A History of Dropsy

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A History of Dropsy
Timothy A. Denton, M.D. Attending
Cardiologist High Desert Heart Institute Victorvil
le, CA
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(No Transcript)
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The Time Line
BC AD
500
2000
0
500
1500
1000
dropsy
Socrates (470-399 BC) Hippocrates (460-377 BC)
Galen (180)
Harvey (1616)
Laënnec (1700)
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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 Laënnecs
stethoscope
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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
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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
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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
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CHF - Dropsy
Dilatation and feebleness of the heart The
hearts action permanently irregular, with an
extended, but not a strong impulse the sounds so
rapid and equal that their analysis is
difficultIt 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
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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 subjectit is impossible to speak too highly
of the efficacy of this treatment
Stokes Diseases of the Heart and the
Aorta 1853
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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
alimentStokes Diseases of the Heart and the
Aorta 1853
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William Harvey
1578-1657 1639 De Motu Cordis
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Groucho on the Circulation
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.
from Horse Feathers (Julius Henry Marx)
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William Withering
Born 1741 - 1799 1775 Obtained first tea from
gypsy
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Foxglove
From German Fingerhut (finger hat or
thimble) Mid-1500s Latinized to digitalis
finger (digitus) Digitalis purpurea a common
variety 1775 William Withering
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CHF
Its a hemodynamic disease !
Afterload
Preload
Contractility
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Preload

• William Stokes (1804-1878) uses Mercury to
  treat CHF
• Southeys tubes
• 1919 - Organomercurial diuretics
• Rotating tourniquets
• 1958 thiazide diuretics
• Oral nitrates improve hemodynamics AHJ
  197590346

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CHF
Southeys Tubes
Used into the late 1950s
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CHF
Its a hemodynamic disease !
Afterload
Preload
Contractility
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Contractility

• Digoxin
• Epinephrine
• Dopamine
• Dobutamine

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CHF
Its a hemodynamic disease !
Afterload
Preload
Contractility
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Afterload

• Lowered afterload improves hemodynamics in
  MR (Ann Int Med 197583312)
• Vasodilator therapy in heart failure (Ann Int
  Med 197583421)
• Hydralazine / Minoxidil in refractory CHF (Ann
  Int Med 197685467)
• Lowered afterload improves hemodynamics in
  AI (Circulation 197653879)
• Lowered afterload improves hemodynamics in
  CHF (Ann Rev Physiology 197739277
• 1987 - CONSENSUS I

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CHF
Its a neurohormonal disease !

• 1963 Plasma norepinephrine elevated in
  CHF (NEJM 1963269653)
• 1970s digoxin reduces plasma renin and
  norepinephrine levels

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CHF

• Its a hemodynamic disease Preload Contractilit
  y Afterload
• Its a neurohormonal disease

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CHF
Systolic vs Diastolic Failure
Systolic
Diastolic
No valvular or mechanical causes
Kitzman,et al., Am J Cardiol, 200187413-419
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CHF
Systole contraction (inotropy) Diastole
relaxation (lusitropy)
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CHF
What is diastolic dysfunction?
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CHF
Dilated Normal
Hypertrophic
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CHF
Normal Heart
Enlarged Heart
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CHF
Diagnosis

• Clinical SOB, DOE, Cough Orthopnea Edema
• CxR
• BNP
• Echo (or equivalent)

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CHF
Diagnosis
What is the EF?
Low
NormalHigh
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CHF
Diagnosis
Is there ischemia?
Yes
No
PTCA CABG EECP
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CHF (systolic dysfunction)

• Preload
• Contractility
• Afterload
• Neurohormonal
• Dysrhythmia
• Dysynchrony

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Emergency Rx CHF
Preload Lasix Nesiritide
Contractility Inotropes Digoxin
Afterload Nipride
Neurohormonal N/A
Dysrhythmia Antiarrhythmics
Dysynchrony N/A
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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
Dysynchrony BiV Pacing
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Preload
IV diuretics Lasix (20,40,80,160,320)
Lasix drip Combination (Lasix /
zaroxolyn) Naturetic peptic (nesiritide) Dialysis
/ Ultrafiltration Nitrates
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Dialysis / Ultrafiltration
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Ultrafiltration
CHF Solutions, Inc.
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Contractility

• Dobutamine
• Milrinone
• Epinephrine
• Dopamine
• LVAD
• Heart transplantation

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Ambulatory Infusion Pumps

• Dobutamine
• Milrinone

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Afterload

• ACE inhibitors
• ARBs
• Hydralazine

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Neurohormonal

• Beta blocker
• Spironolactone / eplerenone
• ACE inhibitors
• ARBs

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Is there a BEST Beta Blocker?
17 Reduction
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Dysrhythmia

• ICD
• Antiarrhythmics
• Beta blockers

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Dysynchrony

• Bi-V pacing

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

• ICD
• BiV pacer
• Heart transplant

• Aggressive MedRx

Systolic Dysfunction
Diastolic Dysfunction
Normal Range
0 10 20 30 40 50
60 70 80 90 100
Ejection Fraction
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Therapy of CHF
I
N Y H A C L A S S
ACE, Beta, ARB
ACE, Beta, ARB, dig
II
ICD, BiV
III
Transplant
IV
0 10 20 30 40 50
60 70 80 90 100
Ejection Fraction
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End
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CHF
Diagnosis
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CHF
Diagnosis

• Clinical
• CxR
• BNP
• Echo