Cardiorenal Debate. Scottish Heart Failure Nurse Forum September Dr Paddy Gibson. Dr Alan Japp. Consultant Cardiologist NHS Lothian

Transcription

1 Scottish Heart Failure Nurse Forum September 2017 Cardiorenal Debate { Dr Alan Japp Consultant Cardiologist NHS Lothian Vifor Pharma UK have sponsored this speakers for this presentation. Vifor Pharma have had no input into the content of the presentation, other than to check for compliance with industry codes of practice. Dr Paddy Gibson Consultant Nephrologist NHS Lothian

2 Understanding cardio-renal disease. Paddy Gibson Consultant Renal Physician Lothian

3 Save the lungs Sod the kidneys

4 Is this a problem? About 30% of patients with heart failure will have abnormal kidney function About 30% of patients undergoing treatment for heart failure will see a decline in their kidney function

5 Why?

6 Why?

7 Why? TYPE 2 DIABETES HYPERTENSION

8 Why? Heart failure leads to: Reduced cardiac output and poor renal perfusion Increased venous congestion, increased intrabdominal pressure and poor renal perfusion

9 Why? Heart failure leads to: Sympathetic activation and renal vasoconstriction causes poor renal perfusion Use of a lot of medicines that cause...poor renal perfusion

10 How does a kidney work?

11 And if it has to work harder...

12 In heart failure?

13 Add in medicines: ACEinhibitors Diuretics

14 So: The obvious thing to do is to stop ACEinhibitors & diuretics

15 What does the patient want? Probably to live a bit longer To stay out of hospital To not be breathless To be less afraid

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20 So: Kidneys can cope with heart failure and the medicines you use People can withstand worse kidney function than you think You may need to use bigger diuretic doses than you re used to Fiddle with medicines rather than stop them And:

21 Save the lungs Sod the kidneys

22 Case 1: PC. 51 y/o male

23 Case 1: PC. 51 y/o male Admitted 3/3/15: Recent admission to RIE with abdo pain, SOB and deranged LFTs in context of longstanding alcohol excess Progressively worsening SOB with orthopnoea + PND Oedema and mild ascites; Atrial fibrillation AKI; mildly deranged LFTs Discharged on spiro 25 and furosemide 40; O/P echo Readmitted 9 days later after attending for echo

24 Case 1: PC Show echo

25 Case 1: PC On re-admission: SOB on any exertion; orthopnoea+++ JVP elevated +++ Peripheral oedema to thighs / groin At least mild ascites AF with rate ~110 BP 95/60 Worsening AKI since last discharge Compliant with spiro and furosemide

26 Case 1: PC Bloods (Day 3) 2 months ago 9 days ago Readmission day 1 Creatinine egfr > Urea K Qs 1. Continue, intensify or reduce diuretic treatment? 2. Any other treatments?

27 Case 1: PC Treatment: Furosemide 100mg IV bd Apixaban Digoxin Nothing else Next day.

28 Case 1: PC Bloods 2 months ago 9 days ago Readmission day 1 Creatinine egfr > Urea K Readmission day 2 Reports good diuresis; otherwise much the same Qs 1. Continue, intensify or reduce diuretic treatment?

29 Case 1: PC Prolonged admission (17 days) High dose IV diuretics AF rate control + anticoagulation Dramatic clinical improvement

30 Case 1: PC Bloods Readmission day 1 Readmission day 2 Readmission day 5 Creatinine egfr >60 Urea K Readmission day 15

31 Remember!

32 Remember! (Congestive kidney failure)

33 Case 1: PC Prolonged admission (17 days) High dose IV diuretics AF rate control + anticoagulation Dramatic clinical improvement Outpatient treatment: Apixaban 5mg bd, Furosemide 40mg daily Lisinopril 10mg daily, Bisoprolol 10mg daily Digoxin 125 migrograms daily, Spiro 25mg daily NYHA class 1; no further hospital admissions

34 Case 1: PC show echo

35 Case 2: HH. 73 y/o male GP Referral This 73 year old man has established cardiac failure, on a background of IHD with CABG, aortic valve replacement and AF. He also has CKD and typically runs an egfr in the low 30's. He presented recently with ankle swelling and SOB with signs of pulmonary oedema. His Furosemide was increased from 20mg to 40mg and his egfr fell to 21. The Furosemide was then reduced back to 20mg. In the past, there was a fall in his egfr on Lisinopril and it was stopped. His BP is also too high and I have increased his Doxazosin from 6mg to 8mg today. I would welcome advice on optimising his medication.

36 Case 2: HH. 73 y/o male Repeat Echocardiogram Normal LV size; mild to moderate LVH Abnormal septal motion (prev surgery) at worst mild LVSD Dilated left atrium Mild to moderate mitral regurgitation Aortic prosthesis well seated, satisfactory function RV normal size and function; Dilated right atrium TR velocity 2.6 cm/s

37 Case 2: HH. 73 y/o male Cardiologist response (not me) I suspect that the fundamental problem here is diastolic dysfunction which is also known as heart failure with a preserved ejection fraction. Hypertension, LVH and advancing years will all be contributing. The trick is to use the lowest possible dose of loop diuretic and treat the BP aggressively. I would maintain Frusemide 20 mg mane and try to bring the systolic pressure to 140 or less. Given the troublesome ankle swelling with Amlodipine I would try instead Lercanidipine 10 mg daily. If BP remains high or he has trouble with Lercanidipine then I would try Hydralazine 25 mg b.d., rechecking U+E after 1-2 weeks.

38 Case 2: HH. 73 y/o male Cardiologist response (not me) I suspect that the fundamental problem here is diastolic dysfunction which is also known as heart failure with a preserved ejection fraction. Hypertension, LVH and advancing years will all be contributing. The trick is to use the lowest possible dose of loop diuretic and treat the BP aggressively. I would maintain Frusemide 20 mg mane and try to bring the systolic pressure to 140 or less. Given the troublesome ankle swelling with Amlodipine I would try instead Lercanidipine 10 mg daily. If BP remains high or he has trouble with Lercanidipine then I would try Hydralazine 25 mg b.d., rechecking U+E after 1-2 weeks. Do you agree?

39 Case 2: HH. 73 y/o male My ward round (10 days later) Day 1 Background as detailed. Worsening SOB and ankle swelling for last month or so. Worsening renal function. Weight gain (14 kg). O/E: Hypertensive. AF with rate JVP up (6-7 cm). Bilat pitting oedema. HS1+2 + MR murmur at apex, TR murmur and soft early ESM aortic area. No diastolic murmurs. Imp: Combined heart failure (LVH, LVSD) and renal failure. Suspect recent deterioration in GFR due in part to renal congestion. Rate control excessive at the moment (both bisop and dig renally excreted) Plan:

40 Case 2: HH. 73 y/o male Chest X-Ray AKI on CKd,?any infection causing this, also CCF Report Comparison made with the previous x-ray dated 10 10/14. Central sternotomy wires and coronary clips. The heart is enlarged. Features of fluid overload with congested pulmonary vascularity, peribronchial cuffing and a new right pleural effusion.

41 Case 2: HH. 73 y/o male Bloods (Day 1) 2 weeks pre Day 1 Creatinine egfr Urea K Qs 1. What would you do with diuretic treatment? 2. Any other treatment changes?

42 Case 2: HH. 73 y/o male My ward round (10 days later) Day 1 Background as detailed. Worsening SOB and ankle swelling for last month or so. Worsening renal function. Weight gain (14 kg). O/E: Hypertensive. AF with rate JVP up (6-7 cm). Bilat pitting oedema. HS1+2 + MR murmur at apex, TR murmur and soft early ESM aortic area. No diastolic murmurs. Imp: Combined heart failure (LVH, LVSD) and renal failure. Suspect recent deterioration in GFR due in part to renal congestion. Rate control excessive at the moment (both bisop and dig renally excreted) Plan: Increase IV furosemide (50 bd to 80 bd). Fluid restrict L. Reduce dose bisop for now. Daily weights / U&E.

43 Case 2: HH. 73 y/o male US Kidneys worsening renal function (over months). proteinurea. Heart failure.?structural cause for decline in function/altered kidney size. Report Both kidneys are least 10 centimetres in length but diffuse parenchymal thinning to less than a centimetre and diffusely increased echotexture consistent with nonspecific nephropathic process. No mass or collecting system dilatation. Normal bladder. There is diffuse cardiomegaly. No pericardial collection. Distended hepatic veins and IVC.

44 Case 2: HH. 73 y/o male My ward round Day 3 Overall improvement but slower than expected progress and mild decline in egfr. P Hypertensive. Still quite significant residiual oedema and JVP remains up. Plan:

45 Case 2: HH. 73 y/o male Bloods (Day 3) 2 weeks pre Day 1 Day 2 Day 3 Creatinine egfr Urea K

46 Case 2: HH. 73 y/o male Bloods (Day 3) 2 weeks pre Day 1 Day 2 Day 3 Creatinine egfr Urea K Qs 1. Continue, intensify or reduce diuretic treatment? 2. Anything else to consider (renal or cardiac)?

47 Case 2: HH. 73 y/o male My ward round Day 3 Overall improvement but slower than expected progress and mild decline in egfr. P Hypertensive. Still quite significant residual oedema and JVP remains up. Plan: Keep in over weekend. Repeat U+E Sunday. Echo today. Increase furosemide slightly. Continue to withhold dig. Add ISMN. Hopefully home start of next week.

48 Case 2: HH. 73 y/o male Weekend ward round Day 5 BG Hx noted: 1. Combined heart failure (LVH, LVSD) and renal failure Renal func remains poor Urea:14.7 (15) Creat 322 (312) egfr: 16 (17) P: 1. R/v mane by Cardio

49 Case 2: HH. 73 y/o male Bloods (Day 5) 2 weeks pre Day 1 Day 2 Day 3 Day5 Creatinine egfr Urea K

50 Case 2: HH. 73 y/o male My ward round Day 6 Feeling better. Weight down. Still has significant residual oedema but JVP now only marginally elevated. HS unchanged. Further slide in renal function. HR now ~70 (AF) Plan: IV to oral diuretics. Stay off dig in view of GFR. Increase ISMN; stop doxazosin. Echo and bloods tmrw then home tmrw afternoon with F/U in MDU. NB: discharged on oral Furosemide 80 mg bd.

51 Case 2: HH. 73 y/o male MDU review (junior doc attached to cardio) 1 week later appears symptomatically well. His ET is almost back to baseline, and he reports no orthopnoea and no PND. His peripheral oedema continues to improve. His weight continues to decrease, and today is 94.1kg (was >100kg on admission). HR is 69 and BP is 181/84. Sats 96% on room air. He has a visible JVP which is slightly elevated, he has quiet bibasal creps,. He has peripheral oedema to his mid shin which is much improved since admission. Bloods show egfr of 15, creatinine of 345 (from 322). His renal function has slowly been creeping down over the past 2 weeks in the context of high dose diuretics.

52 Case 2: HH. 73 y/o male Bloods (Day 2) 2 weeks pre Day 1 Day 2 Day5 1 week later Creatinine egfr Urea K

53 Case 2: HH. 73 y/o male MDU review (junior doc attached to cardio) 1 week later continued Overall, I think Mr H's heart failure is improving, and I think his renal function may be contributing to his peripheral congestion. I have decreased his furosemide to 80mg/40mg and asked him to get his renal function rechecked in 1 weeks time to ensure his renal function is improving. He has follow up with renal team on 18/5/17.

54 Case 2: HH. 73 y/o male MDU review (junior doc attached to cardio) 1 week later continued Overall, I think Mr H's heart failure is improving, and I think his renal function may be contributing to his peripheral congestion. I have decreased his furosemide to 80mg/40mg and asked him to get his renal function rechecked in 1 weeks time to ensure his renal function is improving. He has follow up with renal team on 18/5/17. Do you agree?

55 Case 2: HH. 73 y/o male MDU review (junior doc attached to cardio) 1 week later continued Overall, I think Mr H's heart failure is improving, and I think his renal function may be contributing to his peripheral congestion. I have decreased his furosemide to 80mg/40mg and asked him to get his renal function rechecked in 1 weeks time to ensure his renal function is improving. He has follow up with renal team on 18/5/17. Paddy, do you agree?

56 Case 2: HH. 73 y/o male No

57 Case 2: HH. 73 y/o male Paddy Gibson clinic letter The priority for Mr H is going to be keeping him clear of fluid. It will be his tendency to fluid overload and pulmonary oedema that causes him to be admitted to hospital.

58 Case 2: HH. 73 y/o male Paddy Gibson clinic letter The priority for Mr H is going to be keeping him clear of fluid. It will be his tendency to fluid overload and pulmonary oedema that causes him to be admitted to hospital. I think his clinical condition will not be influenced all that much by his biochemistry and I would be cautious in making reductions in his diuretic dose because of impaired biochemistry.

59 Case 2: HH. 73 y/o male Paddy Gibson clinic letter The priority for Mr H is going to be keeping him clear of fluid. It will be his tendency to fluid overload and pulmonary oedema that causes him to be admitted to hospital. I think his clinical condition will not be influenced all that much by his biochemistry and I would be cautious in making reductions in his diuretic dose because of impaired biochemistry. I think it is likely that there is a Furosemide dose that keeps him free of fluid with stable biochemistry and once this dose is achieved it should be maintained.

60 Case 2: HH. 73 y/o male 7 weeks later.. My clinic CURRENT MEDICATIONS: Furosemide 80 mg am; 40 mg lunchtime Folic acid 5 mg o.d. Isosorbide mononitrate 60 mg b.d. Atorvastatin 10 mg nocte Bisoprolol 5mg Warfarin as per INR MEDICATION CHANGES:? I reviewed Mr. H in Dr. Japp's clinic today. Since discharge his SOB has continued. A CXR in mid July showed pulmonary congestion. There was evidence of this today with an elevated JVP, bilateral pitting oedema to knees and crackles to the mid zones. He describes 3 pillow orthopnoea but no PND.

61 Case 2: HH. 73 y/o male 7 weeks later.. My clinic CURRENT MEDICATIONS: Furosemide 80 mg am; 40 mg lunchtime Folic acid 5 mg o.d. Isosorbide mononitrate 60 mg b.d. Atorvastatin 10 mg nocte Bisoprolol 5mg Warfarin as per INR MEDICATION CHANGES: Increase Frusemide today to 120 mg mane, 80 mg at lunchtime. For review by GP in 2 to 3 weeks' time and increase to 120 mg b.d. if required Review rate - consider increase Bisoprolol to 7.5 mg o.d.

62 Case 3: EG. 69 y/o female Cardiology referral letter Mrs G was referred to my clinic for syncope during exercise but at the same time she had developed nephrotic syndrome with Bence Jones protein.the syncope tends to happen after strenuous exercise or more specifically during it. The echo shows a small LV cavity with moderate concentric left ventricular hypertrophy. The patient is only 69 and has not got any ischaemic heart disease. I wonder if this finding is significant.

63 Case 3: EG. 69 y/o female Cardiology (not me): There is mild LVH on echocardiogram with septal thickness of 17 mm. The aortic valve is bicuspid but there is no stenosis. I note that she is being referred elsewhere because of proteinuria. I do not think that the clinical picture is consistent with hypertrophic cardiomyopathy but I will arrange both a cardiac MRI scan and a 24-hour ambulatory blood pressure profile before writing again.

64 Case 3: EG. 69 y/o female Other symptoms: 1. bilateral feet pains which are of an unusual character 2. some back pain

65 Show echo / MRI Case 3: EG. 69 y/o female

66 Case 3: EG. 69 y/o female Last Review (Haematology Outpatients) DIAGNOSES: 1. AL Amyloidosis with cardiac and renal involvement 2. Low level plasma cell dyscrasia - less than 10% in bone marrow at baseline 3. Completed 5 cycles of VCD chemotherapy This lady returned for further assessment in the Haematology clinic accompanied by her daughter. She has now completed 5 cycles of chemotherapy which she has tolerated extraordinarily well. Having said that she continues to have a sensory polyneuropathy being troubled by neuropathic pain and paraesthesia in her hands and feet.

67 Thank you