Acute heart failure, beyond conventional treatment: persisting low output

Transcription

1 Acute heart failure, beyond conventional treatment: persisting low output Alexandre Mebazaa, FESC Hôpital Lariboisière, Université Paris 7 U942 Inserm

2 Conflict of Interest Lecture fee: Orion No other conflicts for this lecture

3 Clinical history 75-year-old male Weight 66 Kg Patient came to the ER with shortness of breath

4 Medical history Ischaemic cardiomyopathy diagnosed in 1997 Four previous hospitalisations for decompensated CHF; the last one in April 2006 Echocardiography 6 months ago showed LVEF 35%, dilated LV and RV, global akinesia NYHA Class IV Standard medication for advanced CHF: ACE inhibitor, -blocker, nitrate, furosemide, spironolactone

5 Physical examination when admitted to our hospital Extreme anxiety, dyspnoea Cool extremities Dilated jugular veins BP 101/65 mmhg HR 85 bpm RR 36 /min Pulmonary auscultation no rales, a bit of wheeze No urine output

6 Biological variables O 2 sat 94% under 6 L/min Creatinine 245 µmol/l (NR <120 µmol/l) Proteins 42 g/l BNP 2761 pg/ml

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8 Persisting low output History of chronic heart failure Heavily treated Decision to go forward depends on: - the mechanism of low CO (ECG, echo) - organ dysfunction yes or no

9 Cardiac Resynchronisation as a Rescue Therapy in Patients with Catecholamine-Dependent Overt Heart Failure Milliez P et al. Eur J Heart Failure 2007

10 Methods 20 patients were predominantly male with a mean age of 67 ± 10 years, with ischemic cardiomyopathy in 12 and non-ischemic in 8 with mean QRS duration of 174 ± 25 ms and LVEF of 18 ± 3%. All patients were on dobutamine infusion (7.5 ± 2.5 µg/kg/min). Catecholamine-dependant overt HF (CDOHF) patient status was defined as the recurrence of clinical and biological signs of low cardiac output despite 3 attempts of very progressive weaning of catecholamine agents. Milliez P et al. Eur J Heart Failure 2008

11 Immediate improvement after cardiac resynchronisation Parameters Before CRT implantation 24 hours after p CRT implantation SBP (mmhg) 84 ± 7 99 ± 10 < DBP (mmhg) 55 ± 5 60 ± 6 <0.001 Urine output (ml/day) 817 ± ± 1550 <0.01 Dobutamine (µ/kg/mn) 7.5 ± < QRS duration 174 ± ± 18 <0.01 BNP (pg/ml) 2176 ± ± 520 <0.001 Uremia (mmol/l) 12 ± 5 9 ± 4 <0.001 Creatinine (µmol/l) 185 ± ± 34 <0.001 LVEF (%) 18 ± 3 21 ± 4 <0.05 Milliez P et al. Eur J Heart Failure 2008

12 Echocardiography Predominent right ventricular failure Global heart failure Predominent left ventricular failure TAMPONADE? Yes No Massive mitral regurgitation? No Echocardiographic guided pericardiocentesis or surgical intervention PA catheter LV dysfunction Pulmonary vasodilators Pulmonary hypertension? RV ischaemia? Reduce RV afterload, avoid excess volume, use inotropes if CO low Any CO monitoring, ideally non invasive Optimise LV pre- and afterload, Inotropes if required Mebazaa et al. Intensive Care Med, 2004;30:185-96; Antonelli et al. Intensive Care Med, 2007;33:575-90

13 Inotropes & Vasoactive agents?

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15 ALARM-HF included 4953 AHF patients Mebazaa et al Intensive Care Medicine 2011

16 In-hospital mortality Diuretics Levosimendan Nitrates Days Epinephrine Norepinephrine Dopamine Dobutamine Whole cohort Mebazaa et al Intensive Care Medicine 2011

17 Mebazaa et al Intensive Care Medicine 2011 SBP < 100 mmhg (n=318) SBP mmhg (n=334) SBP mmhg (n=618) SBP > 160 mmhg (n=694)

18 Device therapy?

19 Mebazaa et al Crit Care 2010

20 Mebazaa et al Crit Care 2010

21 Does post-discharge treatment influence shortand long-term outcome??

22 All-Cause Mortality by Beta-Blocker Use at Baseline and Discharge 1.0 Probability of survival Baseline Discharge Yes / Yes No / Yes No / No Yes / No Days since start of study drug infusion M. Boehm et al. Crit Care Medicine 2011

23 Effects of beta-blockers on patients admitted for acute respiratory failure CARDIAC CAUSES NON-CARDIAC CAUSES No/Yes Yes/Yes No/No Yes/Yes No/Yes No/No Yes/No Yes/No Noveanu et al Crit Care 2011

24 In summary Mechanism(s): Large QRS? RVF? Global heart failure? Treatment: Avoid catecholamines nitrates ECMO as early as possible before end organ dysfunction