Case Study - Adult - Hypertension - Heart Failure

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74 year old female
Severe hypertension (187/85, MAP 115mmHg)
Prior renal failure and heart failure
8wks in ICU

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  • How do you treat this patient without knowing CO and SVR?
  • Let’s remind ourselves!
  • Let’s remind ourselves!
  • BSA – 1.49High SV - 126High SVI - 85 (Typical 30-55)Low SVR – 697 (Typical 1000-1800)Low SVRI – 468 (Typical 2000-3400)HighCO – 13 (Typical 2.5-6.0)High CI – 8.7 (Typical 2.4-3.6)
  • BSA – 1.49High SV - 79High SVI – 53 (Typical 30-55)Low SVR – 1007 (Typical 1000-1800)Low SVRI – 676 (Typical 2000-3400)HighCO – 7.3 (Typical 2.5-6.0)High CI – 4.9 (Typical 2.4-3.6)
  • Case Study - Adult - Hypertension - Heart Failure

    1. 1. Hypertension – Heart Failure Presentation 74 year old female Severe hypertension (187/85, MAP 115mmHg) Prior renal failure and heart failure 8wks in ICU Treatment CRRT and controlled fluid GTN 1.5ug/min/kg – vasodilator for HTwww.uscom.com.au The Measure of Life
    2. 2. Hypertension – Heart Failure Effect of Vasodilator on SV Frank Starling Curve 126cm3 SV Dilator SV response to preload (filling pressure or LV volumes)www.uscom.com.au The Measure of Life
    3. 3. Hypertension – Heart Failure Hypertension treatments: - Offload fluid – diuretics. (SVV) - Reduce SV – Ca blockers and B Blockers (SV, CO, CPo, SW, II) - Decrease SVR – dilate arteries with ACE inhibitors/GTN (SVR) Is the abnormality in the heart or the vessels (CO/SV and SVR)? Complex issues of cardiac and renal disease require careful circulatory optimization.www.uscom.com.au The Measure of Life
    4. 4. Hypertension – Heart Failure Which treatment is right for this patient? What is the cause of her hypertension? CO/SV? SVR? What is her fluid status? What is her best treatment? Fluid – increase/decrease? Inotropes – yes or no? Vasoactives - yes or no?www.uscom.com.au The Measure of Life
    5. 5. Hypertension – Heart Failure USCOM exam BP 185/85, MAP 115mmHg Can you treat this patient without knowing CO and SVR?www.uscom.com.au The Measure of Life
    6. 6. Hypertension – Heart Failure Result High CO Low SVR The low SVR is raising the CO and increasing the MAP. The vasodilator is actually raising the MAP! Should the vasodilators and CRRT be stopped?www.uscom.com.au The Measure of Life
    7. 7. Hypertension – Heart Failure Treatment The GTN and CRRT was stopped Result Increased SVR Decreased CO MAP 115 to 94 The vasodilator was actually raising the MAP!www.uscom.com.au The Measure of Life
    8. 8. Hypertension – Heart Failure SVR SV 1479 126 1600 140 1400 120 1200 1007 Dyne.s.cm-5 100 83 79 1000 866 697 80 66 cm3 800 60 600 400 40 200 20 0 0 Base Post Day2 Norm Base Post Day2 Norm MAP CPo 115 3.2 120 102 3.5 94 100 3 82 2.5 2.1 80 mmHg Watts 2 1.5 60 1.5 1 40 1 20 0.5 0 0 Base Post Day2 Norm Base Post Day2 Normwww.uscom.com.au The Measure of Life
    9. 9. Hypertension – Heart Failure Summary Hypertension can be caused by excess fluid, high CO or high SVR. Appropriate therapy requires identification of abnormality - need to measure CO/SV and SVR. Hypertension, heart failure and renal failure are closely related. This relationship is complex and complicates fluid and circulatory management. Conclusion Trend measures of objective hemodynamics provide unique insights into renal and cardiac disease and may improve cardiovascular therapywww.uscom.com.au The Measure of Life

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