cardiac_asthma_elderly ppt asma.pdf

Geriatrics Resident Rounds January 9 2012

Jonah Mizzau PGY-2 Internal Medicine

You are asked to see an 80F in the ER with worsening SOB. She has a h/o “heart problems” and is an ex-smoker. When you examine her she has signs of decompensated heart failure but a significant wheeze. You remember hearing the term “cardiac asthma” and wonder if it applies to this patient and if so what does that mean for her treatment and prognosis…

Review basics of cardiac asthma (definition, pathophysiology)

Review characteristics of cardiac asthma in geriatric population

Review specific treatment options in this setting

1st described in 1832 by James Hope Multiple definitions, usually asthma-type sx w/out 1° lung Commonly defined now as wheezing, coughing and

orthopnea due to CHF

Tanabe, T. et al. Cardiac Asthma: New insights into an old disease. Expert Review of Respiratory Medicine. 6.6:705 (2012)

Mechanisms: 1. Bronchial vasc circulation changes 2. Pulmonary edema, ↑ blood vol in lungs 3. Airway remodelling 4. Bronchial hyper-responsiveness

Tanabe, T. et al. Cardiac Asthma: New insights into an old disease. Expert Review of Respiratory Medicine. 6.6:705 (2012)

Leading cause of acute SOB in elderly Approx 10% of pop > 80 have dx HF Significant in-hospital mortality (13-29%)

Rich M. Heart Failure in the 21st Century: a Cardiogeriatric syndrome. Journal of Gerontology 56A: 88-96 (2001)

Single centre, prospective study to look at incidence, pt characteristics, tx outcomes Included: pts > 65 Acute SOB CHF (TTE or BNP) Excluded: Asthma exacerbation

Jorge, S., et al. Cardiac asthma in elderly patients: incidence, clinical presentation and outcomes. BMC Cardiovascular Disorders 7:16 (2007)

Divided into: Cardiac asthma (wheeze detected in ED) Classical CHF (no wheeze) 514 initially included, 212 proven to have HF (by TTE or BNP) Outcomes were survival (in-hosp, 1 yr) and re-admission


Results: 35% (75) fit “cardiac asthma” 65% (137) fit “classical CHF” BNP/NT-pro-BNP lvls similar PFT’s similar (restrictive) but w ↑ distal airway obstruction in

“cardiac asthma” pts ↑ tobacco use, ↓ pH, ↑ pCO2 as well


Concluded: Higher incidence than previously reported (35%) Same outcomes btw both groups (despite differences in

presentation)


Maybe our lady does fit into this “cardiac asthma” group, after all it’s not uncommon… …and her outcomes can be expected to be similar to that of our classic decompensated HF pts. …how do we treat her?

Best evidence supports conventional therapy for LV systolic dysfn (provided her HF is systolic): ACEi/ARB BB (safe for COPD, maybe even survival benefit) Spironolactone Digoxin Acutely loop diuretic + nitrate

40 pts in Greece w orthopnea, LV sys dysfn (TTE), pulm edema (CXR)

Measured resp fn sitting to supine, w or w/out SL nitrates Improved fn while supine w nitrates

Spyratos, D. et al. Assessment of respiratory mechanics by impulse oscillometry in orthopneic patients with acute left ventricular failure. Heart & Lung 40:97-104 (2011)

β-agonists: may ↑ fluid resorption and ↓pulm edema (ex-vivo study,

post-lung resection study) Meta-analysis 2011 - no reason to withhold (ischemia,

arrhythmia) as acute tx for ?HF but no demonstrated benefit (physiologically may make sense)

Maak, C., Tabas, J. and McClintock, D. Should acute treatment with inhaled beta agonists be withheld from patients with dyspnea who may have heart failure? Journal of Emergency Medicine 40:2: 135-145 (2011)

Anti-cholinergics: Small study in Am J of Cardio, showed statistically sig

difference in PFT’s in NYHA 2/3 HF pts tx’ed w ipratropium Not routinely recommended

Kindman, L. et al. Abnormalities of pulmonary function in patients with congestive heart failure, and reversal with ipratropium bromide. American Journal of Cardiology 73:258-262 (1994)

Cardiac asthma common presentation of CHF in elderly pts Challenging diagnosis – remember “Not all that wheezes is

(bronchial) asthma” Best tx is chronic HF tx

Hunt, S. et al. 2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 119(14), 391-479 (2009) Jorge, S., et al. Cardiac asthma in elderly patients: incidence, clinical presentation and outcomes. BMC Cardiovascular Disorders 7:16 (2007) Kindman, L. et al. Abnormalities of pulmonary function in patients with congestive heart failure, and reversal with ipratropium bromide. American Journal of Cardiology 73:258-262 (1994) Lien C. et al. Heart failure in frail elderly patients: diagnostic difficulties, co-morbidities, polypharmacy and treatment dilemmas. European Journal of Heart Failure 4:91-98 (2002) Maak, C., Tabas, J. and McClintock, D. Should acute treatment with inhaled beta agonists be withheld from patients with dyspnea who may have heart failure? Journal of Emergency Medicine 40:2: 135-145 (2011) Manzano, L. et al. Diagnosis of elderly patients with heart failure. European Journal of Heart Failure. 14: 1097-1103 (2012) Rich M. Heart Failure in the 21st Century: a Cardiogeriatric syndrome. Journal of Gerontology 56A: 88-96 (2001) Spyratos, D. et al. Assessment of respiratory mechanics by impulse oscillometry in orthopneic patients with acute left ventricular failure. Heart & Lung 40:97-104 (2011) Tanabe, T. et al. Cardiac Asthma: New insights into an old disease. Expert Review of Respiratory Medicine. 6.6:705 (2012)

cardiac_asthma_elderly ppt asma.pdf

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