계 명 대 학 교 심 장 내 과 김 형 섭
Congestive Heart
Failure
Case I – Brief Hx
• Male 40 yrs
• Worsening dyspnea on resting
• P/I ; Previous healthy
Mild URI Hx. 1 week ago
Dyspnea on exertion and worsening
Adm. to ER, without improving despite taking medicine
• V/S ; BP; 160/110 mmHg, HR; 94 bpm, Tm; 36.6º, RR; 20
• P/Ex ; Lung; BLLF-crackle, Heart; RHS without mm Pitting edema (-/-), NVD (-/-)
Case I – Chest X ray
At ER
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Case I – ECG
At ER
Case I – Question 1.
• 이 환자에서 심부전 원인 진단에 가장 도움이 되는 항목은?
1) Troponin-I 2) NT-ProBNP 3) D-dimer
4) Pulmonary function test 5) Eye ground
Clinical Classification of AHF
Eur J Heart Fail 2008;10:933-89.
Clinical Classification of AHF
Coronary artery disease Non-ischemic dilated cardiomyopathy
Myocardial infarcation Familial/genetic disorders
Myocardial ischemia Infiltrative disorders
Chronic pressure overload Toxic/drug-induced damage
Hypertension Metabolic disorder
Obstructive valvular disease Viral
Chronic volume overload Disorders of rate and rhythm Regurgitant valvular disease Chronic bradyarrhythmias Intracardiac (left to right) shunting Chronic tachyarrhythmias Extracardiac shunting
Depressed EF (< 40%)
Preserved EF (> 40 – 50%)
Pathologic hypertrophy Restrictive cardiomyopathy
Primary (hypertrophic cardiomyopathies) Infiltrative disorders (amyloidosis, sarcoidosis) Secondary (hypertension) Storage diseases (hemochromatosis)
Aging Fibrosis
Endomyocardial disorders
Investigations for CHF
BMJ 2010;341:c3657.
Case I – Echocardiography
At ER
Case I – Question 2.
• 이 환자의 치료 및 예후에 가장 도움이 적은 약제는?
1) Angiotensin converting enzyme inhibitors 2) Beta blocker
3) Calcium channel blocker 4) Aldosterone antagonists 5) Diuretics
Activated system for HF
• Renin-angiotensin-aldostrone (RAA) system
• Adrenergic nervous system
• Incresed ANP and BNP
• Increased PGE2 and PGI2
• Increassed NO
Drugs for HF
Diuretics
Angiotensin converting enzyme inhitors Angiotensin receptor blockers
Beta blockers
Additional therapies
Spironolactone Eplerenone
Combination of hydralazine/isosorbide dinitrate Fixed dose of hydralazine/isosobide dinitrate Digoxin
Drugs for the treatment of chronic heart failure
Follow-up with treatment
Case II – Brief Hx
• Male 65 yrs
• Acute dyspnea on resting
• P/I ; No problem in daily activities
Experienced a resting chest pain 5 days ago Presented with acute dyspnea
• V/S ; BP; 127/67 mmHg, HR; 102 bpm, Tm; 37.2º, RR; 25
• P/Hx ; Diabetes for 10 yrs, Hypertension for 10 yrs
• P/Ex ; Heart; RHS without mm, Lung; decreased LS with rale.
Case II – Lab
• Lab ; CBC; 8,290 - 13.6 - 41.0 - 185,000
BUN/Cr; 49/2.1 Na/K; 138/4.9 OT/PT;24/17 TC/TG/HDL/LDL; 129/122/41/76
CK-MB; 4.2 - 2.6 ng/mL, Troponin-I; 1.63 - 1.26 ng/mL
T3; 125.9 ng/dL, FT4; 1.5 ng/dL, TSH; 4.1 uIU/mL.
• Prev. medication
Aspirin 100 mg, Valsartan 80 mg, Cavedilol 6.25 mg
Case II – Chest X ray
At ER
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Case II – ECG
At ER
Case II – Echocardiography
At ER 1 week later
Case II – Echocardiography
At ER 1 week later
Case II – Echocardiography
At ER 1 week later
Case II – Question
• 심부전의 원인으로 우선 고려해야 할 진단은 ?
1) Hyperthyroidism
2) Stress induced cardiomyopathy 3) Renovascular hypertension
4) Perimyocarditis
5) Coronary artery disease
Case II – Echocardiography
At ER 1 week later
Case II – SPECT
Case II – CAG
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Stress induced cardiomyopathy
Apical ballooning syndrome, Tako-tsubo cardiomyopathy Presentation
Pulmonary edema, Hypotension, Chest pain.
Mechanism
1) Intense sympathetic activation with heterogeneity of myocardial autonomic innervation
2) Diffuse microvascular spasm 3) Direct catecholamine toxicity
A. Significant organic or spasm of coronary artery Desirable for CAG in acute stage
Necessary for CAG in chronic stage B. Cerebrovascular disease
C. Pheochromocytoma
D. Viral or idiopathic myocarditis Exclusion
Case III – Brief Hx
• Male 49 yrs
• Worsening dyspnea for 1 week
• P/I ; No problem in daily activities
Presented with worsening dyspnea, 1 week ago
• V/S ; BP; 133/84 mmHg, HR; 162 bpm, Tm; 36.5º, RR; 24
• P/Hx ; Diabetes / Hypertension (-/-)
• P/Ex ; Heart; Rapid, RHS without mm, Lung; BLLF - Rale.
Case III – Lab
• Lab ; CBC; 5,400 – 17.4 - 50.0 - 302,000
BUN/Cr; 8/1.0 Na/K; 143/4.0 OT/PT;45/46 Pro-BNP; 5,727 pg/mL
CK-MB; 5.0 - 2.5 ng/mL, Troponin-I; 0.04 – 0.04 ng/mL
T3; 123.3 ng/dL, FT4; 1.45 ng/dL, TSH; 2.1 uIU/mL.
• Prev. medication
None
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Case III – ECG
At ER
Case III – Chest X ray
At ER
Case III – Echocardiography
At ER
Case III – Question
• 이 환자에서 심부전 원인 감별에 가장 중요한 검사는 ?
1) Holter study 2) Renal Doppler 3) Cardiac biopsy
4) Coronary angiography
5) 5-Hydroxyindoleacetic acid (HIAA)
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Case III – ECG after ablation
Case III – 6 Mon F/U Echocardiography
Case III – Chest X ray
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Tachycardia induced cardiomyopathy
New onset LV dysfunction
& Tachycardia
ECG evidence of
ACS
Emergent Coronary lesion ?
Coronary
revascularization
Precipitant For LVD ?
Treat
precipitating cause
Possible TIC
Cardiac Fn normalize
in week ?
Dilated cardiomyopathy with secondary tachycardia
TIC combined with Dilated cardiomyopathy
Definite TIC
Yes No
Partial Yes
No No
No
Yes
Yes
Case IV – Brief Hx
• Female 69 yrs
• Worsening dyspnea for 3 days
• P/I ; Dyspnea with NYHA II class
Presented with worsening dyspnea, 3 days ago
• V/S ; BP; 150/90 mmHg, HR; 102 bpm, Tm; 36.7º, RR; 22
• P/Hx ; Diabetes (-) / Hypertension for 8 yrs Renal dysfunction for 2 yrs
• P/Ex ; Heart; Rapid, irregular without mm, Lung; BLLF - Rale.
Case IV – Lab
• Lab ; CBC; 8,200 – 10.5 - 30.4 - 155,000
BUN/Cr; 27/1.8 Na/K; 142/4.5 OT/PT;38/13 Pro-BNP; 17,649 pg/mL
CK-MB; 0.7 - 0.5 ng/mL, Troponin-I; 0.04 – 0.06 ng/mL
T3; 107.3 ng/dL, FT4; 1.30 ng/dL, TSH; 2.0 uIU/mL.
• Prev. medication; None
Case IV – Chest X ray
At ER
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Case IV – ECG
At ER
Case IV – Echocardiography
At ER
Case IV – Echocardiography
Mitral E velocity; 90cm/s Mitral DT; 100ms
IVRT; 40ms
TDI-s’; 5cm/s TDI-e’; 5cm/s LA Volume; 55mL/m2
Case IV – Question
• 이 환자의 좌심실 기능에 대한 적절한 소견은 ?
1) LV EF는 65% 정도 이다.
2) LA AP diameter는 4.0 cm 정도 이다.
3) Grade III 이상의 LV diastolic dysfunction이다.
4) LV end diastolic pressure는 5mmHg 정도 이다.
5) Mitral inflow는 relaxation abnormality 소견이다.
Case IV – Echocardiography
Mitral E velocity; 90cm/s Mitral DT; 100ms
IVRT; 40ms
TDI-s’; 5cm/s TDI-e’; 5cm/s LA Volume; 55mL/m2
