A.J. MANOLISA.J. MANOLIS MD, FACC, FESC, FAHAProfessor of Cardiology, Emory University USAClinical Director, Cardiology DepartmentAsklepeion Voula General Hospital, Athens
CASE REPORTCASE REPORT
BP 165/90 mmHgHR 75 bpm
Temp 36,5°CRR 22 min
ECGECG: SR, LBBB (new)
Weight: 66 kgr
Height: 169 cm
BMI : 23,1
CASE REPORTCASE REPORT
• 79 year old woman
• 2-hour chest pain
• Radiating to jaw
• Sudden onset
►► NSTEMINSTEMI
►► Renal impairmentRenal impairment
►► Uncontrolled hypertensionUncontrolled hypertension
CURRENT DISEASECURRENT DISEASE
PAST MEDICAL HISTORYPAST MEDICAL HISTORY
►► Ischemic heart disease Ischemic heart disease ((previous myocardial infarctionprevious myocardial infarction))
►► Hypertension Hypertension ((since 25 yearssince 25 years))
►► Chronic renal failureChronic renal failure
►► Insulin dependent diabetes mellitus Insulin dependent diabetes mellitus ((since 25 yearssince 25 years))
►► Positive family history for IHD Positive family history for IHD
Ò Furosemide 40 mg odÒ Lisinopril 20mgÒ Nifedipine cr 30mgÒ Methyldopa 250mgÒ Irbesartan 300mgÒ Glyceryl trinitrate 10mgÒ Clopidogrel 75mg odÒ Rosuvastatin 10mg onÒ Propafenone 13u bd
Ò Respiratory: decreased air entry from mid zones. Right basal rales.
Ò Cardiovascular: S4-S1-S2, apical systolic murmur
Ò Pedal oedema
RADIOGRAPHY
Chest radiography showed cardiomegaly
with right pleural effusion and pulmonary
vascular congestion.
Ò TIMI Risk Score = 5
►► GFRGFRεισόδου = 18,1 ml/min/1,73 m2
TnI < 0,2 ng/mlGlu = 85 mg/dlUrea = 213 mg/dlCreatinine = 2,7 mg/dlΚ+ = 4,8 mEq/lNa+ = 139 mEq/lLDH = 572 U/LCPK = 136 U/LCK-MB = 25 U/LSGPT = 19 U/LSGOT = 31 U/LChol. = 131 mg/dlHDL = 35 mg/dlLDL = 75 mg/dlWBC = 4,19x103HGB = 9,44HCT = 30,1%
Echogenic with increase cortical thickness.
Sagittal lengths: Rt 10,9 cm, Lt 11,4 cm
Ò Αντιμετώπιση NSTEMI και πιθανώνεπιπλοκών
Ò Ρύθμιση Αρτηριακής Πίεσης
Ò Διατήρηση νεφρικής λειτουργίας
Ò NTG i.v. continuo infusion 0.05 mg/min
Ò InsulinÒ Furosemidi 40 mgÒ Omeprazole 40 mgÒ Nifedipine 30 mgÒ Clopidogrel 75mgÒ Rosuvastatin 10 mgÒ Acetylsalicylic acid 100 mgÒ Enoxaparin 40 mg
Urine in a day
B.P. REGULATIONNTG i.v.FurosemideNifedipine
GFR
Heart failure/NSTEMI B.P. Urine day GFR
NTG 0,05 mg/minNTG 0,05 mg/min 180/90 mmHg180/90 mmHg 2800 cc 18,118,1
NTG 0,1 mg/minNTG 0,1 mg/min 130/80 mmHg 1000 cc1000 cc 11
Nifedipine 60mgNifedipine 60mgIsosorbide mononitrate 60mgIsosorbide mononitrate 60mgCarvedilol 13mgCarvedilol 13mgFurosemide 80mgFurosemide 80mg
150/85 mmHg 1500 cc 13,4
Ò Βελτίωση των συμπτωμάτων με χορήγηση ενδοφλέβιανιτρώδη.
Ò ΗΚΓ: SR, (-)T σε I, II, aVF, V4-V6, πτώση ST 4mm II, III, aVF, V4-V6
Ò Μη ρυθμιζόμενη Α.Π.Ò Επεισόδια δύσπνοιας – οξύ πνευμονικό οίδημαÒ Επιδείνωση νεφρικής λειτουργίας, μείωση διούρησηςÒ Άρνηση της ασθενούς και συγγενικού περιβάλλοντος για
στεφανιογραφικό έλεγχο.
LV: ΜΚΔ = 12,5mm, ΟΤΑΚ = 12,5mmΤΣΔ = 44mm, ΤΔΔ = 56 mmΑκινησία βασικού μέσου οπισθιοδιαφραγματικού, κατωτέρου.LVEF = 45%
LA: 49mmMV: MR +2-3/+4 ασβέστωση πτυχώνAoV: ασβέστωση πτυχών με μετρίου βαθμού ανεπάρκεια αυτής.TV: χωρίς σημαντικές αλλοιώσειςRV – RA: χωρίς σημαντικές αλλοιώσεις
Ò Clopidogrel 75mgÒ Acetylsalicylic acid 100mgÒ Carvedilol 13mgÒ Furosemide 80mgÒ Nifedipine 60mgÒ Isosorbide-5-mononitrate 60mgÒ Amiodarone 200mgÒ Epoitin beta 5000 IUÒ Omeprazol 20mg
TnI < 0,2 ng/ml (max 85,4)Glu = 207 mg/dlUrea Urea = 216 mg/dl (max 301)Kreatini = 3,5 mg/dl (max 4.2)Κ+= 4,2 mEq/lNa+= 136 mEq/lLDH = 34 U/LCPK = 42 U/LCK-MB = 6 U/LSGPT = 20 U/LSGOT = 16 U/LChol. = 124 mg/dlHDL = 39 mg/dlLDL = 71 mg/dlTG= 80 mg/dlWBC = 8,72x103HGB = 9,71HCT = 30,7%
DEFINITION
A state of advanced cardiorenal dyseregulation manifest by
one or more of three specific features, including heart
failure (HF) with concomitant and significant renal disease,
worsening renal function (developing during the treatment
of acute decompensated HF (ADHF), and diuretic resistance
Nephrology and Hypertension and division of Cardiology Mayo Clinic
End-Stage
Progression
Initiation
“At Risk”
ESRD
CRI (decreased GFR)
AlbuminuriaProteinuria
Elderly, DiabetesHypertension
CHF
ASCVD Events
CADLVH
Elderly, DiabetesHypertension
CHRONIC RENAL CARDIOVASCULARDISEASE DISEASE
The Cardiorenal Syndrome of HF
Increased Morbidityand Mortality
Developmentof Diuretic and NatriureticResistance
Impaired RenalFunction
Diuretic Therapy
NeurohormonalActivation
DiminishedBlood Flow
Decreased RenalPerfusion
Common Compensatory Responses to Low- and High-Output Cardiac Failure
Schrier. Ann Intern Med. 1990;113:155-59.
Systemic Arterial Vasodilation
High-Output Cardiac Failure
Low-Output Cardiac Failure
Û Sympathetic Nervous System
Arterial Underfilling
Diminished Renal Hemodynamics and Renal
Sodium and Water Excretion
Û Renin-Angiotensin-Aldosterone System
ÛNonosmotic AVP Release
Ü CardiacOutput
0.7 –
0.6 –
0.5 –
0.4 –
0.3 –
0.2 –
0.1 –
0.0 -
• Total of 1906 patients• NYHA class
– III (n=1138)– III/IV (n=607)– IV (n=161)
• Impaired renal function is a strong predictor of mortality
Relationship of GFRc With Mortality in 1906 Patients With CHF
Hillege et al. Circulation. 2000;102:203-210.
0 200 400 600 800 1000 1200Days
Pro
porti
on m
orta
lity
<44 mL/min
44–58 mL/min
59–76 mL/min>76 mL/min
LEVF NYHA
0102030405060708090
100
Patie
nts
(%)
IV Diuretic Dobutamine Dopamine Milrinone Nesiritide Nitroglycerin Nitroprusside
IV Vasoactive Meds
88%
6% 6% 10%3% 1%
10%
ADHERE® Registry. Benchmark Report. 2004.
All Enrolled Discharges (n=105,388) October 2001–January 2004
Ò Decreased renal function and distal Na+ delivery
Ò Variability in diuretic absorption (bioavailability)
Ò Neurohormonal activation (RAAS/SNS)
Ò Drugs/diet—increased sodium intake
Ò Noncompliance with medications
Ò Infrequent dosing
1. Neuberg et al. Am Heart J. 2002;144:31-38.2. Brater. N Engl J Med. 1998;339:387-395.3. Wilcox. J Am Soc Nephrol. 2002;13:798-805.
Ò Restrict daily fluid intake (1.0–1.5 L)
Ò Moderate restriction of daily salt intake (≤2 g)
Ò Avoid NSAIDs
Ò Institute and uptitrate ACE inhibitors and/or angiotensin receptor blocker
Ò Give short-acting loop diuretic orally in several divided(and increasing) doses, bolus, or continuous intravenous administration
Ò Use sequential nephron blockade via combination loop diuretic and thiazide diuretic
Ò Add small doses of spironolactone (12.5–25 mg)
Ò Consider short-term acetazolamide in selected patients
Blood pressure and kidneyImportance for normal blood pressure
ECF Volume Vasoconstriction
BP = Cardiac output x Total peripheral resistance
-
PGs ‘neutral lipid’
Kinins PAF NO
sympatheticnervous system
+
NaCl reabsorption
+
Endothelin
+
ReninAngiotensin (II)
+
Aldosterone
+ +-
-
+
GFR