Heart Failure Symposium: Case Presentation (The crash and burn and the smoldering patient)

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Abraham Smith
5 years ago
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1 Heart Failure Symposium: (The crash and burn and the smoldering patient) Patrick C. Magnus, MBBS, MPH Clinical Fellow Section of Cardiology Dartmouth Hitchcock Medical Center (Case 1) 66 year old man, transferred from an OSH, for further management of an NSTEMI 6 days prior to presentation he describes episodes of feeling just not myself associated with episodes of dizziness, blurred vision, diaphoresis and pain between his shoulder blades lasting 10 minutes He had multiples similar episodes in the ensuing days On the morning of presentation he was awoken with similar symptoms but more severe, additionally he felt confused and developed anterior chest tightness 2 Past Medical/Surgical History Allergies Anxiety disorder Asthma Oral cancer (Base of tongue) s/p resection and radiation therapy complicated by radiation induced osteonecrosis of the jaw requiring long term Abx therapy (Doxycycline) Medications: ASA 81 mg Saw Palmetto Glucosamine/Chondroitin B complex Vitamin D Lorazepam Cetirizine Doxycycline Allergies: Wood dust 3 1

2 Family History: Heart disease (Mother) Cancer (Father) Social History: Divorced Retired carpenter Active, primarily hunting Former smoker, 25 pack year 4 Findings at OSH: Vitals: BP 103/64 P 93 R 16 O2 96% Continues to have on going chest pain Physical examination unrevealing except for low O2 sats Na 140 K 3.8 Cl 103 CO2 27 BUN 21 Cr 1.6 Glu 220 Mg 1.7 Ca 9.1 WBC 16.1 H/H 14.8/45.2 Plt 216 Trop 2.56 D Dimer 582 CXR: Increased pulmonary vascular congestion; Pulmonary edema ECG 5 6 2

3 Initial Management: Oxygen (4 liters to maintain O2 sats) ASA 324 mg Clopidogrel 300 mg Heparin Nitroglycerin gtt Morphine sulphate Transferred to DHMC 7 On arrival to DHMC ICCU, he continues to have low level chest discomfort Physical examination: BP 118/72, P 87 (regular), R 16, O2 100% (4L O2) Ht 6 1, Wt 200lbs (BMI 26.4) General: Oriented, pleasant, mildly dyspneic but in no overt distress Resp: Bibasilar crackles, no wheeze Cards: S1, S2, +S3. JVP not elevated, No rubs or murmurs. Good pulses bilaterally Abd: Soft and NT. No organomegaly. Normal bowel sounds. No bruits Ext: No peripheral edema noted. Extremities are warm and appear well perfused 8 Cath lab course: Ao 93/61 (73), LVEDP 40 Developed worsening hypoxemia and increasing upper airway secretions and hypotension (MAP~50 mmhg) Intubated in the lab Limited echo in cath lab showed severely hypokinetic lateral and inferolateral walls, no significant MR 9 3

4 10 Diagnosis: Posterior STEMI complicated by cardiogenic shock 11 CVCC Course: Dopamine continued at 10 mcg/kg/min Up titrated Lasix drip started Spikes a temp and is pan cultured Worsening pulmonary edema Peak Trop/CK: 41.7/

PASP~38mmHg, Moderate to severe MR 13 14 Right heart cath HD#3: LVEDP 18 mmhg PA PCWP CO CI SVR PVR PA Sat 46/29 25 2.4/2.9 1.13/1.

5 CVCC Course: Afib with RVR with rates in the 120s DCCV fails to restore sinus rhythm Propofol added for additional sedation Amiodarone started Norepinephrine added for worsening hypotension Echo shows: EF 35 40% Anterolateral, inferolateral and inferior WMAs. PASP~38mmHg, Moderate to severe MR Right heart cath HD#3: LVEDP 18 mmhg PA PCWP CO CI SVR PVR PA Sat 46/ / / % Milrinone started: SVR ~ , CI Urine output improves Spikes temps, cultures and started on broad spectrum antibiotics 15 5

6 HD #4 5: Pressors and inotropic support weaned MAPs in the 60s IABP weaned and subsequently pulled Cultures negative x 48 hrs and Abx stopped Continues to spike temps (102) Extubated 16 Over the next few days: Diuresis is continued BUN/Cr continue to rise (91/2.1) Worsening O2 sats requiring re intubation CXR now showing bilateral moderate pleural effusions and left lower lobe infiltrate Broad spectrum antibiotics restarted for HAP Decreased urine output and MAP~50 mmhg Right heart cath: PA PCWP CO CI SVR 48/ Supported with Norepinephrine, Milrinone and Saline infusions Hemodynamics stabilize and renal function improve and he is extubated on HD#14 Eventually transferred from the CVCC to the ICCU and his HAP is treated Discharged to rehab after ~40 days 18 6

7 Summary: 66 y.o with posterior STEMI complicated by cardiogenic shock requiring IABP support, prolonged inotropic support and pressor support 19 (Case 2) 71 year old man with a h/o Chronic lymphocytic leukemia, Hypertension, Hyperlipidemia, Diabetes mellitus, and Bladder Ca Presents to DHMC with worsening SOB and weight gain Seen by the cardiology consult service for acute decompensated systolic heart failure refractory to standard diuretic therapy: 4 months earlier in Florida diagnosed with dilated ischemic cardiomyopathy EF~20% Underwent PCI to LAD and OM CRT D 2 admissions for ADSHF 20 Medical regimen: ASA Spironolactone Furosemide Carvedilol Atorvastatin Clopidogrel Allopurinol Meclizine Paroxitine KCl Metformin Albuterol Physical Examination: Overweight man, mild resp distress BP 87/70P 91 T 36.6 O2 96% Wt 224lbs Ht 5 11 (BMI 31.5 kg/m2) JVP 10 cm Bilateral crackles Distant heart sounds, no murmurs Bilateral leg edema 21 7

8 Data: Pro BNP 5,705 pg/ml WBC 16 20,000 Hb/Hct 9.7/27 Plt 201 BUN/Cr 16/0.77 Cardiac biomarkers negative ECG Paced rhythm

9 Right Heart Cath: RA RV PA PCWP CO CI PA Sat PVR TPR SVR TSR 14 42/17 47/ / /1.3 43% (33) Dobutamine 2.5 mcg/kg/min RA PA PCWP CI 23 58/ Dobutamine 5 mcg/kg/min RA PA PCWP CI 6 47/ Clinical status improves with Dobutamine Unable to wean inotropic support Arrangements made for out patient continuous infusion Develops more frequent ventricular arrhythmias Runs of NSVT ~20 beats 26 Transferred to Tufts Medical Center Undergoes implantation of HeartMate II Post op course complicated by: Need for re exploration for pericardial effusion and thrombus Atrial tachycardia requiring DCCV 27 9

10 Eventually discharged and is being followed as an out patient by the heart failure service Functionally NYHA class III Able to do ADLs No serious issues with VAD to date 28 Summary: 71 y.o with multiple medical comorbidities who presents with decompensated systolic heart failure (Ischemic CMP) Failed outpatient diuretic therapy Inotrope dependent Increased arrhythmia burden Undergoes LVAD implantation as destination therapy 29 Thank you Questions/Comments 10

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