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