CASE STUDIES IN ADVANCED HEART FAILURE

Transcription

1 CASE STUDIES IN ADVANCED HEART FAILURE Navin Rajagopalan, MD Director, Congestive Heart Failure Medical Director, Cardiac Transplantation Gill Heart Institute, Cardiovascular Medicine DISCLOSURES NOTHING TO DISCLOSE 1

2 OBJECTIVES Discuss the different diuretic regimens that t are available for patients t with decompensated heart failure Discuss methods for monitoring fluid status in patients with chronic systolic heart failure CASE #1 34 year old male diagnosed with nonischemic i cardiomyopathy in 2008 LHC: no CAD LVEF 25% Placed on medical therapy including BB/ACEi In 2010 lost job/insurance and stopped all medications, physician follow-up In late 2011 experienced increasing SOB, LE edema, orthopnea 2

3 CASE #1 PE: P 100 BP 96/60 Weight 340 lbs Morbidly obese, tachypneic Clear lungs CV RR, S3 gallop 3+ LE edema BNP 700 Cr 1.8 ECHOCARDIOGRAM 3

4 OPTIONS Initiate intravenous diuresis IV bolus diuretic therapy IV diuretic drip Ultrafiltration ULTRAFILTRATION UNLOAD randomized 200 patients hospitalized with CHF to UF versus standard diuretics UF group: no diuretics; UF up to 48 hours Standard group: IV diuretics at a dose twice that of home dose Primary endpoint: Weight loss and objective dyspnea at 48 hrs Patient characteristics: NYHA III/IV 70% LVEF < 40% Cr 1.5 ± 0.5 Home Lasix dose 120 mg / day 4

5 ULTRAFILTRATION UF group experienced significant weight loss at 48 hours compared to standard care Fewer pts in UF group received vasoactive drugs at 48 hours (NTG, nesiritide, inotropes) No difference in changes in creatinine No change in LOS Oral diuretic dosage was less in the UF group at discharge (p = 0.058) and at 10 days post-discharge (p 0.049) ULTRAFILTRATION UF group experienced significantly lower CHF rehospitalization rate at 90 days as well as fewer ER visits and unscheduled clinic visits Possibly related to lower diuretic dose in UF group 5

6 ULTRAFILTRATION Mechanism for the decrease in rehospitalization is unknown Promising new therapy for volume removal in decompensated CHF patients Economic analysis of UF has not been studied CASE #1 Right heart catherization: CVP 38 mm Hg RV 65/37 PA 65/42 (mean 51 mm Hg) PCWP 41 mm Hg Maintained cardiac output Hemodialysis line placed in right IJ vein Ultrafiltration initiated and titrated up to 250 ml/hour fluid removal Successful 10 L diuresis over 3 days with improvement in serum creatinine (1.8 to 1.3) 6

7 CASE #1 Patient transitioned to IV diuretics, then oral diuretics Discharged on oral Bumex 2 mg bid Chronic HF therapy optimized including ACEi, BB, and aldosterone antagonist 6 months later: No subsequent hospitalizations ti CASE #2 41 year old with dilated cardiomyopathy (LVEF 15%) in setting of HIV (dx 1994) referred by his cardiologist for advanced heart failure options NYHA class III-IV IV symptoms Echo: LV moderately dilated (6.3 cm LVEDD); moderate MR Rx: carvedilol mg bid, lisinopril 2.5 mg qday, lasix 40 mg qday, and HAART Admitted to periods of noncompliance Told me HIV viral load was in the millions and CD4 count was less than 50 7

8 CASE #2 Other hx included several AIDS defining illnesses: PCP pneumonia MAC CMV pneumonitis PE: P 110 BP 100/60 Weight 130 lbs Chronically ill appearing, cachectic; in wheelchair HEENT: JVP 12 cm H20 Lungs Clear CV: tachycardic with S3 gallop and 2/6 MR murmur Abdomen: mild hepatomegaly Ext: 2+ pitting edema QUESTIONS TO CONSIDER Are HIV/AIDS absolute contraindications to heart transplantation and/or VAD placement? Is up-titration of medical therapy and ICD placement his only option? How much is noncompliance playing a role in his poor functional status, failure to thrive? 8

9 LVAD IN HIV PATIENTS Sims DB et al. J Heart Lung Transplant 2011;30: HEART TX IN HIV PATIENTS All patients had negative HIV viral load at time of transplant Uriel N et al. J Heart Lung Transplant 2009;28:

10 CASE #2 Decided to obtain right heart catheterization as outpatient Before RHC was obtained, patient presented with decompensated heart failure and transferred to UK Did well with diuresis, but hospitalization complicated by mental status changes, elevated LFTs, and thrombocytopenia (20K) CASE #2 RHC: CVP 10 mm Hg RV 38/10 PA 38/22 (28 mm Hg) PCWP 20 mm Hg CO 4.2 L/min; CI 2.4 L/min/m2 Conclusion: Relatively compensated HF Plan: outpatient f/u with titration of medical therapy 10

11 CASE #2 Patient started to improve over next 2 months More compliant with HAART improving CD4 count and dropping viral load Improving appetite and muscle strength (started to gain weight) Remained class III HF but less problems with LE edema Baseline HR improved to 80s (from 100s) and was able to tolerat up-titration of beta blocker Another RHC obtained with similar results as previous Eventually was able to lower his diuretic from lasix 80 mg bid to 40 mg bid HOWEVER. One month later (around New Years..) Felt fatigued, and had a few episodes of nausea/emesis Noted lower urine output and increased his lasix from 40 bid to 80 bid Fatigue worsened and some orthostatic symptoms Seen in clinic and appeared dry Labs: Sodium 119; BUN 50; Cr 2.2 Admitted to hospital for IV hydration with improvement in BMP 11

12 NEXT STEP? HF appeared to have stabilized to point where LVAD was not needed Despite patient education/instruction, he seemed particularly prone to episodes of fluid overload and dehydration with need to adjust diuretic therapy Complicating matters was his increasing weight due to improvement in muscle mass, appetite Is there another way to track his fluid status? Ritzema J et al. Circ 2007;116:

13 LA PRESSURE MONITORING LA pressures can be transmitted to clinician daily Adjustments can be made to medications before clinical symptoms arise Safety/utility seen in pilot study of 8 patients Ritzema J et al. Circ 2007;116: LAPTOP-HF LAPTOP-HF is a prospective, multi-center, randomized study assessing benefit of LA pressure monitoring system Randomization 1:1 to sensor implanted providing ongoing LAP readings to the hand held along with physician prescribed medication recommendations OR no sensor implant but a hand-held held device for medication reminders UK is a participating institution and actively enrolling 13

14 Navin Rajagopalan, MD University of Kentucky Office (859) Transplant referral: