CASE REPORT. 79 year old woman 2-hour chest pain Radiating to jaw Sudden onset. BP 165/90 mmhg HR 75 bpm Temp 36,5 C RR 22 min. ECG: SR, LBBB (new)

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1 CASE REPORT A.J. MANOLIS MD, FACC, FESC, FAHA Professor of Cardiology, Emory University USA Clinical Director, Cardiology Department Asklepeion Voula General Hospital, Athens

2 CASE REPORT 79 year old woman 2-hour chest pain Radiating to jaw Sudden onset BP 165/90 mmhg HR 75 bpm Temp 36,5 C RR 22 min ECG: SR, LBBB (new) Weight: 66 kgr Height: 169 cm BMI : 23,1

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4 CURRENT DISEASE NSTEMI Renal impairment Uncontrolled hypertension

5 PAST MEDICAL HISTORY Ischemic heart disease (previous myocardial infarction) Hypertension (since 25 years) Chronic renal failure Insulin dependent diabetes mellitus (since 25 years) Positive family history for IHD

6 Furosemide 40 mg od Lisinopril 20mg Nifedipine cr 30mg Methyldopa 250mg Irbesartan 300mg Glyceryl trinitrate 10mg Clopidogrel 75mg od Rosuvastatin 10mg on Propafenone 13u bd

7 Respiratory: decreased air entry from mid zones.right basal rales. Cardiovascular: S4-S1-S2, apical systolic murmur Pedal oedema

8 RADIOGRAPHY Chest radiography showed cardiomegaly with right pleural effusion and pulmonary vascular congestion.

9 TIMI Risk Score = 5 GFRεισόδου = 18,1 ml/min/1,73 m2

10 TnI < 0,2 ng/ml Glu = 85 mg/dl Urea = 213 mg/dl Creatinine = 2,7 mg/dl Κ+= 4,8 meq/l Na+= 139 meq/l LDH = 572 U/L CPK = 136 U/L CK-MB = 25 U/L SGPT = 19 U/L SGOT = 31 U/L Chol. = 131 mg/dl HDL = 35 mg/dl LDL = 75 mg/dl WBC = 4,19x103 HGB = 9,44 HCT = 30,1%

11 Echogenic with increase cortical thickness. Sagittal lengths: Rt 10,9 cm, Lt 11,4 cm

12 Αντιμετώπιση NSTEMI καιπιθανών επιπλοκών ΡύθμισηΑρτηριακής Πίεσης Διατήρηση νεφρικήςλειτουργίας

13 NTG i.v. continuo infusion 0.05 mg/min Insulin Furosemidi 40 mg Omeprazole 40 mg Nifedipine 30 mg Clopidogrel 75mg Rosuvastatin 10 mg Acetylsalicylic acid 100 mg Enoxaparin 40 mg

14 B.P. REGULATION NTG i.v. Furosemide Nifedipine Urine in a day GFR

15 Heart failure/nstemi B.P. Urine day GFR NTG 0,05 mg/min 180/90 mmhg 2800 cc 18,1 NTG 0,1 mg/min 130/80 mmhg 1000 cc 11 Nifedipine 60mg Isosorbide mononitrate 60mg Carvedilol 13mg Furosemide 80mg 150/85 mmhg 1500 cc 13,4

16 Βελτίωσητων συμπτωμάτων με χορήγησηενδοφλέβια νιτρώδη. ΗΚΓ: SR, (-)T σε I, II, avf, V4-V6, πτώση ST 4mm II, III, avf, V4-V6 Μη ρυθμιζόμενη Α.Π. Επεισόδια δύσπνοιας οξύ πνευμονικό οίδημα Επιδείνωση νεφρικήςλειτουργίας, μείωση διούρησης Άρνηση τηςασθενούς και συγγενικού περιβάλλοντοςγια στεφανιογραφικό έλεγχο.

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18 LV: ΜΚΔ = 12,5mm, ΟΤΑΚ = 12,5mm ΤΣΔ = 44mm, ΤΔΔ = 56 mm Ακινησίαβασικού μέσου οπισθιοδιαφραγματικού, κατωτέρου. LVEF = 45% LA: 49mm MV: MR +2-3/+4 ασβέστωση πτυχών AoV: ασβέστωση πτυχών με μετρίου βαθμού ανεπάρκειααυτής. TV: χωρίςσημαντικέςαλλοιώσεις RV RA: χωρίςσημαντικέςαλλοιώσεις

19 Clopidogrel 75mg Acetylsalicylic acid 100mg Carvedilol 13mg Furosemide 80mg Nifedipine 60mg Isosorbide-5-mononitrate 60mg Amiodarone 200mg Epoitin beta 5000 IU Omeprazol 20mg

20 TnI < 0,2 ng/ml (max 85,4) Glu = 207 mg/dl Urea = 216 mg/dl (max 301) Kreatini = 3,5 mg/dl (max 4.2) Κ+= 4,2 meq/l Na+= 136 meq/l LDH = 34 U/L CPK = 42 U/L CK-MB = 6 U/L SGPT = 20 U/L SGOT = 16 U/L Chol. = 124 mg/dl HDL = 39 mg/dl LDL = 71 mg/dl TG= 80 mg/dl WBC = 8,72x103 HGB = 9,71 HCT = 30,7%

21 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

22 ESRD End- Stage CHF CRI (decreased GFR) Progression ASCVD Events Albuminuria Proteinuria Elderly, Diabetes Hypertension Initiation At Risk CAD LVH Elderly, Diabetes Hypertension CHRONIC RENAL DISEASE CARDIOVASCULAR DISEASE

23 The Cardiorenal Syndrome of HF Increased Morbidity and Mortality Development of Diuretic and Natriuretic Resistance Diuretic Therapy Neurohormonal Activation Diminished Blood Flow Impaired Renal Function Decreased Renal Perfusion

24 Common Compensatory Responses to Low- and High- Output Cardiac Failure High-Output Cardiac Failure Low-Output Cardiac Failure Systemic Arterial Vasodilation Cardiac Output Arterial Underfilling Nonosmotic AVP Release Sympathetic Nervous System Renin-Angiotensin- Aldosterone System Schrier. Ann Intern Med. 1990;113: Diminished Renal Hemodynamics and Renal Sodium and Water Excretion

25 Relationship of GFRc With Mortality in 1906 Patients With CHF 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 Proportion mortality Days <44 ml/min ml/min ml/min >76 ml/min Hillege et al. Circulation. 2000;102:

26 LEVF NYHA

27 All Enrolled Discharges (n=105,388) October 2001 January 2004 Patients (%) % 6% 6% 10% 10% 3% 1% IV Diuretic Dobutamine Dopamine Milrinone Nesiritide Nitroglycerin Nitroprusside ADHERE Registry. Benchmark Report IV Vasoactive Meds

28 Decreased renal function and distal Na+ delivery Variability in diuretic absorption (bioavailability) Neurohormonal activation (RAAS/SNS) Drugs/diet increased sodium intake Noncompliance with medications Infrequent dosing 1. Neuberg et al. Am Heart J. 2002;144: Brater. N Engl J Med. 1998;339: Wilcox. J Am Soc Nephrol. 2002;13:

29 Restrict daily fluid intake ( L) Moderate restriction of daily salt intake ( 2 g) Avoid NSAIDs Institute and uptitrate ACE inhibitors and/or angiotensin receptor blocker Give short-acting loop diuretic orally in several divided (and increasing) doses, bolus, or continuous intravenous administration Use sequential nephron blockade via combination loop diuretic and thiazide diuretic Add small doses of spironolactone ( mg) Consider short-term acetazolamide in selected patients

30 Blood pressure and kidney GFR + Importance for normal blood pressure Renin Angiotensin (II) NaCl reabsorption Aldosterone + - sympathetic nervous system Endothelin PGs neutral lipid Kinins PAF NO ECF Volume Vasoconstriction BP = Cardiac output x Total peripheral resistance

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