A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute...
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Transcript of A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute...
A History of Dropsy
Timothy A. Denton, M.D.Attending Cardiologist
High Desert Heart InstituteVictorville, CA
The Time Line
500 20000 500 1000 1500
Socrates (470-399 BC)Hippocrates (460-377 BC)
BC AD
Galen (180)
Harvey (1616)
Laënnec(1700)
dropsy
CHF~400 B.C. – SOB, edema, ralesFirst described by Hippocrates
Ear directly on chestHow to drain effusions
caused by excess of “phlegm” (cold humor)Moving from brain to chest
~180 AD -- Galen – the heart as a source of heat
1616 – Harvey and circulation
1700 – Laënnec’s stethoscope
CHF - Dropsy
A morbid condition characterized by the accumulationof watery fluid in the serous cavitiesor the connective tissue of the body.
Hydrops, Idropsie
First use in 1290 – “Some fullen in-to be dropesie”
OED
CHF - Dropsy
A woman, 50 years of age, had been affected for twelve years with all the symptoms of disease of the heart, in a very high
degree, viz. strong and frequent palpitations, habitual dyspnoea, breathlessness on using the least exercise, sudden startings from
sleep, almost constant endema of the lower extremitites, and lividity of the cheeks, nose and lips.
Laennec“A Treatise on the Diseases of the Chest”
1821
CHF - Dropsy
Oedema of the Lungs
The symptoms of this affection are extremely equivocal. Impeded respiration, slight cough and a watery expectoration are the only
signs of it.
Laennec“A Treatise on the Diseases of the Chest”
1821
CHF - DropsyDilatation and feebleness of the heart…
The heart’s action permanently irregular, with an extended, but not a strong impulse; the sounds so rapid and equal that their analysis is difficult…It occurs in gouty and debilitated habits, and is almost always attended with chronic bronchitis and enlargement of the
liver.
Stokes“Diseases of the Heart and the Aorta”
1853
CHF - DropsyTreatment of the Weak and probably Dilated Heart…
…we next proceed to examine that of the weakened hearts, of which the two most common forms are dilatation of the cavities, associated with pulmonary and hepatic disease; and again, the
fatty degeneration.
It is remarkable, that although the beneficial action of mercury in the affection is known to may practical physicians, but little
practical information can be found on the subject…it is impossible to speak too highly of the efficacy of this treatment…
Stokes“Diseases of the Heart and the Aorta”
1853
CHF - DropsyTreatment of the Weak and probably Dilated Heart…
During this treatment, and especially when free diuresis is established, it is necessary that wine or some other diffusible
stimulus should be carefully administered, and the system supported by a proper aliment…
Stokes“Diseases of the Heart and the Aorta”
1853
William Harvey
1578-16571639: De Motu Cordis
“We then come to the bloodstream.The blood rushes from the head, down to the feet…gets a look at those feet,and rushes back to the head again.”
Groucho on the Circulation
from “Horse Feathers”(Julius Henry Marx)
William Withering
Born: 1741 - 17991775: Obtained first “tea” from gypsy
Foxglove
From German: Fingerhut (finger hat or thimble)Mid-1500’s: Latinized to “digitalis” – finger (digitus)Digitalis purpurea – a common variety1775 – William Withering
CHFIt’s a hemodynamic disease !
Preload
Afterload
Contractility
Preload
• William Stokes (1804-1878) uses Mercuryto treat CHF
• Southey’s tubes• 1919 - Organomercurial diuretics• Rotating tourniquets• 1958 – thiazide diuretics• Oral nitrates improve hemodynamics
AHJ 1975;90:346
CHF
Used into the late 1950’s
Southey’s Tubes
CHFIt’s a hemodynamic disease !
Preload
Afterload
Contractility
Contractility
• Digoxin• Epinephrine• Dopamine• Dobutamine
CHFIt’s a hemodynamic disease !
Preload
Afterload
Contractility
Afterload• Lowered afterload improves hemodynamics in MR
(Ann Int Med 1975;83:312)• Vasodilator therapy in heart failure
(Ann Int Med 1975;83:421)• Hydralazine / Minoxidil in refractory CHF
(Ann Int Med 1976;85:467)• Lowered afterload improves hemodynamics in AI
(Circulation 1976;53:879)• Lowered afterload improves hemodynamics in CHF
(Ann Rev Physiology 1977;39:277• 1987 - CONSENSUS I
CHF
It’s a neurohormonal disease !
• 1963 – Plasma norepinephrine elevated in CHF(NEJM 1963;269:653)
• 1970’s digoxin reduces plasma renin and norepinephrine levels
CHF
• It’s a hemodynamic diseasePreloadContractilityAfterload
• It’s a neurohormonal disease
CHFSystolic vs Diastolic Failure
Kitzman,et al., Am J Cardiol, 2001;87:413-419
45%
55%Diastolic
Systolic
*No valvular or mechanical causes
CHF
Systole = contraction (inotropy)
Diastole = relaxation (lusitropy)
CHF
What is diastolic dysfunction?
CHF
Dilated Normal Hypertrophic
CHF
Normal Heart Enlarged Heart
CHF
Diagnosis
• ClinicalSOB, DOE, CoughOrthopneaEdema
• CxR• BNP• Echo (or equivalent)
CHF
Diagnosis
What is the EF?
Low NormalHigh
CHF
Is there ischemia?
Yes No
Diagnosis
PTCACABGEECP
CHF (systolic dysfunction)
• Preload• Contractility• Afterload• Neurohormonal• Dysrhythmia• Dysynchrony
Emergency Rx CHF
PreloadLasix
Nesiritide
ContractilityInotropes
Digoxin
Afterload Nipride
Neurohormonal N/A
Dysrhythmia Antiarrhythmics
Dysynchrony N/A
Chronic Rx CHF
Preload
+ Lasix
+ Ultrafiltration
+ Nitrates
ContractilityDigoxin
Transplant evaluation / LVAD
AfterloadACE / ARB
Hydralazine
Neurohormonal
Beta blocker
ACE / ARB
Spironolactone / eplerinone
DysrhythmiaICD
+ Antiarrhythmics
Dysynchrony BiV Pacing
Preload
IV diuretics Lasix (20,40,80,160,320) Lasix drip Combination (Lasix / zaroxolyn)Naturetic peptic (nesiritide)Dialysis / UltrafiltrationNitrates
Dialysis / Ultrafiltration
Ultrafiltration
CHF Solutions, Inc.
Contractility
• Dobutamine• Milrinone• Epinephrine• Dopamine• LVAD• Heart transplantation
Ambulatory Infusion Pumps
• Dobutamine• Milrinone
Afterload
• ACE inhibitors• ARB’s• Hydralazine
Neurohormonal
• Beta blocker• Spironolactone / eplerenone• ACE inhibitors• ARB’s
Is there a BEST Beta Blocker?
17% Reduction
Dysrhythmia
• ICD• Antiarrhythmics• Beta blockers
Dysynchrony
• Bi-V pacing
Therapy of CHF
0 10 20 30 40 50 60 70 80 90 100
Ejection Fraction
Normal
Systolic Dysfunction Diastolic Dysfunction
Therapy of CHF
0 10 20 30 40 50 60 70 80 90 100
Ejection Fraction
NormalRange
Systolic Dysfunction Diastolic Dysfunction
• ICD• BiV pacer• Heart transplant
• Aggressive MedRx
Therapy of CHF
0 10 20 30 40 50 60 70 80 90 100
Ejection Fraction
NYHA
CLASS
I
II
III
IV
ACE, Beta, ARB, dig +ACE, Beta, +ARB
ICD, BiV
Transplant
End
CHF
Diagnosis
CHF
Diagnosis
• Clinical• CxR• BNP• Echo