Heart Failure challenges · Heart Failure challenges: when optimal therapy is not an option Afonso...
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![Page 1: Heart Failure challenges · Heart Failure challenges: when optimal therapy is not an option Afonso Nunes Ferreira Rafael Santos 2019 Cardiology Department, Santa Maria University](https://reader033.fdocuments.us/reader033/viewer/2022050203/5f56806fad7fb054fe1d9cad/html5/thumbnails/1.jpg)
HeartFailurechallenges:whenoptimaltherapyisnotanoption
AfonsoNunesFerreiraRafaelSantos
2019
CardiologyDepartment,SantaMariaUniversityHospital(CHULN),CAML, CCUL,LisbonSchoolofMedicine,Universidade deLisboa,Portugal
![Page 2: Heart Failure challenges · Heart Failure challenges: when optimal therapy is not an option Afonso Nunes Ferreira Rafael Santos 2019 Cardiology Department, Santa Maria University](https://reader033.fdocuments.us/reader033/viewer/2022050203/5f56806fad7fb054fe1d9cad/html5/thumbnails/2.jpg)
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
♂,82yearsSyncope &chest pain while having breakfast
![Page 3: Heart Failure challenges · Heart Failure challenges: when optimal therapy is not an option Afonso Nunes Ferreira Rafael Santos 2019 Cardiology Department, Santa Maria University](https://reader033.fdocuments.us/reader033/viewer/2022050203/5f56806fad7fb054fe1d9cad/html5/thumbnails/3.jpg)
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
♂,82yearsSyncope &chest pain while having breakfast
• ECGMedicalService
![Page 4: Heart Failure challenges · Heart Failure challenges: when optimal therapy is not an option Afonso Nunes Ferreira Rafael Santos 2019 Cardiology Department, Santa Maria University](https://reader033.fdocuments.us/reader033/viewer/2022050203/5f56806fad7fb054fe1d9cad/html5/thumbnails/4.jpg)
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
♂,82yearsSyncope &chest pain while having breakfast
![Page 5: Heart Failure challenges · Heart Failure challenges: when optimal therapy is not an option Afonso Nunes Ferreira Rafael Santos 2019 Cardiology Department, Santa Maria University](https://reader033.fdocuments.us/reader033/viewer/2022050203/5f56806fad7fb054fe1d9cad/html5/thumbnails/5.jpg)
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
♂,82yearsSyncope &chest pain while having breakfast
![Page 6: Heart Failure challenges · Heart Failure challenges: when optimal therapy is not an option Afonso Nunes Ferreira Rafael Santos 2019 Cardiology Department, Santa Maria University](https://reader033.fdocuments.us/reader033/viewer/2022050203/5f56806fad7fb054fe1d9cad/html5/thumbnails/6.jpg)
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
♂,82yearsSyncope &chest pain while having breakfast
• ECGà sick sinus syndrome+LBBB
• Refractory tomedicalTx(atropine 2mg)
MedicalService
![Page 7: Heart Failure challenges · Heart Failure challenges: when optimal therapy is not an option Afonso Nunes Ferreira Rafael Santos 2019 Cardiology Department, Santa Maria University](https://reader033.fdocuments.us/reader033/viewer/2022050203/5f56806fad7fb054fe1d9cad/html5/thumbnails/7.jpg)
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
♂,82yearsSyncope &chest pain while having breakfast
• ECGà sick sinussyndrome +LBBB
• Refractory tomedicalTx(atropine 2mg)
MedicalService
Transcutaneouspacing system
OTI
![Page 8: Heart Failure challenges · Heart Failure challenges: when optimal therapy is not an option Afonso Nunes Ferreira Rafael Santos 2019 Cardiology Department, Santa Maria University](https://reader033.fdocuments.us/reader033/viewer/2022050203/5f56806fad7fb054fe1d9cad/html5/thumbnails/8.jpg)
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
• HeartFailurewithreducedEjectionFraction• Ischemicheartdiseasewithunknowncoronaryanatomy• Peripheral arterydisease
• Rightaorto-femoralbypass• Cerebrovascular disease• Chronickidneydisease; anemia• CVriskfactors:Hypertension, dyslipidemia, diabetes• Medication: Perindopril 4mg,Bisoprolol 2.5mg,spironolactone25mg,furosemide 40mg,
clopidogrel 75mg,rosuvastatin 10mg,metformin 850mgbid,linagliptine 5mg,alopurinol 300mg
Medicalhistory
![Page 9: Heart Failure challenges · Heart Failure challenges: when optimal therapy is not an option Afonso Nunes Ferreira Rafael Santos 2019 Cardiology Department, Santa Maria University](https://reader033.fdocuments.us/reader033/viewer/2022050203/5f56806fad7fb054fe1d9cad/html5/thumbnails/9.jpg)
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
• External pacing system• Summary echocardiography
• Apicaland anteriorwall akinesia,LVEF25-30%• ABG
• pH7.14,O2127mmHg,CO2 24mmHg,Lact 62mg/dL,K+7.5mmol/L,Na+ 135mmol/L,Hb 8g/dL
Hospitaladmission
Metabolic iatrogenic sick sinus syndrome
![Page 10: Heart Failure challenges · Heart Failure challenges: when optimal therapy is not an option Afonso Nunes Ferreira Rafael Santos 2019 Cardiology Department, Santa Maria University](https://reader033.fdocuments.us/reader033/viewer/2022050203/5f56806fad7fb054fe1d9cad/html5/thumbnails/10.jpg)
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
Metabolic iatrogenic sick sinus syndrome
• Clinical andhemodynamicstabilisation
• Extubation
![Page 11: Heart Failure challenges · Heart Failure challenges: when optimal therapy is not an option Afonso Nunes Ferreira Rafael Santos 2019 Cardiology Department, Santa Maria University](https://reader033.fdocuments.us/reader033/viewer/2022050203/5f56806fad7fb054fe1d9cad/html5/thumbnails/11.jpg)
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
• Blood samples
Cardiology wardParameters Day1
Hemoglobin(g/dL) 8.5
C-reactiveprotein
(mg/dL)
4.7
Creatinine(mg/dL) 3.2
CKD-EPI(mL/min/1.73) 17.1
Potassium(mmol/L) 7.4
Sodium(mmol/L) 129
ALT(U/L) 865
LDH(U/L) 982
NT-proBNP (pg/mL) 14021
Troponin T(ng/L) 222
![Page 12: Heart Failure challenges · Heart Failure challenges: when optimal therapy is not an option Afonso Nunes Ferreira Rafael Santos 2019 Cardiology Department, Santa Maria University](https://reader033.fdocuments.us/reader033/viewer/2022050203/5f56806fad7fb054fe1d9cad/html5/thumbnails/12.jpg)
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
• Echocardiography
Cardiology ward
![Page 13: Heart Failure challenges · Heart Failure challenges: when optimal therapy is not an option Afonso Nunes Ferreira Rafael Santos 2019 Cardiology Department, Santa Maria University](https://reader033.fdocuments.us/reader033/viewer/2022050203/5f56806fad7fb054fe1d9cad/html5/thumbnails/13.jpg)
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
• Echocardiography
Cardiology ward
![Page 14: Heart Failure challenges · Heart Failure challenges: when optimal therapy is not an option Afonso Nunes Ferreira Rafael Santos 2019 Cardiology Department, Santa Maria University](https://reader033.fdocuments.us/reader033/viewer/2022050203/5f56806fad7fb054fe1d9cad/html5/thumbnails/14.jpg)
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
• Blood samples• Echocardiography
• DilatedLV,withapicalakinesiaanddifuse hypokinesiamainlyintheseptumandanteriorwall;
• LVEF28%;• Severesecondarymitralregurgitation
• Coronariography
Cardiology ward
![Page 15: Heart Failure challenges · Heart Failure challenges: when optimal therapy is not an option Afonso Nunes Ferreira Rafael Santos 2019 Cardiology Department, Santa Maria University](https://reader033.fdocuments.us/reader033/viewer/2022050203/5f56806fad7fb054fe1d9cad/html5/thumbnails/15.jpg)
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
• Coronariography
Cardiology ward
![Page 16: Heart Failure challenges · Heart Failure challenges: when optimal therapy is not an option Afonso Nunes Ferreira Rafael Santos 2019 Cardiology Department, Santa Maria University](https://reader033.fdocuments.us/reader033/viewer/2022050203/5f56806fad7fb054fe1d9cad/html5/thumbnails/16.jpg)
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
• Coronariography
Cardiology ward
![Page 17: Heart Failure challenges · Heart Failure challenges: when optimal therapy is not an option Afonso Nunes Ferreira Rafael Santos 2019 Cardiology Department, Santa Maria University](https://reader033.fdocuments.us/reader033/viewer/2022050203/5f56806fad7fb054fe1d9cad/html5/thumbnails/17.jpg)
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
• Bloodsamples• Echocardiography• Coronariography
• LM– significantdistalcalcifiedlesion• LAD– longcalcifiedirregularities,70%lesioninmidsegment• Cx withoutsignificantlesions• RCAcalcifiedproximalocclusion,distalsegmentretrogradeperfusion
• Stressechocardiography• Ø viabilityinLADandARDterritories• Ischemiainmidlateralsegment
Cardiology ward
![Page 18: Heart Failure challenges · Heart Failure challenges: when optimal therapy is not an option Afonso Nunes Ferreira Rafael Santos 2019 Cardiology Department, Santa Maria University](https://reader033.fdocuments.us/reader033/viewer/2022050203/5f56806fad7fb054fe1d9cad/html5/thumbnails/18.jpg)
Clinical Case
• Blood samples
Cardiology ward
Parameters Day1 Day2 Day7
Hemoglobin(g/dL) 8.5 10.0 9.9
C-reactiveprotein
(mg/dL)
4.7 5.1 3.07
Creatinine(mg/dL) 3.2 4.1 1.4
CKD-EPI(mL/min/1.73) 17 12.2 47.8
Potassium(mmol/L) 7.4 4.9 4.2
Sodium(mmol/L) 129 136
ALT(U/L) 865 1299 84
LDH(U/L) 982 1020 63
NT-proBNP(pg/mL) 14021 8675
Troponin T(ng/L) 222 348 57
![Page 19: Heart Failure challenges · Heart Failure challenges: when optimal therapy is not an option Afonso Nunes Ferreira Rafael Santos 2019 Cardiology Department, Santa Maria University](https://reader033.fdocuments.us/reader033/viewer/2022050203/5f56806fad7fb054fe1d9cad/html5/thumbnails/19.jpg)
Clinical Case
• Blood samples
Cardiology ward
Parameters Day1 Day2 Day7
Hemoglobin(g/dL) 8.5 10.0 9.9
C-reactiveprotein
(mg/dL)
4.7 5.1 3.07
Creatinine(mg/dL) 3.2 4.1 1.4
CKD-EPI(mL/min/1.73) 17 12.2 47.8
Potassium(mmol/L) 7.4 4.9 4.2
Sodium(mmol/L) 129 136
ALT(U/L) 865 1299 84
LDH(U/L) 982 1020 63
NT-proBNP(pg/mL) 14021 8675
Troponin T(ng/L) 222 348 57
• Re-introduction ofperindopril 2mg/dayàHiperK+ 6.2mmol/L
• Fast normalization after ACEisuspension
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Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
• Metabolic and iatrogenic sick sinus syndrome• HFrEF of ischemic etiology (LVEF28%)• CKDKDIGOIIIà AKIAKINIII• PAD
Clinical summary
Metabolic iatrogenic sick sinus syndrome
Pre-discharge?
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Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
Triplechallenge
OralTherapy Coronary intervention Pacingintervention
![Page 22: Heart Failure challenges · Heart Failure challenges: when optimal therapy is not an option Afonso Nunes Ferreira Rafael Santos 2019 Cardiology Department, Santa Maria University](https://reader033.fdocuments.us/reader033/viewer/2022050203/5f56806fad7fb054fe1d9cad/html5/thumbnails/22.jpg)
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
Triplechallenge
OralTherapy
HFrEF optimizedtherapy Vs Suspensionof
RASi andMRA
Coronary intervention
PCILMSà Cx Vs ConservativeTx
![Page 23: Heart Failure challenges · Heart Failure challenges: when optimal therapy is not an option Afonso Nunes Ferreira Rafael Santos 2019 Cardiology Department, Santa Maria University](https://reader033.fdocuments.us/reader033/viewer/2022050203/5f56806fad7fb054fe1d9cad/html5/thumbnails/23.jpg)
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
Triplechallenge
OralTherapy
HFrEF optimizedtherapy Vs Suspensionof
RASi andMRA
Coronary intervention
Vs ConservativeTx
Pacingintervention
Nointervention Vs PacemakerDDDR Vs CRT-P
PCILMSà Cx
![Page 24: Heart Failure challenges · Heart Failure challenges: when optimal therapy is not an option Afonso Nunes Ferreira Rafael Santos 2019 Cardiology Department, Santa Maria University](https://reader033.fdocuments.us/reader033/viewer/2022050203/5f56806fad7fb054fe1d9cad/html5/thumbnails/24.jpg)
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
Triplechallenge
OralTherapy
HFrEF optimizedtherapy Vs Suspensionof
RASi andMRA
Coronary intervention
Vs ConservativeTx
Pacingintervention
Nointervention Vs PacemakerDDDR Vs CRT-P
PCILMSà Cx
![Page 25: Heart Failure challenges · Heart Failure challenges: when optimal therapy is not an option Afonso Nunes Ferreira Rafael Santos 2019 Cardiology Department, Santa Maria University](https://reader033.fdocuments.us/reader033/viewer/2022050203/5f56806fad7fb054fe1d9cad/html5/thumbnails/25.jpg)
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
Triplechallenge
Pacingintervention
Nointervention Vs PacemakerDDDR Vs CRT-P
![Page 26: Heart Failure challenges · Heart Failure challenges: when optimal therapy is not an option Afonso Nunes Ferreira Rafael Santos 2019 Cardiology Department, Santa Maria University](https://reader033.fdocuments.us/reader033/viewer/2022050203/5f56806fad7fb054fe1d9cad/html5/thumbnails/26.jpg)
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
• Asymptomatic, SR• PMDDDR• Medicaltherapy
• Bisoprolol 2.5mg,furosemide 40mg,clopidogrel 75mg,rosuvastatin 10mg,metformin 850mgbid,linagliptine5mg,alopurinol 300mg
Discharge
![Page 27: Heart Failure challenges · Heart Failure challenges: when optimal therapy is not an option Afonso Nunes Ferreira Rafael Santos 2019 Cardiology Department, Santa Maria University](https://reader033.fdocuments.us/reader033/viewer/2022050203/5f56806fad7fb054fe1d9cad/html5/thumbnails/27.jpg)
Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
♂,82yearsSyncope&chest painwhile having breakfast
MedicalService
FatigueNYHAIII,atypicalchestpain
2monthslater
Decompensated chronic heart failure
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Clinical Case
HF: when OMT is not an option Afonso Nunes Ferreira, Rafael Santos, Cardiology Department, CHULN
• Optimized medicaltherapy• Spironolactone 12.5mg/day,isossorbide dinitrate 20mg,
Bisoprolol 2.5mg,furosemide 40mg,clopidogrel 75mg,rosuvastatin 10mg,metformin 850mgbid,linagliptine5mg,alopurinol 300mg
Discharge
![Page 29: Heart Failure challenges · Heart Failure challenges: when optimal therapy is not an option Afonso Nunes Ferreira Rafael Santos 2019 Cardiology Department, Santa Maria University](https://reader033.fdocuments.us/reader033/viewer/2022050203/5f56806fad7fb054fe1d9cad/html5/thumbnails/29.jpg)
HeartFailurechallenges:whenoptimaltherapyisnotanoption
AfonsoNunesFerreiraRafaelSantos
2019
CardiologyDepartment,SantaMariaUniversityHospital(CHULN),CAML, CCUL,LisbonSchoolofMedicine,Universidade deLisboa,Portugal
@A_NunesFerreira