1. A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA

3. The Time Line 5002000 0500 1000 1500 Socrates (470-399 BC) Hippocrates (460-377 BC) BC AD Galen (180) Harvey (1616) Laënnec (1700) dropsy

4. CHF ~400 B.C. – SOB, edema, rales First described by Hippocrates Ear directly on chest How 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

5. CHF - Dropsy A morbid condition characterized by the accumulation of watery fluid in the serous cavities or the connective tissue of the body. Hydrops, Idropsie First use in 1290 – “Some fullen in-to be dropesie” OED

6. 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

7. 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

8. CHF - Dropsy Dilatation 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

9. CHF - Dropsy Treatment 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

10. CHF - Dropsy Treatment 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

11. William Harvey 1578-1657 1639: De Motu Cordis

12. “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)

13. William Withering Born: 1741 - 1799 1775: Obtained first “tea” from gypsy

14. Foxglove From German: Fingerhut (finger hat or thimble) Mid-1500’s: Latinized to “digitalis” – finger (digitus) Digitalis purpurea – a common variety 1775 – William Withering

15. CHF It’s a hemodynamic disease ! Preload Afterload Contractility

16. Preload William Stokes (1804-1878) uses Mercury to treat CHF Southey’s tubes 1919 - Organomercurial diuretics Rotating tourniquets 1958 – thiazide diuretics Oral nitrates improve hemodynamics AHJ 1975;90:346

17. CHF Used into the late 1950’s Southey’s Tubes

18. CHF It’s a hemodynamic disease ! Preload Afterload Contractility

19. Digoxin Epinephrine Dopamine Dobutamine

20. CHF It’s a hemodynamic disease ! Preload Afterload Contractility

21. 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

22. 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

23. CHF It’s a hemodynamic disease Preload Contractility Afterload It’s a neurohormonal disease

24. CHF Systolic vs Diastolic Failure Kitzman,et al., Am J Cardiol, 2001;87:413-419 Diastolic Systolic *No valvular or mechanical causes

25. CHF Systole = contraction (inotropy) Diastole = relaxation (lusitropy)

26. CHF What is diastolic dysfunction?

27. CHF Dilated Normal Hypertrophic

28. CHF Normal Heart Enlarged Heart

29. CHF Diagnosis Clinical SOB, DOE, Cough Orthopnea Edema CxR BNP Echo (or equivalent)

30. CHF Diagnosis What is the EF? LowNormal High

31. CHF Is there ischemia? YesNo Diagnosis PTCA CABG EECP

32. CHF (systolic dysfunction) Preload Contractility Afterload Neurohormonal Dysrhythmia Dysynchrony

33. Emergency Rx CHF Preload Lasix Nesiritide Contractility Inotropes Digoxin AfterloadNipride NeurohormonalN/A DysrhythmiaAntiarrhythmics DysynchronyN/A

34. Chronic Rx CHF Preload + Lasix + Ultrafiltration + Nitrates Contractility Digoxin Transplant evaluation / LVAD Afterload ACE / ARB Hydralazine Neurohormonal Beta blocker ACE / ARB Spironolactone / eplerinone Dysrhythmia ICD + Antiarrhythmics DysynchronyBiV Pacing

35. Preload IV diuretics Lasix (20,40,80,160,320) Lasix drip Combination (Lasix / zaroxolyn) Naturetic peptic (nesiritide) Dialysis / Ultrafiltration Nitrates

36. Dialysis / Ultrafiltration

37. Ultrafiltration CHF Solutions, Inc.

38. Contractility Dobutamine Milrinone Epinephrine Dopamine LVAD Heart transplantation

39. Ambulatory Infusion Pumps Dobutamine Milrinone

40. Afterload ACE inhibitors ARB’s Hydralazine

41. Neurohormonal Beta blocker Spironolactone / eplerenone ACE inhibitors ARB’s

42. Is there a BEST Beta Blocker? 17% Reduction

43. Dysrhythmia ICD Antiarrhythmics Beta blockers

44. Dysynchrony Bi-V pacing

45. Therapy of CHF 0 10 20 30 40 50 60 70 80 90 100 Ejection Fraction Normal Systolic DysfunctionDiastolic Dysfunction

46. Therapy of CHF 0 10 20 30 40 50 60 70 80 90 100 Ejection Fraction Normal Range Systolic DysfunctionDiastolic Dysfunction ICD BiV pacer Heart transplant Aggressive MedRx

47. Therapy of CHF 0 10 20 30 40 50 60 70 80 90 100 Ejection Fraction NYHACLASSNYHACLASS I II III IV ACE, Beta, ARB, dig +ACE, Beta, +ARB ICD, BiV Transplant

48. End

49. CHF Diagnosis

50. CHF Diagnosis Clinical CxR BNP Echo