The 1st Kuwait-North American Update in Internal Medicine
Cardiology: Challenging Cases
Michael M. Givertz, M.D.
Medical Director, Heart Transplant/Mechanical Circulatory Support
Brigham and Women’s Hospital
Associate Professor of Medicine
Harvard Medical School
Boston, MA
Case Presentation: AK
74 yo Greek woman with new onset HF
• Cardiac risk factors: + HTN, DM; - cigs, lipids, FHx
• History of MI (inferior Q waves)
• 2007: Acute onset chest and epigastric pain in Greece
– US + gallbladder sludge, returned to U.S. for lap chole
– In OR: pus in gallbladder, liver bx + cirrhosis
– Pre-op echo: LVEF 60%, no WMAs, mild MR
• 2011: Viral illness → progressive DOE and LE edema
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LVEDD 56, EF 40%, mod RV dysfxn, 3+ MR, 3+ TR
Furosemide → 7-pound weight loss, marked ↓ symptoms
Beta-blocker added to ACE inhibitor
Transferred for cath and further management
Case Presentation: AK
• Cath: RA 14, PA 48/22/31, PCWP 26 (V 29), CO 6.5,
insignificant CAD, EF 47% with global HK, 2+ MR
• Palpitations lying in bed, no orthopnea/PND. Appetite
“too good”, weight stable. Poor sleep 2° nocturia.
• PMHx: osteoporosis, H. pylori gastritis, basal cell CA
• Meds: lisinopril 10 mg qd, metoprolol 12.5 mg bid,
furosemide mg 40 qd, glipizide 5 mg bid, lansoprazole
mg 30 qd
• Habits: no cigarettes, occasional glass of ouzo
• FHx: no CAD, CMP or sudden death
• SHx: married, retired from restaurant business
Case Presentation: AK
• Physical exam
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Thin older woman, slightly anxious lying at 30°, malar flush
BP 140/60, HR 104 and regular, T 99.6, Ht 5’4, Wt 48.2
JVP 12 cm, no HJR
Lungs clear bilaterally
Non-palpable PMI, parasternal lift, tachycardic RR, soft SEM
at LSB, trace HSM at apex, +S3, no rub
– Abdomen soft, NT, no HSM
– Extremities warm, no edema
• Na 141, K 4.4, BUN 25, Cr 0.8, glucose 224, TC 108,
Hct 32 (MCV 90), WBC 12K, BNP 735, TnI < assay
• CXR: mild cardiomegaly, “no heart failure”
Electrocardiogram
Cardiac MRI
LVEDVI 159 (56-99), LVEF 36%, RVEF 47%, no scar, no edema
Additional Labs
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ANA and RF negative
ESR 18, CRP 1.4
Iron and TIBC normal; ferritin 727 (20-400)
RPR and HIV negative (ordered by the medical student)
Carnitine and selenium levels normal (ordered by the
resident)
• TSH < assay (0.5-5.7)
• T4 18.3 (4.6-10.7)
• Free T4 8.6 (0.9-1.7)
Dx: Thyrotoxicosis, high-output heart failure
What Did We Miss?
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History: palpitations, appetite “too good” (no wt chg)
Exam: 140/60, HR 104 (no ectopy), anxious, flushed
Labs: glucose 224, TC 108, Hct 32 (MCV 90)
Echo and MRI: mild-mod biventricular dysfxn, mod
secondary MR/TR and secondary pulm HTN
• Cath: CO 6.5, but at 5’4, 48.2 kg…BSA 1.46 → CI 4.5
• Repeat ECG during palpiations:
Avoid Red Herrings
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Viral illness
Greek ancestry
Cryptogenic cirrhosis
Overestimation of alcohol use
Secondary (functional) valvular regurgitation
Secondary (post-capillary) pulmonary hypertension
Other Causes of High-Output HF
• Systemic arteriovenous fistula
– History of vascular surgery or trauma
– Cardiac catheterization
– ESRD
• Other endocrinopathies
– Carcinoid, pheochromocytoma
• Thiamine (vitamin B1) deficiency
– Alcoholic, fad diets
• Skeletal disorders (e.g., Paget’s)
• Dermatologic disorders (e.g., psoriasis)
• Cirrhosis
All are
potentially
treatable
Treatment of Hyperthyroidism
• Goal: return patient to euthyroid state
– Leads to normalization of HR, pulse pressure, and CO
– Reverse remodeling: ↓ EDD, ↑ EF
• Anti-thyroid medication
• Beta-blockers
– Especially in patients with tachycardia, AF/flutter
– BUT caution to avoid further ↓ contractility
• Radioactive iodine, thryoidectomy
• NB: amiodarone
Case Presentation: AB
28 yo African American man with LE edema
• Cardiac risk factors: + HTN, cigs; - DM, FHx; ? lipids
• Grew up in Boston, struggled with obesity (109 kg
entering high school)
• SOB during gym class attributed to asthma
• 2009: First noted to be hypertensive (150/100)
– Started on HCTZ 12.5 mg daily
– Told to exercise and lose weight (did neither)
• 2011: Presented to PCP with increased SOB, fatigue
and new LE edema
Case Presentation: AB
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ROS: shoulder and back pain on ambulation
PMHx: asthma, bilateral hernia repair
Meds: HCTZ 25 mg daily, albuterol inhaler prn
Habits: cigarettes 1 ppd since age 14, occasional
marijuana; no alcohol, cocaine or IVDU; 1 tattoo
• FHx: M and F with HTN, DM and obesity; sister with
hypothyroidism; half-brother with hepatitis C
• SHx: engaged, studied computers in community
college, currently working nights in security
Case Presentation: AB
• Physical exam
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Obese young man, appears tired with dull affect
BP 160/100, HR 51 and regular, Ht 5’6, Wt 147.3, BMI 52.3
JVP difficult to assess due to body habitus
Decreased BS at bases, no wheeze
Slow RR, distant S1 and S2, no murmur heard
Abdomen obese, NT
Extremities warm, 2-3+ edema (R>L) to below knees
• Na 141, K 4.0, BUN 11, Cr 1.3, LFTs normal, BNP
21, Hct 50.6, plt 254K, A1c 6.4
• CXR: top normal heart size, clear lungs, no effusions
Electrocardiogram
Echocardiogram
LVEDD 50, mod LVH (15 mm), LVEF 50%, impaired relaxation,
mild RV enlargement and dysfunction, mild TR, estimated PASP 54
Diagnostic Considerations
• Is this HF with preserved EF (HFPEF)?
• What about the RV dysfunction and pulmonary HTN?
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HIV negative
No history of diet pills
Echocontrast study negative for shunt
CT scan negative for PE
PFTs: moderate restrictive defect, normal DLCO
• Role of RHC?
– RA 16, PA 54/27/36, PCWP 18, CO 4.8, PVR 310
– Saturation run: no step up
• What about morbid obesity?
Prevalence of Obesity (BMI > 30) Among
US Adults: NHANES 2007-2008
Men
Women
60
Prevalence, %
50
40
30
20
10
0
All
White
Black
Hispanic
Mex-Am
Flegal et al., JAMA 2010;303:235
Obesity is an Independent Risk Factor
for Heart Failure
6
5
Adjsuted HR
• Framingham Heart Study
• 5881 patients followed for
1st episode HF over 14 yr
• Increased prevalence of
DM and HTN with ↑ BMI
• Overall, 2-fold increase
risk of HF associated with
BMI > 30 kg/m2
Men
Women
4
3
2
1
0
25-29.9 30-34.9 35-39.9
> 40
BMI, kg/m2
Kenchaiah et al, N Engl J Med 2002;347:305
Pathophysiology of HF in Obesity
Hemodynamic
Factors
Vascular
Injury
Neurohormonal
Factors
Heart Failure
in Obesity
SleepDisordered
Breathing
Rheologic
Factors
Systemic and
Pulmonary
Hypertension
Polysomnogram
Severe OSA (AHI 46/h, oxygen saturation ↓ 81%)
Pulmonary Hypertension is Common
in Patients with HFPEF
• N = 244 HFPEF
• Age 76, 45% male
vs.
• N = 719 HTN w/o HF
• Age 66, 44% male
In both groups, patients with PH were older, had
higher systolic BP, higher PCWP and larger LA
Lam et al., J Am Coll Cardiol 2009;53:1119
Bariatric Surgery and Reverse LV
Remodeling
• N = 423 morbidly obese patients vs. 733 non-surgical controls
• At 2-years: BMI  15.4 kg/m2 with bariatric surgery (vs. 0.03)
• Significant reductions in BP, HR and lipids
Owan et al., J Am Coll Cardiol 2011:57:732
CPAP and Reverse RV Remodeling
N = 47, BMI 38 ± 9, OSA with mean AHI 63
60
p < 0.05
RVSP, mmHg
50
40
30
20
10
0
0
Cardiac MRI
3
6
12
Months
Colish et al., Chest 2012;141:674
PDE-5 Inhibition in HFPEF and
Pulmonary Hypertension
N = 44, chronic HTN, LVEF ≥ 50%, PASP > 40 mmHg
Sildenafil also  MPAP 42%, ↑ RVEF and improved QOL
Guazzi et al., Circulation 2011;124:164
Back to Our Patient
• HCTZ changed to furosemide with good
diuretic response
• ACE inhibitor added with good BP response
• Started on CPAP (but did not tolerate it)
• Referred to nutritionist (but did not go)
• Prescribed sildenafil (but could not afford it)
• Follows up intermittently in HF clinic  last
admit Dec. 2013
Thank you for your attention