’s a neurohormonal disease

CHFSystolic vs Diastolic Failure

Kitzman,et al., Am J Cardiol, 2001;87:413-419

45%

55%Diastolic

Systolic

*No valvular or mechanical causes

CHF

Systole = contraction (inotropy)

Diastole = relaxation (lusitropy)

CHF

What is diastolic dysfunction?

CHF

Dilated Normal Hypertrophic

CHF

Normal Heart Enlarged Heart

CHF

Diagnosis

• ClinicalSOB, DOE, CoughOrthopneaEdema

• CxR• BNP• Echo (or equivalent)

CHF

Diagnosis

What is the EF?

Low NormalHigh

CHF

Is there ischemia?

Yes No

Diagnosis

PTCACABGEECP

CHF (systolic dysfunction)

• Preload• Contractility• Afterload• Neurohormonal• Dysrhythmia• Dysynchrony

Emergency Rx CHF

PreloadLasix

Nesiritide

ContractilityInotropes

Digoxin

Afterload Nipride

Neurohormonal N/A

Dysrhythmia Antiarrhythmics

Dysynchrony N/A

Chronic Rx CHF

Preload

+ Lasix

+ Ultrafiltration

+ Nitrates

ContractilityDigoxin

Transplant evaluation / LVAD

AfterloadACE / ARB

Hydralazine

Neurohormonal

Beta blocker

ACE / ARB

Spironolactone / eplerinone

DysrhythmiaICD

+ Antiarrhythmics

Dysynchrony BiV Pacing

Preload

IV diuretics Lasix (20,40,80,160,320) Lasix drip Combination (Lasix / zaroxolyn)Naturetic peptic (nesiritide)Dialysis / UltrafiltrationNitrates

Dialysis / Ultrafiltration

Ultrafiltration

CHF Solutions, Inc.

Contractility

• Dobutamine• Milrinone• Epinephrine• Dopamine• LVAD• Heart transplantation

Ambulatory Infusion Pumps

• Dobutamine• Milrinone

Afterload

• ACE inhibitors• ARB’s• Hydralazine

Neurohormonal

• Beta blocker• Spironolactone / eplerenone• ACE inhibitors• ARB’s

Is there a BEST Beta Blocker?

17% Reduction

Dysrhythmia

• ICD• Antiarrhythmics• Beta blockers

Dysynchrony

• Bi-V pacing

Therapy of CHF

0 10 20 30 40 50 60 70 80 90 100

Ejection Fraction

Normal

Systolic Dysfunction Diastolic Dysfunction

Therapy of CHF

0 10 20 30 40 50 60 70 80 90 100

Ejection Fraction

NormalRange

Systolic Dysfunction Diastolic Dysfunction

• ICD• BiV pacer• Heart transplant

• Aggressive MedRx

Therapy of CHF

0 10 20 30 40 50 60 70 80 90 100

Ejection Fraction

NYHA

CLASS

I

II

III

IV

ACE, Beta, ARB, dig +ACE, Beta, +ARB

ICD, BiV

Transplant

End

CHF

Diagnosis

CHF

Diagnosis

• Clinical• CxR• BNP• Echo