Cardio-hepatic syndrome Organ dysfunction in acute heart ......Nikolaou et al Eur Heart Journal 2013...
Transcript of Cardio-hepatic syndrome Organ dysfunction in acute heart ......Nikolaou et al Eur Heart Journal 2013...
Organ dysfunction in acute heart failure:Cardio-hepatic syndrome
Alexandre MebazaaDepartment of Anesthesia & Critical Care
University Hospitals Saint Louis – Lariboisière, Paris, France University Paris 7; INSERM – UMR 942
Conflict of interest
• Speaker’s bureau Alere, Edwards, Thermofischer
• Consultant for Bayer, Cardiorentis, Novartis, Orion, Vifor Pharma
Short version: HFA/EUSEM/SAEM Eur Heart Journal 2015; Long version: Eur J Heart Failure 2015
Online, free access
‘Clinical scenario 2’ in the CCU:dyspnoea + SBP 110-150 mmHg
Decompensated chronic heart failure
• Dyspnoea develops gradually• Gradual increase in body weight• Systemic oedema• Minimal pulmonary oedema
It is a systemic illness:
• Possible renal dysfunction• Anaemia• Low albumin levels• Increased pulmonary congestion• Systemic congestion
Acute heart failure = right & left ventricular failure:results of meta-analysis
Ishihara S et al (submitted for publication)RAP - right atrial pressure PCWP - pulmonary capillary wedge pressure
LV failure
“Butterfly” pattern on chest X-ray
Monnier-Cholley L Chest X-ray in Acute Heart Failure in Mebazaa A et al (Eds) Acute Heart Failure (2009) Springer Science & Business Media
Acute heart failure = right & left ventricular failure:results of meta-analysis
RV failure
Ishihara S et al (submitted for publication)RAP - right atrial pressure PCWP - pulmonary capillary wedge pressure
Cardiorenal SyndromeType I
Ronco et al. JACC 2008, 52:1527-39
Acute setting?
?
Ronco C et al. J Am Coll Card 2008, 52:1527-39
‘abrupt worsening of cardiac function (e.g. from ADHF) leading to acute kidney injury’
Worsening Renal Function (%)CVP (p<0.01) CI
SBP PCWP
Effects of CVP, CI, SBP and PcwP on worsening renal function In Acute Heart Failure patients
Mullens et al. JACC 2009, 53:589-596
p=0.30 p=0.006
p=0.58
p=0.007
Association between baseline creatinine level and invasive haemodynamics in AHF: results of a meta-analysis
Ishihara S et al (submitted for publication)
Gheorghiade et al. Eur J Heart F 2010
Abstract of the review
« The main reason for hospitalization for acute heart failure is CONGESTION, rather than low cardiac output ».
Gheorghiade et al. Eur J Heart F 2010
Several interactions have been described in acute heart failure
- Cardio-renal syndromes
- Cardio-liver syndrome(s) ???
EFICALaboratory Tests on Admission
Zannad F, Mebazaa A, et al. Eur J Heart Fail. 2006
EFICARisk Factors of 4-week Mortality
Zannad F, Mebazaa A, et al. Eur J Heart Fail. 2006
Mechanical ventilation can worsen liver congestion
• 38 y.o. man, dilated cardiomyopathy• referred to the emergency room for
shortness of breath• predominant right heart failure• major hepatic cytolysis (AST: 10000 IU/l;
ALT: 5000); lactate: 5.4 mmol/L; PT 35%• Renal failure
Gatecel et al. Anesthesiology, 1995, 82:588
DANGER
Mechanical ventilation can worsen liver congestion
Gatecel et al. Anesthesiology, 1995, 82:588
Mechanical ventilation can worsen liver congestion
Gatecel et al. Anesthesiology, 1995, 82:588
Outflow pressure
Arterialpressure
Intra-tissular pressure = 0
Effect of HeartFailure
on Organ Congestion
Stable CHF
MAP > Tissular pressure
Normal
AHF
MAP < Tissular pressure
ARVF
PA
Liver/KidneyCONGESTION
RV
volume loading
RAPTR
± high PAP
Liver dysfunction in AHF:Clinical characteristics
Alk Phosphatase
normal abnormal
Transaminases
normal abnormal(37%)(22%)
Nikolaou et al Eur Heart Journal 2013
6-month mortality as a function of liver cytolysis
Nikolaou et al Eur Heart Journal 2013
6-month mortality as a function of cholestatis
Nikolaou et al Eur Heart Journal 2013
Normalliver lobule
bile ductcompression(increased AP)
and cytolysis(increased transaminanses)
AHF-induced liver congestion(increased BNP)
bile ductcompression(increased AP)
+++++
+ +++++
Nikolaou et al Eur Heart Journal 2013
Normalliver lobule
bile ductcompression(increased AP)
and cytolysis(increased transaminanses)
AHF-induced liver congestion(increased BNP)
bile ductcompression(increased AP)
+++++
+ +++++
Nikolaou et al Eur Heart Journal 2013
Nikolaou et al Eur Heart Journal 2013
Factors associated with elevated alkaline phosphatase
Mebazaa et al Intensive Care Medicine 2011
inotropes
ALARM-HF: IV treatment at admission
0 5 10 15 20 25 30
0.0
0.1
0.2
0.3
0.4
0.5
0.6
Days
In-hos
pital m
ortality
Whole cohort
DopamineDobutamine
Epinephrine
Norepinephrine
Levosimendan
Diuretics
Vasodilatators
HFA/EUSEM/SAEM Eur Heart Journal 2015
Online, free access
What to do in the first 30-60 min (1)
HFA/EUSEM/SAEM Eur Heart Journal 2015
What to do in the first 30-60 min (1)
SEVERITY SCORE
HFA/EUSEM/SAEM Eur Heart Journal 2015
Next 120 min
HFA/EUSEM/SAEM Eur Heart Journal 2015
Admission/ discharge
HFA/EUSEM/SAEM Eur Heart Journal 2015
Main messages (1)
•Congestion is the main disease in acute heart failure
•Novel therapies, such as novel vasodilators, aim at reducing congestion
•« time is muscle «
Main messages (2)
•There are evidence for a cardio-liver syndrome in AHF
•Cholestasis is associated with signs of congestion
•Hepatolysis is associated with decreased blood flow
In summary
• There are evidence for a cardio-liver syndrome in AHF
• Cholestasis is associated with signs of congestion
• Hepatolysis is associated with decreased blood flow