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DYSPNEA : Is it the Heart or the Lung? Prof. Roland KASSAB Head of Division of Cardiology HDF CARDIOPACE, Le Royal Hotel, 11/03/2011.

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Presentation on theme: "DYSPNEA : Is it the Heart or the Lung? Prof. Roland KASSAB Head of Division of Cardiology HDF CARDIOPACE, Le Royal Hotel, 11/03/2011."— Presentation transcript:

1 DYSPNEA : Is it the Heart or the Lung? Prof. Roland KASSAB Head of Division of Cardiology HDF CARDIOPACE, Le Royal Hotel, 11/03/2011

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3 n Dyspnea : n Hypoxia: Definitions Subjective experience of breathing discomfort that consists of qualitative sensations that vary in intensity (American Thoracic Society) Deficiency in oxygen as measured by pulse oxymetry (SpO2)

4 n Dyspnea - common complaint/symptom “shortness of breath” or “breathlessness” n Defined as abnormal/uncomfortable breathing n Multiple etiologies - 2/3 of cases - cardiac or pulmonary etiology

5 Differential Diagnosis Dyspnea Cardiac: Pulmonary: Other: COPD Asthma OSA Pneumonia Interstitial Lung Disease Pulmonary Embolism Pneumothorax Pleural effusion Chest wall deformity Pulmonary HTN ACS/AMI CHF Pericardial effusion/ tamponade Arrhythmia Pericarditis Valvular disease Anemia Anxiety Ascites Acidosis CVA Iatrogenic/Drugs * Many of these will also cause hypoxia

6 n History: How does patient describe sensation? When did it start? (acute vs. subacute vs. chronic) Precipitating factors? Past Medical history Initial Approach  Review recent events  Meds given  Trend of vital signs : tachycardia, tachypnea, high/low BPs, hypoxia

7 n General Appearance: Speaking in full sentences? Use of accessory muscles? Cyanosis? n Respiratory: Diminished/absent breath sounds? Wheezes, rales, or rhonchi? n Cardiac: Heart sounds: rate, rhythm, murmurs, rub, S3/S4 JVP Peripheral pulses/edema Physical Exam

8 Easily Performed Diagnostic Tests n Chest radiographs n Electrocardiograph n Screening spirometry

9 n ABG n Labs: CBC, Renal function panel, BNP, Cardiac enzymes? n Further imaging as warranted: PE protocol CT vs. V/Q scan Transthoracic Echo Other Diagnostic Testing

10 n Commonly used to evaluate acute dyspnea n Can provide information about altered pH, hypercapnia, hypocapnia or hypoxemia n Normal ABGs do not exclude cardiac/pulmonary dx as cause of dyspnea Remember- ABGs may be normal even in cases of acute dyspnea - ABGs do not evaluate breathing ABGs

11 n Rapid, widely available, noninvasive means of assessment in most clinical situations- Insensitive (may be normal in acute dyspnea) n The % of Oxygen saturation does not always correspond to PaO 2 n The hemoglobin desaturation curve can be shifted depending on the pH, temperature or arterial carbon monoxide or carbon dioxide levels PULSE OX

12 Echocardiography n The first approach to assess left ventricular and valvular function in patients in whom the history, physical and laboratory examinations, and the chest radiograph do not establish the cause of dyspnea n Less sensitive in identifying diastolic dysfunction n Does not rule out cardiogenic pulmonary edema

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14 Case 1 n A 60 year old non-smoking woman complained of cough, dyspnoea and right sided pleuritic chest pain for 3 days. She was pyrexial (39.3 C) and a pleural rub was audible at the right lung base. Her white cell count was raised. n What are the notable observations ?

15 Case 1 n A 60 year old non-smoking woman complained of cough, dyspnoea and right sided pleuritic chest pain for 3 days. She was pyrexial (39.3 C) and a pleural rub was audible at the right lung base. Her white cell count was raised.

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17 Case 1 diagnosis n Right lower lobe pneumonia

18 Case 2 n This 22 year old woman complained of sudden onset right sided chest pain, followed by progressive dyspnoea. By admission, she was in distress and appeared cyanosed. Her pulse was 140, with respiratory rate 40. On chest auscultation, breath sounds were noted to be quiet, especially on the right

19 Case 2 n This 22 year old woman complained of sudden onset right sided chest pain, followed by progressive dyspnoea. By admission, she was in distress and appeared cyanosed. Her pulse was 140, with respiratory rate 40. On chest auscultation, breath sounds were noted to be quiet, especially on the right.

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21 Case 2 diagnosis n Tension pneumothorax

22 Case 3 n This 68 year old man was admitted with a myocardial infarct 5 days ago. He became acutely breathless at 3am. On examination he was sitting up in bed and sweating. His respiratory rate was 40 and pulse 130. His chest was dull to percussion at the bases and crackles were heard there on auscultation.

23 Case 3 n This 68 year old man was admitted with a myocardial infarct 5 days ago. He became acutely breathless at 3am. On examination he was sitting up in bed and sweating. His respiratory rate was 40 and pulse 130. His chest was dull to percussion at the bases and crackles were heard there on auscultation.

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25 Case 3 diagnosis n Acute pulmonary oedema due to congestive cardiac failure.

26 n 78yo male heavy smoker with h/o COPD, CAD and ICM EF 40% presented with chest pain and was admitted to the ED for r/o ACS. Overnight he developed dyspnea and noted that his chest “felt funny” n Differential? n What do you do? Case 4

27 n SEE THE PATIENT! n VS: T 37 P 130 R 20 BP 140/85 O2 Sat 90% PaCO2 46 HCO3 35 n CV: irregular pulse, tachycardic, 2+ pulses, normal S1/S2, 2/6 SEM RUSB, no rubs or gallops n Resp: faint rales at bases, diffuse ↓ of VM Case 4

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29 CXR

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31 Stevenson and Perloff. JAMA. 1989;261: The Limited Reliability of the Physical Examination in Heart Failure n Prospectively compared physical signs with hemodynamic measurements in 50 hospitalized patients n Rales, edema, jugular venous pulse elevation absent in 18 of 43 patients with pulmonary capillary wedge >24mmHg n Sensitivity 58%, Specificity 100%

32 Methods Used in the Differential Diagnosis of Heart Failure n Electrocardiogram n Chest x-ray n Echocardiogram n Stress test (echo / nuclear imaging) n Spiral computed tomography (CT) scanning n Right heart catheterization (Swan-Ganz) n Left heart catheterization

33 Significant Indecision Exists - 43% Physician Report on Clinical Probability of Congestive Heart Failure Clinical Indecision in the Emergency Room Number of Cases Pretest Probability of CHF

34 Assessment of Severity and Progression of Congestive Heart Failure n Symptoms do not correlate well with left ventricular dysfunction or with prognosis n Many “markers” are elevated in CHF (cytokines, catecholamines, etc) but are not useful in assessing severity or following progression: Wide variability in values Difficult to measure Not often elevated until CHF is severe

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36 B-Type Natriuretic Peptide (BNP) n 32-amino acid peptide secreted primarily from the ventricles of the heart n Released in response to stretch and increased volume in the ventricles n BNP levels correlate with: Left ventricular end-diastolic pressure and volume New York Heart Association (NYHA) functional classification Extent of reversible ischemia n Rapid, point-of-care assay for BNP now available to facilitate diagnosis of CHF and use as a prognostic marker

37 Natriuretic Peptides

38 DIAGNOSTIC VALUE : BNP

39 All Age All non-CHF Non-CHF Male Non-CHF Female BNP Levels in Non-CHF Patients BNP (pg/mL) (n=478)

40 HypertensionDiabetesCOPDAfrican American Caucasian BNP (pg/mL) Yes No BNP Levels in Other Common Conditions

41 Class IClass IIClass IIIClass IV Mean Triage ® BNP package insert. Data on File at Biosite Diagnostics Inc. Relationship of BNP and NYHA Classification BNP (pg/mL)

42 86 +/ / BNP (pg/mL) COPD n=56 CHF n=94 Cause of Dyspnea Dao Q, Maisel A, et al. J. Am Coll Cardio. 2001;37(2): BNP Levels in Patients with Dyspnea Secondary to CHF or COPD

43 BNP Concentration (pg/mL) 186 ± ± ± 266 Mild (n=27) Moderate (n=34) Severe (n=36) Dao Q, Maisel A, et al. J. Am Coll Cardio. 2001;37(2): BNP Concentration for the Degree of CHF Severity

44 321 Patients with dyspnea (gold standard dx of CHF, pts with COPD with RHF dx with CHF). Morrison LK et al. J Am Coll Cardiol. 2002;39: CHFCOPDAsthmaAct Bronch PneumoniaPE Cause of Dyspnea BNP (pg/mL) BNP Assay for Differentiating Heart Failure from Lung Disease

45 Chi-SensSpecAccuracy Variable Square Significances(%)(%)(%) History of CHF Heart size Murmurs Pulm. Venous Hypertension EKG-Atrial Fibrillation Pedal Edema BNP Dao Q, Maisel A, et al. J. Am Coll Cardio. 2001;37(2): All 250 Cases Multivariate Analysis with BNP Analyzed Last

46 AUC.86 ( ) ED Probability.90 ( ) BNP.93 ( ) Combined BNP improves diagnostic accuracy BNP Combined with Clinical Judgment

47 Indecision (%) Clinical Evaluation Clinical Evaluation and BNP * P< BNP Reduces Clinical Indecision by 74% Clarification of Diagnosis and BNP

48 BNP Elevations n Right sided heart failure Cor pulmonale: pg/mL Primary pulmonary hypertension: pg/mL Acute pulmonary embolism: pg/mL n Non heart failure elevations Acute coronary syndromes: pg/mL Acute myocardial infarction: 40 - >1300 pg/mL End-stage renal disease: 80 - >1300 pg/mL

49 Maisel A. Rev Cardiovasc Med. 2002;3(suppl 4):S13. Patient presenting with dyspnea Physical examination, chest x-ray, ECG, BNP level BNP <100 pg/mL BNP pg/mL BNP > 400 pg/mL CHF very unlikely (2%) Baseline LV dysfunction, underlying cor pulmonale or acute pulmonary embolism? Yes No Possible exacerbation of CHF (25%) CHF likely (75%) CHF very likely (95%) Heart Failure Diagnostic Algorithm

50 BNP group n=225 Patients with Acute Dyspnea Start of Specific Treatment Clinical group n=227 Randomized History, Physical Exam, ECG, Chest X-ray, Blood Tests, SaO2 Rapid BNP Test (15min) Hospital Discharge Time to discharge 30 Day Outcomes Brain Natriuretic Peptide for Acute Shortness of Breath Evaluation (BASEL) N Engl J Med. 2004;350:

51 Brain Natriuretic Peptide for Acute Shortness of Breath Evaluation (BASEL) N Engl J Med. 2004;350:

52 Clinical group BNP group P= ,0 2,0 4,0 6,0 8,0 10,0 12,0 14,0 Time to Discharge (days) n= n= % -26% Clinical group BNP group P= Total Treatment Cost ($) ] ] n= n= % Brain Natriuretic Peptide for Acute Shortness of Breath Evaluation (BASEL) N Engl J Med. 2004;350:

53 PROGNOSTIC VALUE : BNP

54 Natriuretic peptides: NT-proBNP Elecsys-proBNP Serum or plasma samples Required volume 20  l Time for evaluation 18 min Advantages of NT-proBNP: n Longer half-life n Higher stability propeptide1 NH 2 COOH disulfide bridge N-terminal (NT) propeptide biological active peptide BNPNT-proBNP

55 BNP versus NT-BNP Assay for HF CharacteristicBNPNT-proBNP ComponentsBNP moleculeNT fragment (1-76) NT-proBNP (1-108) Molecular Weight3.5 kilodaltons8.5 kilodaltons Hormonally ActiveYesNo, inactive peptide GenesisCleavage from NT-proBNPRelease from ventricular myocytes Half-life20 minutes120 minutes Clearance mechanismNeutral Endopeptidase Clearance Receptors Renal Clearance Increases with Normal Aging+++++ Approved cutoff(s) for CHF diagnosis 100 pg/mLAge <75: 125 pg/mL Age ≥75: 450 pg/mL Available at the Point-of-CareYesNo Studies Completed Entry on US MarketNovember 2000December 2002 McCullough. Rev Cardiovasc Med

56 DIAGNOSTIC VALUE : pro-BNP

57 NT-proBNP (median) (pmol/l) NYHA Class Control IIIIIIIV n = 408; LVEF < 45% n = 16; controls NT-proBNP in CHF: Verification Haass M et al. Medimont Publ 2001; Zugck C et al. JACC 2002

58 Control IIIIIIIV n = 408; LVEF < 45% n = 16; controls NT-proBNP Control NYHA I (pmol/l) * Haass M et al. Medimont Publ 2001; Zugck C et al. JACC 2002 NT-proBNP (median) (pmol/l) NYHA Class NT-proBNP in CHF: Early Identification

59 Median conc (pg/ml) NoLVD ASLVD SLVD P < Northern Glasgow MONICA NT-BNP, Symptoms and LVD No LVD ASLVDSLVD P < ANOVA LOG NT-BNP (95%CI) ASLVD - Asymptomatic LVD SLVD - Symptomatic LVD SLVD - Symptomatic LVD

60 BNP vs pro-BNP

61 PRIDE study (Massach. Gen. Hosp) Rate of False-Negative Natriuretic-Peptide test for a diagnosis of HF: Higher sensitivity of NT-proBNP in Preserved EF MarkerNonsystolic HF n = 76 Systolic HF n = 77 NT-proBNP (%) 9 * 7 BNP (%) 20 7

62 BNP vs NT-proBNP ♥ Use of NT-proBNP in routine testing and comparison to BNP: no clinically significant advantage of BNP testing could be found. Pfister and al. Eur J Heart Fail 2004; 6 : ♥ BNP and NT-proBNP may be equally useful as an aid in the diagnosis of CHF in short of breath patients. Mueller J and al. Heart 2005; 91: ♥ Pro-BNP more stable but less reliable in elderly.

63 Role of the BNP Assay n Diagnosis: BNP levels accurately reflect the cause of dyspnea in patients presenting to the ED and add additional information beyond standard Hx, PE, and diagnostic testing n Screening: BNP accurately detects abnormal left ventricular function in patients with or without Sx of CHF or a previous history of CHF n Risk Stratification: BNP levels are associated with risk of hospitalization and death in patients with heart failure and risk of CV events and death in patients with AMI and ACS n Treatment Guide: Early studies suggest BNP may guide initiation and titration of heart failure therapy

64 GUIDELINES

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66 HFSA 2010 Practice Guideline n Recommendation 4.6 It is recommended that BNP or NT ProBNP levels be assessed in all patients suspected of having HF when the diagnosis is not certain. Strenght of Evidence = B J Card Fail 2010 Jun; 16(6): e44-56

67 ACC/AHA 2009 Guidelines n Measurement of BNP or NT-ProBNP can be useful in the evaluation of patients presenting in the urgent care setting in whom the clinical diagnosis of HF is uncertain. Should not be used in isolation to confirm or exclude the presence of HF. (Class IIa; Level of Evidence: A)

68 Conclusions and Recommendations n Dyspnea situation : Treatment can be provided while the diagnostic steps are taken Begin with a careful History and Physical Examination Electrocardiogram ABG and Laboratory exams Measurement of plasma BNP Chest radiograph Transthoracic Echocardiogram Pulmonary-artery catheter

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