Dott C Mazzone Centro Cardiovascolare ASS 1 Triestina.
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Transcript of Dott C Mazzone Centro Cardiovascolare ASS 1 Triestina.
Dott C Mazzone
Centro Cardiovascolare
ASS 1 “Triestina”
• Donna di 78 anni• Casalinga, mai fumato, allergia ASA• Ipertensione art. controllata in terapia (dal
1983)• Diabete mellito NID (dal 2002),• Dislipidemia controllata con statine (dal 2004)• Obesità (BMI 1984: 30.7; 2001: 35.9, 2002:
32.2) • Familiarità per ipertensione art ed ictus
(madre) e cardiopatia non precisata nel padre
• Dal 1992 (62 aa) brevi episodi di FAP;
• 1999 (69 aa) diagnosi di SCC in corso di FA ad elevata FC
• ECO: IVS, dil VSn+, FE conservata, dil ASn + CVE profilassi con amiodarone
• Dal 2000 multiple recidive di FA trattate con CVE
• Terapia AA: amiodarone (sospeso per ipertiroidismo); propafenone inefficace; sotatolo fino a dosaggi 80+120+80mg
• FA cronica + dispnea da sforzo (NYHA II-III)• PA e DM in (probabile) discreto controllo,
ipotiroidismo subclinico (TSH 6.81 FT4 10.9), gonartrosi importante
• Terapia: Sotalolo 280 mg, Irbesartan 300 1cp, Furosemide 25 mg, Spironolattone 37.5 mg, Acenocumarolo, atorvastatina 20 mg;
• EO BMI 35.9; PA 130/80 mmHg; non SCC• Rx torace: interstiziopatia bibasale, ispessimenti
pleurici bilaterali, non cardiomegalia
• Obesità, FA, betabloccanti, interstiziopatia -ispess pleuriciDISPNEA!........però……
• Abbiamo fatto ecocardiogramma
• “Grossolanamente” normale cinetica biventricolare
• pattern restrittivo (E 1msec, TdecM 100-120msec)
• Dieta ipocalorica, terapia ipoglicemizzante
• (Sotalolo 280 mg/die)*
• Digossina 0.25 mg/die
• Irbesartan 300mg/die
• Lasitone 1cp/die
• Sintrom sec INR seguito dal MMG
• atorvastatina 20mg la sera– *NB Suggerita sostituzione sotalolo -> verapamil non
attuata dalla pz
Gestione MMG• BMI da 35.928.7 (4-05)30.5(2-06)• HbA1C 8.8% (3-04)7 (10-04)7.4 (4-05)7.9
(2-06) • Ipotiroidismo subclinico• Normale funzione renale e Hb• “Intolleranza” a metformina >850mg x 2 e
glitazoni, levotiroxina (FA ad elevata frequenza) • Coxartrosi e gonartrosi importante talora con
uso di FANS; polimialgia reumatica (2-2006)
• Dispnea da sforzo nuovamente peggiorata (NYHA II-III)
• EO: BMI 29,76, PA 135/85mmHg, non SC• ECG FA 80 bpm, BBDx, EAS• Rx torace invariato• Terapia: sostituzione sotalolo 280 mg/die
con verapamile 80 mg x3 ,aggiunto HCTZ,resto invariata
• dispnea peggiorata NYHA III, nega DPN (transitorio miglioramento dopo sostituzione dei betabloccanti con verapamile)
• EO: BMI 37, PA 130/80mmHg,
• IM lieve, non segni SC
• Ematochimici: creat 0.93, CT 174, TG 174, HDL 52, Hb 13.8, glic 164*, HBbA1C 8.7%*, VES 54*, TSH 6.31*, FT4 8.4, microalbuminuria 0.58mgdl,
• BNP: 358pg/ml*
• 6MWT: 280m
• PFR: VC 1.81(69%) , FVC 1.77(68%) , FEV1 1.50 (69%) , FEV1/VC 83.03% (112%) : quadro restrittivo
ECG
• IVS lieve (1.3cm setto),• DTD/DTS 5.7/3.8cm, • Area Asn 30cmq, Adx 25cmq.• E 1,2m/sec, T dec169 msec,
E/E’ 17, • IT gr1, vel IT 2.8m/sec PAPS
36mmHg
• La diagnosi è certa?• Possiamo migliorare la terapia?
– Verapamile 240, irbesartan, 300, furosemide 25, spironolattone 37.5, idroclorotiazide (aggiunto), sintrom?
• Quanto una terapia aggressiva delle comorbidità – diabete, obesità, ipotiroidismo - può influenzare l’evoluzione dello SC?
• E’ (o sarebbe stato) indicato cercare una ischemia coronarica – FR ++, BMI ++?
LUNG DISEASE 53%
< EF 9%AF 8%
VALVE DISEASE 8%
OBESITY 32%
> PAP 17%
DIASTOLIC DYSFUNCTION 3%
MYOCARDIAL ISCHEMIA
DISPNEA da SFORZO con EF NORMALE
DISFUNZIONEDIASTOLICA
E’ SOLO UNAdelle VARIE CAUSE !!!!
““Patients with diastolic heart failure Patients with diastolic heart failure likely represent the likely represent the largest grouplargest group of of patients with a cardiovascular patients with a cardiovascular disorder of substantial public health disorder of substantial public health impact who have not been impact who have not been systematically studied.”systematically studied.”
Am J Med, 2000Am J Med, 2000
““Diastolic Heart Failure: Diastolic Heart Failure: Miles to Go Before We Sleep”Miles to Go Before We Sleep”
Lynne W. StevensonLynne W. Stevenson
Clinical characteristics
AgeSexHypertensionDiabetes mellitusPrior MIObesitàCOPDGallopAtrial fibrillationCardiomegaly
DHF
ElderlyFemale
+ + + + + +
+ + + +
+ +S4 + ++
SHF
All ages(tipically 50 - 70 y)
Male+ ++ +
+ + + + 0S3 +
+ +
““Utility of Utility of HistoryHistory, , Physical ExaminationPhysical Examination, , ElectrocardiogramElectrocardiogram, , and and Chest RadiographChest Radiograph for Differentiating Normal from for Differentiating Normal from
Decreased Systolic Function in Patients with Heart Failure”Decreased Systolic Function in Patients with Heart Failure”
Segni e sintomi: SC Sistolico Vs. Diastolico
Scompenso cardiaco Sistolico vs Diastolico
0 20 40 60 80 100
Disp.Sforzo
Disp.Paross.
Ortopnea
Dist. Giug.
Rantoli
Itto Apicale
S4
S3
Percentuale di pazienti
SC Diast
SC Sist
Nessun segno e nessun sintomo è specifico di SC Sist. O SC Diast.
Zile et al, Circulation.2002;105:1387-93
CHF vs. Non CHF and CHF Systol.vs Non-Systol. In CHF vs. Non CHF and CHF Systol.vs Non-Systol. In 452 Pts.with CHF: B-Type Natriuretic Peptide 452 Pts.with CHF: B-Type Natriuretic Peptide
0.0 0.5 1.0
0.5
1.0
0.0 0.5
0.5
1.0
AUC = 0.66;P<0.001
0.0 0.5 1.0
0.5
1.0
300300AUC = 0.90;P<0.001
1-SPEC.1-SPEC.1-SPEC.1-SPEC.0.0 0.5
0.5
1.0
400
200
100
300200
100CHF vs. Non-CHF vs. Non-CHFCHF
CHF Systol. vs. Non-Syst
SENS.SENS.SENS.SENS.
1) BNP is accurate in distinguishing CHF and Non-CHF (BNP=100 pg/ml: Sens 90, Spec 73, Accur. 81)
2) BNP is not accurate in distinguishing Systol. Vs Non-Systol. CHF (BNP=100 pg/ml: Sens 95, Spec 14, Accur. 66)
BNP pg/ml
Maisel et al., JACC.2003
The Natural History of Diastolic Function and LV Filling
AbnormalAbnormalrelaxationrelaxation
Pseudo-Pseudo-normalizationnormalization
RestrictionRestriction(reversible)(reversible)
RestrictionRestriction(irreversible)(irreversible)
Treatment of cardiac Treatment of cardiac pathophysiologicalpathophysiologicalmechanismsmechanisms
• Maintain atrial contraction Cardioversion for A FibSequential A-V Pacemaker
• Prevent or reduce LVH Antihypertensive drugs
Surgery (AVR for AS)• Prevent/treat ischemia -blocker, Ca++ entry blocker
Nitrates• Reduce HR/increase -blocker, Ca++ entry blocker
filling time Digitalis (AF)• Avoid LVOT obstruction Avoid arterial vasodilatators• Reduce interstitial fibrosis Ace-i/ARBs, antialdosterone
Goal of therapy Methods of treatment
• Nessun trattamento ha mostrato convincentemente di ridurre la mortalità e la morbidità
• Diuretici: riducono edema e dispnea
• Terapia aggressiva per il controllo della PA (ACEI/ARB 1a scelta)
• Terapia aggressiva per il controllo dell’ischemia
• Controllo della FC nei pazienti in FA (verapamil)
• Terapia aggressiva del diabete
ESC Guidelines 2008
EHJ 2007; 28: 2539-2550
by dr Carmine Mazzone
In absence of a comprehensive diastolic assessment
Simple echocardiographic criteria
- left atrial enlargement- normal LV dimension- left ventricular hypertrophy- wall motion abnormalities- elevated pulmonary pressures
Considerazioni
• Tipico paziente con SC diastolico vedi dia andrea da inserire eventualmente anche dia su FP dispnea cardiaca
• Mai ricoveri ospedalieri per sc almeno negli ultimi 7 anni (in precedenza comunque solo ricoveri per FA da cardiovertire eccetto uno dei primi episodi di FA associati ad
importante sintomatologiaSC) prognosi favorevole• Gestione integrata MMG-Cardiologo• Poteva essere proponibile ablazione FA in
passato almeno?
Si poteva fare di meglio?
• Forse si, forse no……credo di no
• Chiudere con dia filosofica da andrea
Trends in Prevalence and Outcome of Heart Failure with Preserved Ejection Fraction
Theophilus E. Owan, M.D., David O. Hodge, M.S., Regina M. Herges, B.S., Steven J. Jacobsen, M.D., Ph.D., Veronique L.
Roger, M.D., M.P.H., and Margaret M. Redfield, M.D.
Volume 355:251-259 July 20, 2006 Number 3
EF “CUT-OFF” : 40% or 50%EF “CUT-OFF” : 40% or 50% ?1) Some studies report a EF cut-off 40% and others 50%
2) The frequency of EF among 40-50% is approximately 10%
3) When preserved EF was defined as >50% the results of mortality, readmission and functional decline remained similar to the group of EF 40-50% (Smith GL et al, JACC 2003)
The predominant pathophysiological cause of heart failure in these patients is abnormal diastolic function (Zile MR)
““EF CUT-OFF” seem to be EF CUT-OFF” seem to be >> 40% 40%
The Natural History of Diastolic Function and LV Filling
4040
00
NormalNormalAbnormalAbnormalrelaxationrelaxation
Pseudo-Pseudo-normalizationnormalization
RestrictionRestriction(reversible)(reversible)
RestrictionRestriction(irreversible)(irreversible)
Mean LAPMean LAP
TAUTAU
NYHANYHA I-III-II II-IIIII-III III-IVIII-IV IVIV
GradeGrade II IIII IIIIII IVIV
Mean LAPMean LAP
TAUTAU
NYHANYHA I-III-II II-IIIII-III III-IVIII-IV IVIV
GradeGrade II IIII IIIIII IVIV
N-N-
The PREVALENCE of CHF with NORMAL EF INCREASES with AGE
5 yrs
1 yr
Pooled study from Circulation 2002;105;1387
Among the elderly CHF portends a grim prognosis independent of the level of measured EF. Michele Senni JACC 2001;38:1277
Metabolic syndrome and risk of development of atrial fibrillation
The Niigata preventive Medicine Study
• Prospective community-based observational cohort study with annual checkup
• To study the risk of development of AF• 28449pts without baseline AF• The metabolic syndrome was present 13%-16%• FU 4.5 y• In pt with MS: obesity HR 1.64, elev BP HR
1.69, low HDL HR 1.52, impaired insulin tolerance HR 1.44-1.35risk for AF
Circulation 2008; 117: 1255-1260