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CARDIAC INSUFFICIENCY

CARDIAC INSUFFICIENCY. FROM THE ED TO THE ICU: OLD THERAPIES AND NEW DRUGS. WILLIAM MALLON MD FACEP LAC + USC MEDICAL CENTER. CARDIAC DISEASE. Hypertensive cardiomyopathy Ischemic cardiomyopathy Cor pulmonale Alcoholic cardiomyopathy Infectious cardiomyopathy

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CARDIAC INSUFFICIENCY

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  1. CARDIACINSUFFICIENCY FROM THE ED TO THE ICU: OLD THERAPIES AND NEW DRUGS

  2. WILLIAM MALLON MD FACEPLAC + USC MEDICAL CENTER

  3. CARDIAC DISEASE • Hypertensive cardiomyopathy • Ischemic cardiomyopathy • Cor pulmonale • Alcoholic cardiomyopathy • Infectious cardiomyopathy • Valvular disease L >>R VENTRICULAR PUMP FAILURE

  4. TYPICAL PULMONARY EDEMA CLINICAL SCENARIO • 1-2 day history of increasing dyspnea • Chest pain is variable in severity • Baseline CAD or hypertensive cardiomyopathy • BP = 180/115 HR = 120 RR = 30 • Wet lungs, with rales 2/3 of lungs • Pulse oximetry 88% on room air, and 92% on high flow oxygen • The patient is anxious or agitated (panic?)

  5. NEUROENDOCRINE CAREOF ACUTE PULMONARY EDEMA • Adrenergic surge is counterproductive • Catecholamines increase myocardial oxygen consumption and increases AFTER-load • Rate increases and dysrhythmia increases: Ectopy, A-FIB, and V-Tach • This cascade creates the EMERGENCY • BNP↑, Renin↑, and Epinephrine↑ A NEW DIAGNOSTIC AND TREATMENT FOCUS HAS EMERGED….

  6. The Triage® System: Technologythat is Simple & Easy to Use Compatible with busy EDs Step 1 Step 2 Step 3 Add a few drops of whole blood to device Insert device into instrument Read results Perfect for all near-patient testing(ED, HF Clinic, CCU, Telemetry)

  7. Optimal Diagnostic Accuracy Achieved @ 100 pg/ml N = 1586 1.0 BNP = 50 (pg/ml) BNP = 80 (pg/ml) 0.8 BNP = 100 (pg/ml) BNP = 125 (pg/ml) BNP = 150 (pg/ml) 0.6 Sensitivity AUC = 0.91 (0.90 – 0.93) 0.4 0.2 0.0 0.0 0.2 0.4 0.6 0.8 1.0 1-Specificity ROC CURVE ANALYSIS

  8. THE NEED FOR SPEED

  9. BEDSIDE BNP TESTING

  10. “B-Type Natriuretic Peptide and Clinical Judgment in Emergency Diagnosis of Heart Failure” Analysis From Breathing Not Properly (BNP) Multinational Study Purpose: Determine the degree to which B-type natriuretic peptide (BNP) adds to clinical judgment in the diagnosis of CHF McCullough, et al Circulation, Vol.106, No 4, 2002

  11. “A Rapid Bedside Test for BNP Predicts Treatment Outcomes in Patients Admitted for Decompensated HF: A Pilot Study” Purpose: To determine if BNP levels can predict outcomes in patients admitted with de-compensated heart failure Van Cheng, et al Journal of American College of Cardiology 2001

  12. “The Prognostic Value of B-Type Natriuretic Peptide in Patients with Acute Coronary Syndromes” Purpose: To evaluate the utility of BNP in ACS De Lemos, J.S. et al New England Journal of Medicine October, 2001

  13. TESTING BNP : JUST A GIMMICK? • A negative review of the utility of BNP testing in dyspnea patients • 100 pg/cc cutoff (see prior ROC) • Mean BNP in NON-cardiac dyspnea = 110! • In the intermediate pretest for CHF group; SENSITIVITY = 79% SPECIFICITY = 71% • Authors note if pretest probability is HIGH or LOW that NO TESTING IS NEEDED. Hohl CM et al, Can J Emerg Med 5(3):162, May 2003

  14. BNP TESTING VERSUSBNP TREATING • Validity of testing does NOT insure validity of treating • VMAC (LLSA article over many objections) • If treating, you can no longer TEST • COSTS: Medicare pays $9 Test cost $25 • We need important outcome trials that are NOT Scios sponsored • Vasotec versus BNP ?

  15. ELDERLY WOMEN and BNP • Treatment is proceeding for CHF : U-N-L-O-A-D-M-E + B-B-B? • Diagnostic confidence is HIGH • ACS is ruling out • BNP test returns at 1300 ! • Does this affect disposition and/or consultation? • Is BNP interpretation on a sliding scale instead of an ROC cutoff?

  16. BNP THERAPY • Neurohumeral treatment of CHF • Many questions remain: - Is it superior to ACE-Inhibitors? - Is prognosis changed? (long term benefit) - Is the cost justified? • Cannot follow levels during therapy • Enormous drug company push • Early ACC acceptance

  17. UNLOADME BBB • Urine out…..Foley • Nitrates (lead with nitrates) • Lasix • Oxygen • Diuretics AND / OR Dialysis • Morphine (venodilation + histamine release) • Exsanguinate • B1, BNP, BiPAP

  18. Noninvasive Ventilation

  19. BiPAP and CPAP

  20. BiPAP IN THE ED • Full face, half face, or nose mask • IPAP/EPAP at 8/4→15/5 as tolerated • Successful (with coaching) in many patients • Avoidance of intubation • Physiology is often within reach in 1 hour A THERAPEUTIC BRIDGE

  21. NON-INVASIVE MONITORING

  22. Non-invasive Monitoring

  23. BIOTHORACIC IMPEDANCE • The new version of Swann-Ganz • Signal-Noise ratio improved • Sensor technology improved • More reliable now, with data print-outs • Billable procedure in the USA • Critical care data drives therapy in the ED IS PACING THE LAST BASTION OF THE CENTRAL LINE IN THE ED?

  24. U/S : EARLY VALUE

  25. NORMAL APICAL VIEW

  26. U/S TECHNOLOGY • Portable • Durable • Cost efficient • Security issues • Tissue harmonics • Probes !

  27. PORTABILITY • Sonosite • Get larger screen • Very mobile • Code Blue usage • Commonplace at LAC+USC

  28. NOT FOR THE EMERGENCY PHYSICIAN • Valvular pathology • Endocardial cushion defects • Wall Motion : Hypokinesis • Cardiac Output calculations • Valvular areas (Critical Aortic Stenosis) • New U/S perfusion dyes are coming! STILL NOT DONE BY THE E.P.

  29. BEDSIDE CARDIAC MARKERS • MULTIPLE STUDIES HERE…. • PHC testing ?! Triage to a Coronary Center: Svennson L et al, J Intern Med Mar. 2003 • 1/3 (CK Mgb Trop) + and PPV for ACS: - surprisingly poor results - PPV from 36-65% - Combinations got to 82% (Dredged!) Kratz A et al, Arch Path Med Dec 2002

  30. DO ENZYMES REALLY CHANGE THE ACS RACE ?

  31. BLOOD DRAW ANEMIA • Not trivial in Critical Care patients • Average daily draw = 41 cc! • If LOS is long, increased transfusion needs • Anemia and transfusion = increased mortality • Several similar studies • Is sample volume an important ED issue? Vincent JL et al, JAMA Sept 25, 2002

  32. VASOPRESSIN OVERVIEW • Animal studies are ALL very positive • ACLS endorsement before human data • Did the AHA consent your grandmother? • At least Vasopressin is NOT expensive • ACLS drugs never have done much • Now the human data is in…..

  33. HUMAN VASOPRESSIN DATA • Cochrane Data Base 2004 : “Who knows?” • European Resusc Council : Mixed outcome No change in VF ! No change in PEA Asystole was BETTER • Ian Steill et al, in Canada : No outcome change for INHCA in 2001 • Not EXACTLY earth-shattering….

  34. VASOPRESSIN vs. EPI • Triple Blinded RCT • ED, CCU, Ward cases of INHCA • 40u Vasopressin versus 1 mg Epinephrine • Survival to D/C : • Survival 1 hour : NO CHANGE • Neurologic Outcome : Steill IG et al, Lancet 2001 July 14;358(9276):105-9

  35. COCHRANE ON VASOPRESSORS • Reviewed the widely accepted treatment • BP<90…..give Dopamine, Epi, Norepi, Dobutamine, Vasopressin, etc. • RCT on ANY kind of circulatory failure : 8 • No definitive outcome improvement • “Current evidence NOT suited to inform clinical practice” as of 2004 ! Mullner M et al, Cochrane Database Syst Rev 2004(3):CD003709

  36. AMIODARONE STUDIES • Skrifvars MB et al, NO PATIENT LIVED • Dorian P in NEJM NO SURVIVAL CHANGE ROSC INCREASED • SHOCK and LOAD is not successful • New EMS friendly premixed ampules available • ACLS endorsement without good data

  37. CONCLUSIONS • Neuroendocrine care focus is here to stay: ACE-I, BNP, and beta blockers • Non-invasive monitoring is providing ICU type data in the ED to guide care • BiPAP has replaced intubation and provides a powerful therapeutic bridge • Pressors for cardiogenic shock have not yielded favorable outcomes to date • Bedside testing and bedside ECHO are gaining some ground in this arena

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