Organ dysfunction in acute heart failure: Cardio-hepatic syndrome
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1 Organ dysfunction in acute heart failure: Cardio-hepatic syndrome Alexandre Mebazaa Department of Anesthesia & Critical Care University Hospitals Saint Louis Lariboisière, Paris, France University Paris 7; INSERM UMR 942
2 Conflict of interest Speaker s bureau Alere, Edwards, Thermofischer Consultant for Bayer, Cardiorentis, Novartis, Orion, Vifor Pharma
3 Online, free access Short version: HFA/EUSEM/SAEM Eur Heart Journal 2015; Long version: Eur J Heart Failure 2015
4 Clinical scenario 2 in the CCU: dyspnoea + SBP 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
5 Acute heart failure = right & left ventricular failure: results of meta-analysis LV failure RAP - right atrial pressure PCWP - pulmonary capillary wedge pressure Ishihara S et al (submitted for publication)
6 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
7 Acute heart failure = right & left ventricular failure: results of meta-analysis RV failure RAP - right atrial pressure PCWP - pulmonary capillary wedge pressure Ishihara S et al (submitted for publication)
8 Cardiorenal Syndrome Type I Acute setting abrupt worsening of cardiac function (e.g. from ADHF) eading to acute kidney injury?? Ronco 52: Ronco Cet et al. al. JJACC Am Coll2008, Card 2008, 52:
9 CVP (p<0.01) SBP Worsening Renal Function (%) Effects of CVP, CI, SBP and PcwP on worsening renal function In Acute Heart Failure patients CI PCWP Mullens et al. JACC 2009, 53:
10 Association between baseline creatinine level and invasive haemodynamics in AHF: results of a meta-analysis p=0.30 p=0.006 p=0.58 p=0.007 Ishihara S et al (submitted for publication)
11 Gheorghiade et al. Eur J Heart F 2010
12 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
13 Several interactions have been described in acute heart failure - Cardio-renal syndromes - Cardio-liver syndrome(s)???
14 EFICA Laboratory Tests on Admission Zannad F, Mebazaa A, et al. Eur J Heart Fail. 2006
15 EFICA Risk Factors of 4-week Mortality Zannad F, Mebazaa A, et al. Eur J Heart Fail. 2006
16 DANGER 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: IU/l; ALT: 5000); lactate: 5.4 mmol/l; PT 35% Renal failure Gatecel et al. Anesthesiology, 1995, 82:588
17 Mechanical ventilation can worsen liver congestion Gatecel et al. Anesthesiology, 1995, 82:588
18 Mechanical ventilation can worsen liver congestion Gatecel et al. Anesthesiology, 1995, 82:588
19 Arterial pressure Normal Intra-tissular pressure = 0 Outflow pressure MAP > Tissular pressure Stable CHF MAP < Tissular pressure AHF Effect of Heart Failure on Organ Congestion
20 ± high PAP volume loading PA RAP ARVF TR RV Liver/Kidney CONGESTION
21
22 Liver dysfunction in AHF: Clinical characteristics Alk Phosphatase normal Transaminases abnormal (22%) normal abnormal (37%) Nikolaou et al Eur Heart Journal 2013
23 6-month mortality as a function of liver cytolysis Nikolaou et al Eur Heart Journal 2013
24 6-month mortality as a function of cholestatis Nikolaou et al Eur Heart Journal 2013
25 AHF-induced liver congestion (increased BNP) Normal liver lobule + bile duct compression (increased AP) bile duct compression (increased AP) and cytolysis (increased transaminanses) Nikolaou et al Eur Heart Journal 2013
26 AHF-induced liver congestion (increased BNP) Normal liver lobule + bile duct compression (increased AP) bile duct compression (increased AP) and cytolysis (increased transaminanses) Nikolaou et al Eur Heart Journal 2013
27 Factors associated with elevated alkaline phosphatase Nikolaou et al Eur Heart Journal 2013
28
29 ALARM-HF: IV treatment at admission inotropes Mebazaa et al Intensive Care Medicine 2011
30 Norepinephrine Dopamine 0.2 Dobutamine 0.1 Whole cohort Diuretics Levosimendan 0.0 In-hospital mortality Epinephrine Vasodilatators Days 25 30
31 Online, free access HFA/EUSEM/SAEM Eur Heart Journal 2015
32 What to do in the first min (1) HFA/EUSEM/SAEM Eur Heart Journal 2015
33 What to do in the first min (1) SEVERITY SCORE HFA/EUSEM/SAEM Eur Heart Journal 2015
34 Next 120 min HFA/EUSEM/SAEM Eur Heart Journal 2015
35 Admission/ discharge HFA/EUSEM/SAEM Eur Heart Journal 2015
36 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 «
37 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
38 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
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