CARDIAC INSUFFICIENCY

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CARDIACINSUFFICIENCY

• FROM THE ED TO THE ICU OLD THERAPIES AND
  NEW DRUGS

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WILLIAM MALLON MD FACEPLAC USC MEDICAL CENTER
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CARDIAC DISEASE

• Hypertensive cardiomyopathy
• Ischemic cardiomyopathy
• Cor pulmonale
• Alcoholic cardiomyopathy
• Infectious cardiomyopathy
• Valvular disease
• L gtgtR VENTRICULAR PUMP FAILURE

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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?)

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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.

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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)
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ROC CURVE ANALYSIS
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THE NEED FOR SPEED
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BEDSIDE BNP TESTING
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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

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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

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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

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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

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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 ?

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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?

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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

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UNLOADME BBB

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

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Noninvasive Ventilation
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BiPAP and CPAP
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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

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NON-INVASIVE MONITORING
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Non-invasive Monitoring
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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?

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U/S EARLY VALUE
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NORMAL APICAL VIEW
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U/S TECHNOLOGY

• Portable
• Durable
• Cost efficient
• Security issues
• Tissue harmonics
• Probes !

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PORTABILITY

• Sonosite
• Get larger screen
• Very mobile
• Code Blue usage
• Commonplace at
• LACUSC

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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.

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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

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DO ENZYMES REALLY CHANGE THE ACS RACE ?
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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

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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..

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HUMAN VASOPRESSIN DATA

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

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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
  14358(9276)105-9

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COCHRANE ON VASOPRESSORS

• Reviewed the widely accepted treatment
• BPlt90..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

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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

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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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