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Dealing with controversies The complexity of the every day HFrEF patient Inês Gonçalves João R. Agostinho Serviço de Cardiologia, Centro Hospitalar Universitário Lisboa Norte, CCUL, CAML, Universidade de Lisboa, Portugal
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Page 1: Dealing with controversiesTSH 1.36 µU/mL NT-proBNP 990 pg/mL CRP 0.81 mg/dL Protein electroph. Normal Ca2+ 9.1 mmol/L HIV Neg. The complexity of the every day HFrEF patient João

Dealing with controversiesThe complexity of the every day HFrEF patient

Inês GonçalvesJoão R. Agostinho

Serviço de Cardiologia,Centro Hospitalar Universitário Lisboa Norte, CCUL, CAML,

Universidade de Lisboa, Portugal

Page 2: Dealing with controversiesTSH 1.36 µU/mL NT-proBNP 990 pg/mL CRP 0.81 mg/dL Protein electroph. Normal Ca2+ 9.1 mmol/L HIV Neg. The complexity of the every day HFrEF patient João

Clinical Case• Male, 62 years-old

• Previous diagnosis:• HTN (amlodipine 5mg q.d.)• Type 2 DM (metformin 1000mg b.i.d.)• Ex-smoker

• No significant alcohol consumption• No relevant familial history

The complexity of the every day HFrEF patient João R. Agostinho, Inês Gonçalves, Cardiology Department, CHULN

Page 3: Dealing with controversiesTSH 1.36 µU/mL NT-proBNP 990 pg/mL CRP 0.81 mg/dL Protein electroph. Normal Ca2+ 9.1 mmol/L HIV Neg. The complexity of the every day HFrEF patient João

Clinical Case• Male, 62 years-old

• Previous diagnosis:• HTN (amlodipine 5mg q.d.)• Type 2 DM (metformin 1000mg b.i.d.)• Ex-smoker

• No significant alcohol consumption• No relevant familial history

• May 2018• Dry cough with exertion • Shortness of breath with moderate exertion • Orthopnea

• Beginning of June 2018• Hospital admission due to acute heart failure

– NYHA functional class III

The complexity of the every day HFrEF patient João R. Agostinho, Inês Gonçalves, Cardiology Department, CHULN

Page 4: Dealing with controversiesTSH 1.36 µU/mL NT-proBNP 990 pg/mL CRP 0.81 mg/dL Protein electroph. Normal Ca2+ 9.1 mmol/L HIV Neg. The complexity of the every day HFrEF patient João

Clinical Case• First hospital admission (other hospital)

• ECG:• HR: 120 bpm; typical atrial flutter; LBBB (QRS duration ~140 ms)

• Echocardiography:• Dilated left ventricle with severely depressed ejection fraction (~20%)

• Coronary angiography:• Distal left anterior descending artery severe lesion PCI with DES• 2nd Obtuse coronary artery chronic total occlusion (small vessel)

The complexity of the every day HFrEF patient João R. Agostinho, Inês Gonçalves, Cardiology Department, CHULN

Page 5: Dealing with controversiesTSH 1.36 µU/mL NT-proBNP 990 pg/mL CRP 0.81 mg/dL Protein electroph. Normal Ca2+ 9.1 mmol/L HIV Neg. The complexity of the every day HFrEF patient João

Clinical Case• First hospital admission (other hospital)

• Discharge diagnosis:• Acute heart failure / Heart failure with reduced ejection fraction

– NYHA functional class II

• Typical atrial flutter• 2-vessel coronary artery disease• Medication: ASA 100mg q.d.; clopidogrel 75mg q.d.; apixaban 5mg b.i.d.;

carvedilol 6,25mg b.i.d.; enalapril 5mg b.i.d.; furosemide 40mg q.d.; rosuvastatin20mg q.d.; metformin 1000mgb.i.d.

The complexity of the every day HFrEF patient João R. Agostinho, Inês Gonçalves, Cardiology Department, CHULN

Page 6: Dealing with controversiesTSH 1.36 µU/mL NT-proBNP 990 pg/mL CRP 0.81 mg/dL Protein electroph. Normal Ca2+ 9.1 mmol/L HIV Neg. The complexity of the every day HFrEF patient João

Clinical Case• During June 2018

• NYHA functional class II III

• End of June 2018• 2nd Hospital admission due to acute heart failure (another hospital)• Intravenous loop diuretic• Discharge: NYHA functional class II• Medication: ASA 100mg q.d.; clopidogrel 75mg q.d.; apixaban 5mg b.i.d.;

carvedilol 12,5mg b.i.d.; enalapril 10mg b.i.d.; spironolactone 25mg q.d.;furosemide 40mg q.d.; rosuvastatin 20mg q.d.; metformin 1000mgb.i.d.

The complexity of the every day HFrEF patient João R. Agostinho, Inês Gonçalves, Cardiology Department, CHULN

Page 7: Dealing with controversiesTSH 1.36 µU/mL NT-proBNP 990 pg/mL CRP 0.81 mg/dL Protein electroph. Normal Ca2+ 9.1 mmol/L HIV Neg. The complexity of the every day HFrEF patient João

Clinical Case• August 2018

• NYHA functional class II III• Shortness of breath with minimal exertion• Orthopnea, PND, lower limb edema

• 3rd Hospital admission due toacute heart failure • Cardiology ward

HR 100bpm

92/58mmHg

Pulmonary crackles

Leg edemaAdequate peripheral perfusion

JVD

The complexity of the every day HFrEF patient João R. Agostinho, Inês Gonçalves, Cardiology Department, CHULN

Page 8: Dealing with controversiesTSH 1.36 µU/mL NT-proBNP 990 pg/mL CRP 0.81 mg/dL Protein electroph. Normal Ca2+ 9.1 mmol/L HIV Neg. The complexity of the every day HFrEF patient João

Clinical Case• ECG

The complexity of the every day HFrEF patient João R. Agostinho, Inês Gonçalves, Cardiology Department, CHULN

Page 9: Dealing with controversiesTSH 1.36 µU/mL NT-proBNP 990 pg/mL CRP 0.81 mg/dL Protein electroph. Normal Ca2+ 9.1 mmol/L HIV Neg. The complexity of the every day HFrEF patient João

Clinical Case• Echocardiography

The complexity of the every day HFrEF patient João R. Agostinho, Inês Gonçalves, Cardiology Department, CHULN

Page 10: Dealing with controversiesTSH 1.36 µU/mL NT-proBNP 990 pg/mL CRP 0.81 mg/dL Protein electroph. Normal Ca2+ 9.1 mmol/L HIV Neg. The complexity of the every day HFrEF patient João

Clinical Case• Blood tests

Hb 13.4 g/dL

Htc 37%

Leuc 7.09 x 109/L

Neut 4,32 x 109/L

Urea 45 mg/dL

sCr 1.59 mg/dLeGFR (CKD-EPI) 46 mL/min/1.73Na+ 136 mmol/L

K+ 3.5 mmol/L

ALT 21 U/L

ALP 70 U/L

GGT 44 U/L

Tot. Bil. 0.66 mg/dL

Fe 41 µg/dL

Transf. Sat. 21%

Ferritin 264 µg/LHbA1c 6.6%

TSH 1.36 µU/mL

NT-proBNP 990 pg/mL

CRP 0.81 mg/dL

Protein electroph. Normal

Ca2+ 9.1 mmol/L

HIV Neg.

The complexity of the every day HFrEF patient João R. Agostinho, Inês Gonçalves, Cardiology Department, CHULN

Page 11: Dealing with controversiesTSH 1.36 µU/mL NT-proBNP 990 pg/mL CRP 0.81 mg/dL Protein electroph. Normal Ca2+ 9.1 mmol/L HIV Neg. The complexity of the every day HFrEF patient João

Clinical Case• Hospital admission

• I.V. Loop diuretic Torasemide 10mg • Carvedilol 25mg b.i.d.

• Typical atrial flutter ablation

HR 100bpm

96/62mmHg

No pulmonary crackles

No leg edema

Adequate peripheral perfusion

No JVD

The complexity of the every day HFrEF patient João R. Agostinho, Inês Gonçalves, Cardiology Department, CHULN

Page 12: Dealing with controversiesTSH 1.36 µU/mL NT-proBNP 990 pg/mL CRP 0.81 mg/dL Protein electroph. Normal Ca2+ 9.1 mmol/L HIV Neg. The complexity of the every day HFrEF patient João

Clinical Case• ECG

The complexity of the every day HFrEF patient João R. Agostinho, Inês Gonçalves, Cardiology Department, CHULN

Page 13: Dealing with controversiesTSH 1.36 µU/mL NT-proBNP 990 pg/mL CRP 0.81 mg/dL Protein electroph. Normal Ca2+ 9.1 mmol/L HIV Neg. The complexity of the every day HFrEF patient João

Clinical Case• Hospital admission (10 days)

• NYHA functional class II • Enalapril 10mg b.i.d. Sacubitril/Valsartan 24/26mg b.i.d.• Carvedilol / Ivabradine 25/5mg b.i.d.

HR 85bpm

104/60mmHg

NT-proBNP 301 pg/mL

sCR 1.19 mg/dL

eGFR (CKD-EPI) 65 mL/min/1.73

K+ 4.9 mmol/L

The complexity of the every day HFrEF patient João R. Agostinho, Inês Gonçalves, Cardiology Department, CHULN

Page 14: Dealing with controversiesTSH 1.36 µU/mL NT-proBNP 990 pg/mL CRP 0.81 mg/dL Protein electroph. Normal Ca2+ 9.1 mmol/L HIV Neg. The complexity of the every day HFrEF patient João

Clinical Case• Post-discharge visit

• NYHA functional class II• Sacubitril/Valsartan 49/51mg b.i.d.

NT-proBNP 271 pg/mL

sCR 1.3 mg/dL

eGFR (CKD-EPI) 59 mL/min/1.73

K+ 4.9 mmol/L

HR 62bpm

102/56mmHg

No pulmonary crackles

No leg edema

Adequate peripheral perfusion

No JVD

The complexity of the every day HFrEF patient João R. Agostinho, Inês Gonçalves, Cardiology Department, CHULN

Page 15: Dealing with controversiesTSH 1.36 µU/mL NT-proBNP 990 pg/mL CRP 0.81 mg/dL Protein electroph. Normal Ca2+ 9.1 mmol/L HIV Neg. The complexity of the every day HFrEF patient João

Clinical Case• 2nd Visit

• NYHA functional class II• Continue medication

NT-proBNP 290 pg/mL

sCR 1.32 mg/dL

eGFR (CKD-EPI) 58 mL/min/1.73

K+ 5.1 mmol/L

HR 60bpm

94/52mmHg

No pulmonary crackles

No leg edema

Adequate peripheral perfusion

No JVD

The complexity of the every day HFrEF patient João R. Agostinho, Inês Gonçalves, Cardiology Department, CHULN

Page 16: Dealing with controversiesTSH 1.36 µU/mL NT-proBNP 990 pg/mL CRP 0.81 mg/dL Protein electroph. Normal Ca2+ 9.1 mmol/L HIV Neg. The complexity of the every day HFrEF patient João

Clinical Case• 3 Months later…

• Cardiac CMR:• Dilated left ventricle with moderately depressed ejection fraction (33%);• Distal infero-lateral wall transmural LGE;• Slight septal midwall LGE.

The complexity of the every day HFrEF patient João R. Agostinho, Inês Gonçalves, Cardiology Department, CHULN

Page 17: Dealing with controversiesTSH 1.36 µU/mL NT-proBNP 990 pg/mL CRP 0.81 mg/dL Protein electroph. Normal Ca2+ 9.1 mmol/L HIV Neg. The complexity of the every day HFrEF patient João

Clinical Case• ECG

The complexity of the every day HFrEF patient João R. Agostinho, Inês Gonçalves, Cardiology Department, CHULN

Page 18: Dealing with controversiesTSH 1.36 µU/mL NT-proBNP 990 pg/mL CRP 0.81 mg/dL Protein electroph. Normal Ca2+ 9.1 mmol/L HIV Neg. The complexity of the every day HFrEF patient João

Clinical Case• Follow-up visit

• NYHA functional class I-II• ICD implant

NT-proBNP 326 pg/mL

sCR 1.2 mg/dL

eGFR (CKD-EPI) 64 mL/min/1.73

K+ 5.0 mmol/L

HR 64bpm

96/58mmHg

No pulmonary crackles

No leg edema

Adequate peripheral perfusion

No JVD

The complexity of the every day HFrEF patient João R. Agostinho, Inês Gonçalves, Cardiology Department, CHULN

Page 19: Dealing with controversiesTSH 1.36 µU/mL NT-proBNP 990 pg/mL CRP 0.81 mg/dL Protein electroph. Normal Ca2+ 9.1 mmol/L HIV Neg. The complexity of the every day HFrEF patient João

Thank you for your attention

Inês GonçalvesJoão R. Agostinho

@JoaoRAgostinho Serviço de Cardiologia,

Centro Hospitalar Universitário Lisboa Norte, CCUL, CAML,Universidade de Lisboa, Portugal


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