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