A story of heart failure

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 %

Acute management Acute management

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

After stabilizationAfter stabilization

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

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

Monitoring in Intensive Monitoring in Intensive care unitcare unit

Chest X-ray: pulmonary oedema, Chest X-ray: pulmonary oedema, cardiomegalycardiomegaly

0

200

400

600

800

1000

1200

Normal Class I Class II Class III Class IV

12.3 95.4 221.5 459.1 1006.3

BNP (pg/mL)

Corelation between BNP levels Corelation between BNP levels /NYHA class /NYHA class

Survival probability according with BNP levelsSurvival probability according with BNP levels

A normal A normal echocardiographyechocardiography

Our Patient:

• LV dilatation, hypokinesis ; LVEF = 20 %

• H-sPAP

• Normal valves, no sign of myocardial infarction

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

Discharge from intensive care Discharge from intensive care unitunit: D3: D3

Check up• EKG

• Chest X Ray

• Echocardiography

• Blood tests

• Coronaro-angiography

• Holter

• Sleep apnea detection (polygraphy)

• Exercise test

Coronaro angiography

Other posibility: CT

Family history: the patient had an uncle who died from HF at 50 years

MRI does not show any specific etiology

Idiopathic DMCIdiopathic DMC

Sustained Sinus rythm: 80 bpm No bradycardia, no pause Rare PVC :

• 300 in 24 h and 5 bigeminy

Holter Holter

SAS quite severe

• AHI = 35/hour (every episode > 10 sec)

• Central (typically for HF) Indication for device by bi-pap

Detection of sleep apnoeaDetection of sleep apnoea

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

VO 2 Exercise test (D13) : a very VO 2 Exercise test (D13) : a very poor performancepoor performance

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

And then…And then…

Evolution

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

Re-evaluation at D60: a patient Re-evaluation at D60: a patient stable and well treatedstable and well treated

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

ConclusionConclusion

battery

Overdrive to reboot the heart

The heart starts up again normally

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) ++

Evolution (1)Evolution (1)

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

Evolution (2)Evolution (2)

Reinforce the medical treatment (diuretics)Indication for Pacemaker: Cardiac resynchronization therapy

15 /09/2008

Wide QRS

Narrower QRS

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

Evolution (1)Evolution (1)

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)

Evolution (2)Evolution (2)

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

Outpatient check-up – December Outpatient check-up – December 2009 (3 years after the beginning 2009 (3 years after the beginning of the disease)of the disease)

Muscle-MRI : healthy subject vs Muscle-MRI : healthy subject vs heart failure patientheart failure patient

VO2 = 14 VO2 = 8

June 2006 September 2009

How does heart failure patient die?

Total mortalityTotal mortality

PlaceboPlacebo BêtabloquantBêtabloquant

17 %17 %17 %17 % 12 %12 %12 %12 %

IDMIDM

12,2 % 12,2 %

6,3 %6,3 % 3,6 %3,6 %

3,5 %3,5 % 2,7 %2,7 %

RRRR pp

0,660,660,660,66 < 0,0001< 0,0001< 0,0001< 0,0001

0,710,71 0,00490,0049

0,560,56

0,740,74

0,00110,0011

0,170,17

0,6 %0,6 % 0,5 %0,5 % 0,850,85 0,750,75

CIBIS II. Lancet 1999;353:9-13;suivi 15 mois.

9 %9 %

Heart failure: mortality causesHeart failure: mortality causes

Cardiac deathCardiac death

HF deathHF death

Sudden deathSudden death

Others...Others... -------- -------- -------- --------

Relative mortality :HF mortality/total mortality

0%

10%

20%

30%

40%

50%

60%

pas de betabloquant (CIBIS 2)

bêta bloquant(CIBIS 2)

DAI ( EVADEF) GISSI HF

Icard

morts subites

How does heart failure patient die?

Definition Definition : :

Death during the first hour following the symptoms: oficial definition Death during the first hour following the symptoms: oficial definition CIBIS 2CIBIS 2

Around 1/3 of total mortality Around 1/3 of total mortality MechanismsMechanisms (sometimes unknown): (sometimes unknown):

• • ArrhythmiasArrhythmias- Mainly ventricular fibrilation

• • SStroketroke- - Ischemic or haemoragic (VKA)

• • Pulmonary embolismPulmonary embolism, cardiac tamponade…, cardiac tamponade…

Sudden deathSudden death

BetablockersBetablockers ICD : Implantable Cardioverter Defibrillator ICD : Implantable Cardioverter Defibrillator • • Ex : the study SCD–HeFT Ex : the study SCD–HeFT

- Without ICD : 29 %

- With ICD : 22 % (p = 0,007)

follow-up 45 months

Prevention of sudden deathPrevention of sudden death

Around ¼ of total mortalityAround ¼ of total mortality MecanismsMecanisms::

• • Dilation of the 4 cardiac chambers Dilation of the 4 cardiac chambers

• Low cardiac outputLow cardiac output

End-stage heart failureEnd-stage heart failure

Pulmonary congestionPulmonary congestion : :

• Sub-PO persistent

Low cardiac output : :• • Kidney: renal insufficiencyKidney: renal insufficiency• • Brain : encephalopathyBrain : encephalopathy• • Muscle : amyotrophyMuscle : amyotrophy• • Skin : Pale skinSkin : Pale skin

……………………....

Clinical : painful death (1)Clinical : painful death (1)

High pressure in the right heart High pressure in the right heart ::

••Painful Painful hepatomegalia hepatomegalia

• • Generalized oedema : Generalized oedema :

- 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…

Clinical : painful death (2)Clinical : painful death (2)

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

Survival: average : 10 years Survival: average : 10 years

(http://www.agence-biomedecine.fr)

Slightly improvement of functional status No improvement in peak VO2 : 8,5 ml/kg/min

Hospitalization for readaptationHospitalization for readaptation

3 événements CV (4%)

24 événements CV (31%)

BNP BNP (et ANP)(et ANP)BNP BNP (et ANP)(et ANP)

Endopeptidase neutre

Clairance

NatriurieVasodilatation

Beneficial trophic effect

Inhibitionof RAA and cathecolamine

proBNPproBNP

Secretion

N-BNP

Cardiac wall stretch (heart failure)

Cardiaque myocyte

The BNP (Brain Natriuretic The BNP (Brain Natriuretic Peptides)Peptides)

Coronarographie in the D4: Coronarographie in the D4: normale coronariesnormale coronaries