artwork by aaron jameson cast of characters n importance n evaluate a case n explain the...

168

Upload: moris-alexander

Post on 26-Dec-2015

216 views

Category:

Documents


2 download

TRANSCRIPT

Page 1: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work
Page 2: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Artwork by

Aaron Jameson

Page 3: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Cast of Characters

Page 4: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Importance Evaluate a Case Explain the Pathophysiology Develop the Armamentarium

– Why they work– How to monitor

Cover the important evidence for each group

Plan of Attack

Page 5: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

CHF and Super Heroes

The Role of Rx Man

Page 6: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Surgeon General’s Warning This lecture will require you to

write some things down You could develop carpal tunnel

syndrome You could develop an irreversible

hand cramp You could retain something longer

than 5 minutes

Page 7: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

A Fatal Choice You can have a cancer that:

kills 40% of people in 5 years

OR You can have your first

episode of symptomatic CHF

Page 8: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Did You Choose CHF?

OOPS !!

Page 9: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Epidemiology

CHF Kills A LOT of People CHF Makes A LOT of People’s

lives miserable CHF costs a WHOLE LOT of $

Page 10: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

New York Heart Association

Class I Class II Class III Class IV

Page 11: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

New Approach to the Classification of Heart Failure

Marked symptoms at rest despite maximal medical therapy (eg, those who are recurrently hospitalized or cannot be safely discharged from the hospital without specialized interventions)

Refractory end-stage HFD

Known structural heart disease Shortness of breath and

fatigue Reduced exercise tolerance

Symptomatic HFC

Previous MI LV systolic dysfunction Asymptomatic valvular disease

Asymptomatic HFB

Hypertension CAD Diabetes mellitus Family history of

cardiomyopathy

High risk for developing heart failure (HF)

APatient Description

Stage

Hunt SA et al. J Am Coll Cardiol. 2001;38:2101–2113.

Page 12: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

A At high risk for heart failure but without structural heart disease or symptoms of heart failure (eg, patients with hypertension or coronary artery disease)

Classification of HF: Comparison Between ACC/AHA HF Stage and NYHA Functional ClassACC/AHA HF Stage NYHA Functional Class

NoneNone

B Structural heart disease but without symptoms of heart failure

I Asymptomatic

C Structural heart disease with prior or current symptoms of heart failure

II Symptomatic with moderate exertion

III Symptomatic with minimal exertion

D Refractory heart failure requiring specialized interventions

IV Symptomatic at rest

2113.

Hunt SA et al. J Am Coll Cardiol. 2001;38:2101–2113.

Page 13: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

PenelopeA 74 year old white female 5 feet tall 160 pounds S/P CVA Hx mild CHF , HTN and DM 2

Page 14: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Penelope : Episode 1

Admitted to ER with Acute SOB.

Auscultation reveals crackles 1/2 way up on both sides

CXR shows mild interstitial infiltrates

BP: 150/80 2+ pitting edema

Page 15: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work
Page 16: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Penelope : Episode 1

Admitted to ER with Acute SOB. Auscultation reveals crackles

1/2 way up on both sides CXR shows mild interstitial

infiltrates BP: 150/80 2+ pitting edema NYHA class?

Page 17: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Penelope

Drugs: Insulin Dyazide daily Zestril 5 mg daily

Page 18: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Penelope is tied to the railroad tracks

You can save her from floods You can give her a pillow and

make her more comfortable You can even delay the train But you can’t take her off the

tracks.

Page 19: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Circulation Review

Page 20: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work
Page 21: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work
Page 22: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work
Page 23: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

PreloadPreload AfterloadAfterload

Low Low pressurepressure

High High pressurepressure

Page 24: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Famous Last Words

Everything that can be invented has been invented.”

--Charles H. Duell, Commissioner, U. S. Office of Patents, 1899.

Page 25: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Systolic vs. Diastolic Dysfunction

Page 26: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

120 ml

Normal Heart

Page 27: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

70ml

EF 70/120

58 %EF 70/120

58 %

CO = 70ml /beatCO = 70ml /beat

Normal Heart

120 ml

* 72/min* 72/min=5040 ml/min=5040 ml/min

Page 28: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Systolic Dysfunction

160 ml

Page 29: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

40ml

Systolic Dysfunction

160 ml

CO = 40ml /beatCO = 40ml /beat * 72/min* 72/min=2880 ml/min=2880 ml/min

EF 70/120

58 %EF 40/160

25 %

Page 30: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work
Page 31: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work
Page 32: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

57 ml

Diastolic

Dysfunction

Page 33: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

40ml

Diastolic Dysfunction

57 ml

EF 70/120

58 %EF 40/57

70%

CO 40ml / beatCO 40ml / beat * 72/min* 72/min =2880 ml/min=2880 ml/min

Page 34: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Diastolic Heart Failureand Intravascular Congestion

Page 35: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Describe Diastolic Dysfunction

Page 36: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Other Neuroendocrine mediators

Arginine Vasopressin (ADH)

Stimulated by extreme low kidney perfusion, just like Aldosterone. Causes free water retention and hyponatremia

Endothelin

One of the absolute most potent vasoconstrictors. Endothelin antagonists in the works

Atrial and B-type Natriuretic peptide

Stimulated by stretch of the atria and the ventricles and cause sodium and water excretion. Sort like a counter-regulatory hormone to aldosterone

Page 37: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

CHF: CompensationCardiac Output

Kidney Perfusion

ReninAngiotensinAldosterone

Na+ & H2O

retention

Preload

SNS

Cardiac Output

((Compensated)

Page 38: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

CHF: CompensationCardiac Output

Page 39: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

CHF: Compensation

Kidney Kidney PerfusionPerfusion

Cardiac Output

Page 40: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

CHF: Compensation

Kidney Perfusion

ReninReninAngiotensinAngiotensinAldosteroneAldosterone

Cardiac Output

Page 41: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

CHF: Compensation

Kidney Perfusion

ReninAngiotensinAldosteroneAldosterone

Na+Na+ andand H2OH2O

retentionretention

Cardiac Output

Page 42: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

CHF: Compensation

Kidney Perfusion

ReninAngiotensinAldosteroneAldosterone

PreloadPreload

Cardiac Output

Na+Na+ andand H2OH2O

retentionretention

Page 43: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

CHF: Compensation

Kidney Perfusion

ReninAngiotensinAldosteroneAldosterone

PreloadPreload

CardiacCardiacOutputOutput

(CompensatedCompensated))

Cardiac Output

Na+Na+ andand H2OH2O

retentionretention

Page 44: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work
Page 45: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

CHF: Compensation

Kidney Kidney PerfusionPerfusion

ReninAngiotensinAldosterone

Na+ and H2O

retention

Preload

Cardiac Output CardiacCardiacOutputOutput

(Compensated)Compensated)

Page 46: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

CHF: Compensation

Kidney Perfusion

ReninAngiotensinAngiotensinAldosterone

Na+ and H2O

retention

SNSSNS

Cardiac Output CardiacCardiacOutputOutput

(CompensatedCompensated))

Preload

Page 47: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

CHF: Warning: New Slide!

Cardiac Output

WHY?

Page 48: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

CHF: Warning: New Slide!

Cardiac Output

WHY?

SystolicSystolic DilatedDilated CardiomyopathyCardiomyopathy CADCAD HTNHTN

Page 49: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

CHF: Warning: New Slide!

Cardiac Output

WHY?

SystolicSystolic DilatedDilated CardiomyopathyCardiomyopathy CADCAD HTNHTN

Diastolic

Hypertension

CAD

Hypertrophic Cardiomyopathy

Page 50: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Another famous last quoteGod is Dead

Nieztsche 1885

Page 51: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Nieztsche is

DeadGoGod d

20072007

Page 52: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

CHF: The Viscious CycleThe Viscious Cycle

Kidney Perfusion

ReninAngiotensinAldosterone

Cardiac Output

Page 53: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

CHF: The Viscious Cycle

Kidney Perfusion

ReninAngiotensinAngiotensinAldosterone

VasoconstrictionVasoconstriction

SNS

Cardiac Output

Page 54: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

CHF: The Viscious CycleCardiacCardiac OutputOutput

Kidney Perfusion

ReninAngiotensinAngiotensinAldosterone

VasoconstrictionVasoconstriction

SNS

AfterloadAfterload

Page 55: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

High Pressure

Left VentricleLeft Ventricle ArteriesArteries

Page 56: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

High Pressure: Vasoconstriction

Left VentricleLeft Ventricle ArteriesArteries

Page 57: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

CHF: The Viscious Cycle

Kidney Perfusion

ReninAngiotensinAldosteroneAldosterone

Cardiac Output

Page 58: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

CHF: The Vicious Cycle

Kidney Perfusion

ReninAngiotensinAldosteroneAldosterone

Na+Na+ andand H2OH2O

retentionretention

Cardiac Output

Page 59: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

CHF: Vicious Cycle

Kidney Perfusion

ReninAngiotensinAldosteroneAldosterone

PreloadPreload and and Pulmonary EdemaPulmonary Edema

Cardiac Output

Na+Na+ andand H2OH2O

retentionretention

Page 60: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

CHF: Vicious Cycle

Kidney Perfusion

ReninAngiotensinAldosteroneAldosterone

PreloadPreload and and Pulmonary EdemaPulmonary Edema

Cardiac Output

Na+Na+ andand H2OH2O

retentionretention

StrainStrain

Page 61: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

CHF: Symptoms

Kidney Perfusion

ReninAngiotensinAldosteroneAldosterone

PreloadPreload and and Pulmonary EdemaPulmonary Edema

Cardiac Output

Na+Na+ andand H2OH2O

retentionretention

StrainStrainLow PerfusionLow PerfusionLow PerfusionLow Perfusion

Fluid OverloadFluid OverloadFluid OverloadFluid Overload

Page 62: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

CHF Pharmacotherapy

New Drugs Mechanism(s)

Monitoring for Efficacy

Monitoring for Adverse Effects

Page 63: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Back to Penelope: Episode 1

Admitted to ER with Acute SOB.

Auscultation reveals crackles 1/2 way up on both sides

CXR shows mild interstitial infiltrates

BP: 150/80 2+ pitting edema

Page 64: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work
Page 65: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work
Page 66: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

This is a Job for...

Page 67: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Water Boy

Page 68: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Diuretics: Mechanism

Sodium and Water Excretion

Preload

Necessary Poison

Page 69: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Low perfusion Loss of Renal Function

Fluid OverloadPulmonary Edema

Page 70: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Low perfusion Loss of Renal Function

Fluid OverloadPulmonary Edema

Page 71: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Low perfusion Loss of Renal Function

Fluid OverloadPulmonary Edema

Page 72: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Diuretics: Efficacy

~1 Kg / day (short term) ~1000 mls net loss / day 700 mls insensible loss

(output) Lung Sounds / CXR Decreased Edema

Page 73: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Diuretics: Efficacy

Example:

Input: IV at 100ml/hour

Output: 2700 ml in 24 hours

Net:

Don’t forget 700ml insensible + 300ml = 1000ml lost

Page 74: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Diuretic Dosing

Long Term:Be a Sissy.

Short Term:The Nike Rule

Page 75: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Diuretics: Thiazides vs LoopsLoopstorsemide vs furosemideAbsorption, duration and CostOther loops

Potency vs efficacy

Page 76: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Diuretics: Side Effects

BUN / Cr Ratio Potassium Do Orthostatics !! Clinical Hydration Status Glucose Uric Acid Ca++

Page 77: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Penelope : Episode 1 Admitted to ER with Acute SOB. Auscultation reveals crackles

1/2 way up on both sides CXR shows mild interstitial

infiltrates BP: 150/80 2+ pitting edema

BP 150/80

Page 78: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Which rule should we use? Nike or Sissy?

Page 79: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Penelope : Episode 1 Admitted to ER with Acute SOB. Auscultation reveals crackles

1/2 way up on both sides CXR shows mild interstitial

infiltrates BP: 150/80 2+ pitting edema

BP 150/80

What about the Zestril dose?

Page 80: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

ACE of Hearts

Page 81: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Angiotensin IAngiotensinogen

Renin

Page 82: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

COW HERE

Page 83: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Angiotensin IAngiotensinogen

Renin

Page 84: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Angiotensin I

Angiotensin II

Angiotensinogen

ACE

Renin

Page 85: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Angiotensin I

Angiotensin II

Aldosterone

Vasoconstriction

Angiotensinogen

ACE

Renin

Na+

K+K+ Lost

Na+ Retained

Page 86: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Aldosterone

Angiotensin I

Angiotensin II

Vasoconstriction

ACE I

Angiotensinogen

ACE

Renin

K+K+ Retained

Aldosterone

Page 87: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Angiotensin I

Angiotensin II

Aldosterone

Vasoconstriction

Kinins

Breakdown

ACE I

Angiotensinogen

Renin

ACE

Kinins

Page 88: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

OK,

So how does this benefit the fluid overloaded, under-perfused CHF patient

Page 89: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

insert preload diagram hereinsert preload diagram here

Page 90: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

LowLowPressurPressuree

Whew !!!

I Can Breathe !!

Page 91: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

High Pressure: AfterloadHigh Pressure: Afterload

Left VentricleLeft Ventricle ArteriesArteries

Page 92: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

High Pressure: Post DilationHigh Pressure: Post Dilation

Left VentricleLeft Ventricle ArteriesArteries

Page 93: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work
Page 94: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

OK,

So how does this benefit the fluid overloaded, under-perfused CHF patient

Page 95: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Breathing and fluid

improved

Exercise capacity improved

Mental Status Improved

B. P.

Ace Inhibitors: Efficacy

Page 96: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

BUN / Creatinine

Ace I: Adverse Effects

Potassium

Hypotension (dizziness)

Cough

AngioedemaACE & Kidneys

Page 97: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Ace Inhibitors:Warning Signs

Impaired Renal Perfusion Diuretic CHF

– Especially w/ Hyponatremia Ascites

Page 98: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Ace Inhibitors : Dosing

CHF vs HTN Caution: Hyponatremia

Page 99: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Ace Inhibitors : Drug Intx

Potassium Sparing Diuretics NSAIDS

Page 100: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

What is the intx with ACE Inhibitors and NSAIDS?

Page 101: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

V-HeFT I

Enalapril vs. Placebo Class II & III Mortality

– 34.3 vs 25.6 @ 2 years NNT 11.5– 53.6 vs 49.7 @ 4 years NNT 25.6

(benefit diminishes w/ time)

Page 102: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

CONSENSUS I

Class IV Mortality at one year 52% vs 36% NNT 6 !!! Average dose 18.4 mg /day

Page 103: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

SOLVD-Treatment

Class II & III Mortality at 4 years 39.7 % vs 35.2 % NNT 22 Mean daily dose of enalapril= 16.6

mg

Page 104: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Penelope :

Increase Zestril to 10 mg daily

Page 105: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Because :

Ace Inhibitors Save Lives

Page 106: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Penelope : Episode 2

One month later…

Develops an intractable cough

Your questions?

Your recommendation?

Page 107: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work
Page 108: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Vasoconstriction

Angiotensin I

Angiotensin II

Aldosterone

Angiotensinogen

Renin

Na+

K+

Kinins

Breakdown

Chymase

Aldosterone Vasoconstriction

K+ Retained

Page 109: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Aldosterone

Vasoconstriction

AT1 AT1

Angiotensin IIAngiotensin II

AT2

AT3

AT4

Feedback Fetal effects Many others

Page 110: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

ARBs

Similar to ACE inhibitors but also many differences

Highly variable half lives Highly variable AT1 receptor

affinity

Page 111: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

RESOLVD

Candesartan vs. candesartan +enalapril vs. enalapril alone

Class II – IV Terminated early due to

candesartan groups doing worse. Difficult to interpret due to

unusually low mortality and morbidity in enalapril group

Page 112: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

RESOLVD

Because the study wasn’t powered to show mortality, the authors conclusion didn’t mention higher mortality in the candesartan groups!

“Candesartan was as effective, safe, and tolerable as enalapril”

“The Combination… was more beneficial for preventing left ventricular remodeling”

Page 113: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Elite II Losartan 50mg / d vs. placebo Class III & IV Mortality: No difference

Page 114: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

ValHeft

Valsartan Class II-IV Some benefit added to ACE OR

to a Beta Blocker INCREASED MORTALITY When added to both !!

Page 115: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

CHARM (as in snake?)

Alternative – In ACE intolerant

patients – Improved outcomes

moderately Added

– Improved outcomes minimally

– Beta blocker would be better (opinion)

Preserved– No statistical

improvement Overall

– Statistical improvement

Page 116: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Penelope

Cozaar 50mg daily Continue Lasix etc.

Page 117: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Penelope: Episode 3

Four months later…

There has been trouble getting weights in the nursing home

Another episode of SOB, 02 saturation 85% Weight 178 pounds BUN / Cr: 40 / 1.4

Page 118: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Penelope

Treatment now?

Right Again! Vitamin L

Treatment: Lasix 80 mg BID

What will that do to the BUN / Cr?

Page 119: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Penelope:

Two weeks later…

Wt. 175 pounds Breathing improved but not good No CXR or ausculation BUN / Cr 50 / 1.5 What do you recommend ?

Page 120: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

My Momma Always Said:

Patience is a Virtue

Page 121: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Penelope

Weight decreases to 158 over the next 2 months.

Breathing greatly improved in the last month.

BP: 110 / 70 Guesses on the BUN and Creat?? 90 / 2.0

Page 122: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Penelope: Episode 5

What next??

Decline in mental status. Sleeping 18 to 20 hours per day. Confused, wild delusions.

What do you do now?

Page 123: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work
Page 124: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

The Hemodynamic Duo!!

Page 125: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Nitrates / Hydralazine: Mechanisms

Hemodynamic effects similar to Ace

Inhibitors

Nitrates decrease Preload

Hydralazine decreases afterload

Page 126: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Nitrates / Hydralazine PERHAPS a little:

– less mortality benefit

– more symptom benefit

Less renal impairment risk

Page 127: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Nitrates / Hydralazine: Efficacy

Similar to Ace Inhibitors Better in African Americans?

Page 128: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Nitrates / Hydralazine: Adverse Effects

P.O.S. (Pill overload syndrome)

Headache

Nausea

Hypotension

Page 129: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Nitrates / Hydralazine:

BIDIL®

Page 130: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Could we use digoxin?

Digimon

Page 131: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Digoxin: Mechanisms

Increased force of contraction

Decreased hospitalizations

No mortality benefit or harm

Page 132: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Digoxin: Efficacy

Urine Output

Mental Status

Exercise capacity improved

Page 133: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Digoxin: Adverse Effects

Potassium

Mental Status

Pulse / EKG

Nausea / Vomiting

Page 134: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Digoxin: Evidence

The Dig Trial

No difference in mortality 67.1% vs 64.3%

hospitalization 1% vs 2 % hospitalized for

suspected dig toxicity

Page 135: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Digoxin Pharmacology? Clinical Effect?

Page 136: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Meanwhile, Penelope is still on the Railroad Tracks

Increase Cozaar BUN goes to 120 (oops) Decrease Cozaar Add Hydralazine and Nitrates Titrate up to 50 mg TID and

20 mg TID

Page 137: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Penelope

Result?

Somnolence improves Delusions resolve BUN / Cr 80 / 1.8 Weight 158 BP: 100/60 Add a beta blocker?

Page 138: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Sir Blocksalot

Page 139: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

0

10

20

30

40

50

60

70

80

Mean + SD.Adapted from Bristow M. J Am Coll Cardiol. 1993;22(4 Suppl A):61A–71A.

Normal function (n=12) Cardiomyopathy (n=54)

1

2

1*P<.05 vs normal function

Rec

epto

r d

ensi

ty (

fmo

l/mg

p

rote

in)

1: 2 80%:20% 1: 2 65%:35%

Adrenergic Receptors in Normal vs Failing Left Ventricles

*

Page 140: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Beta Blockers

Improve Cardiac Function ??

Decreased Mortality

Don’t Use Unless CHF is stable

Beta Blockers Block

Death

Page 141: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Beta Blockers: MERIT-HF

Metoprolol XL Mostly Class II & III Mortality over one year

– 11% vs. 7.2% NNT 26 Dosing

Page 142: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Beta Blockers:Carvedilol Trial

Mostly Class II & III Mortality over 6 months

– 3.2% vs. 7.8% NNT 21 hospitalization 14% vs 19% NNT 20 2% died or deteriorated during run in

Page 143: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Which beta blockers are proven in CHF?

Page 144: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Penelope

She does well for 3 months

Penelope died July 9, 1998

Page 145: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Penelope

What do we know now that we didn’t know then?

Page 146: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Spiro the Super Mouse

Page 147: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

CHF: Vicious Cycle

Kidney Perfusion

ReninAngiotensinAldosteroneAldosterone

PreloadPreload and and Pulmonary EdemaPulmonary Edema

Cardiac Output

Na+Na+ andand H2OH2O

retentionretention

StrainStrain

AldosteroneAldosterone

Page 148: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Sodium Retention Magnesium and Potassium Loss Sympathetic Activation Parasympathetic Inhibition Myocardial fibrosis Vascular Fibrosis Impairs arterial compliance

AldosteroAldosteronene

Page 149: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

RALES

Spironolactone 25 mg / d vs. Placebo

Class III & IV Mortality at 11 months (stopped early) 46% vs 35 % NNT: 9

Page 150: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Newbies

Tezosentan endothelin receptor antagonist Who knows

Levosimendan Calcium sensitizer on troponin C may increase force of contraction without increasing myocardial oxygen consumption.

Page 151: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Nesiritide - Origin

Stretch receptors in the Atria (ANP) and the Ventricles (BNP)

Cause natriuresis and vasodilation Makes perfect sense Easy to Market Benefit??

Page 152: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Nesiritide This is also known as BNP and

causes diuresis and vasodilation. Studies show it superior to placebo

and equal to conventional therapy. If you don’t count mortality It costs about $1 million per dose,

may be useful in highly specific cases

Page 153: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Nesiritide – On the Other Hand

BNP is a good test in diagnosing CHF <100 mcg/ml NOT CHF 101 to 999 NOT normal, but

probably not CHF 1000 to 4000 CHF or related

condition >4000 almost certainly

CHF

Page 154: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Seven Roles for Rx Man

Sell them a scale Poke at their ankles Ensure labs (K+) Teach them to take their pulse NSAIDS Salt Police Cough Syrup patrol

Page 155: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Clinical Signs and Sx of CHF

Fluid Overload Shortness of Breath DOE Orthopnea / PND Pedal Edema CXR

Page 156: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Clinical Signs and Sx of CHF

Inadequate Perfusion Decreased Urine Output Increased BUN/Cr ratio Impaired Mental Status Cool, Clammy Skin Fatigue

Page 157: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Recap: AHA/ACC Heart Failure GuidelinesJ Heart Lung Transplant Feb, 2005

Class I Recommendations– Diuretics for patients with fluid retention (A)– ACEI for all patients unless contraindicated

(A)– Beta-blockers for all stable patients unless

contraindicated (A)– Digitalis for treatment of symptoms (A)– Withdrawal of drugs that may adverse the

status of heart failure patients (NSAIDs, most antiarrhythmics, most calcium channel blockers) (B)

Page 158: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Recap: AHA/ACC Heart Failure GuidelinesJ Heart Lung Transplant Feb, 2005

Class I Recommendations (cont’d)• Exercise training• Implantable defibrillator if history of

arrest, V Fib or bad V. Tach• Resynchronization therapy where

indicated

Page 159: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Recap: AHA/ACC Heart Failure GuidelinesJ Heart Lung Transplant Feb, 2005

Class IIa Recommendations (conflicting evidence/opinion but evidence favors)– Spironolactone for recent Class IV symptoms (B)– ARBs for patients not tolerating ACEI due to cough or

angioedema (A)– Combination of hydralazine + nitrate in patients not an

ACEI candidate due to hypotension/renal insufficiency (B)• Digitalis for treatment of symptoms (A)• Use of a CCB with negative inotropic effect may be harmful low

ejection fraction (A)

Class IIb Recommendations (conflicting evidence/opinion with less evidence to support)– Addition of an ARB to an ACEI (B)– Addition of nitrate +/- hydralazine to patients on ACEI (B)

Page 160: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Recap: AHA/ACC Heart Failure GuidelinesJ Heart Lung Transplant Feb, 2002

Class III Recommendations (no data or harmful)– Intermittent IV positive inotropes (C)– ARB instead of an ACEI in patients never tried

on or could tolerate an ACEI (B)– Use of an ARB before beta-blocker in a patient

on an ACEI– Use of a CCB to treat CHF (B)– Routine use of nutritional supplements

(CoQ10, etc.) or hormones (thyroid, growth) (C)

Page 161: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Case #1

KK is a 71 year old male with known history of CHF admitted for hypotension and shortness of breath

Page 162: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Case #1 Albuterol Ipratropium Phenytoin Neurontin Levothyroxine Protonix Lasix 20mg /day Amiodarone Verapamil 240mg/day

Page 163: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Labs BNP 995 Troponin <0.3 x 3 LDL <100 Na 137 K 4.1 Cl 101 TCO2 29 BUN 33 Creat 1.3

Page 164: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Weight on admission= 84 kg BP 102/63 Heart Rate 58 TSH 2.2

Page 165: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

#1 Monitoring Parameter? 84 Kg on admission Day 1: 83.5 Day 2: 83.3 Day 3: 83.1

Page 166: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work

Case #1

Page 167: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work
Page 168: Artwork by Aaron Jameson Cast of Characters n Importance n Evaluate a Case n Explain the Pathophysiology n Develop the Armamentarium –Why they work