![Page 1: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/1.jpg)
A History of Dropsy
Timothy A. Denton, M.D.Attending Cardiologist
High Desert Heart InstituteVictorville, CA
![Page 2: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/2.jpg)
![Page 3: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/3.jpg)
The Time Line
500 20000 500 1000 1500
Socrates (470-399 BC)Hippocrates (460-377 BC)
BC AD
Galen (180)
Harvey (1616)
Laënnec(1700)
dropsy
![Page 4: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/4.jpg)
CHF~400 B.C. – SOB, edema, ralesFirst described by Hippocrates
Ear directly on chestHow 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 – Laënnec’s stethoscope
![Page 5: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/5.jpg)
CHF - Dropsy
A morbid condition characterized by the accumulationof watery fluid in the serous cavitiesor the connective tissue of the body.
Hydrops, Idropsie
First use in 1290 – “Some fullen in-to be dropesie”
OED
![Page 6: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/6.jpg)
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
![Page 7: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/7.jpg)
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
![Page 8: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/8.jpg)
CHF - DropsyDilatation and feebleness of the heart…
The heart’s action permanently irregular, with an extended, but not a strong impulse; the sounds so rapid and equal that their analysis is difficult…It 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
![Page 9: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/9.jpg)
CHF - DropsyTreatment 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 subject…it is impossible to speak too highly of the efficacy of this treatment…
Stokes“Diseases of the Heart and the Aorta”
1853
![Page 10: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/10.jpg)
CHF - DropsyTreatment 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 aliment…
Stokes“Diseases of the Heart and the Aorta”
1853
![Page 11: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/11.jpg)
William Harvey
1578-16571639: De Motu Cordis
![Page 12: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/12.jpg)
“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.”
Groucho on the Circulation
from “Horse Feathers”(Julius Henry Marx)
![Page 13: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/13.jpg)
William Withering
Born: 1741 - 17991775: Obtained first “tea” from gypsy
![Page 14: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/14.jpg)
Foxglove
From German: Fingerhut (finger hat or thimble)Mid-1500’s: Latinized to “digitalis” – finger (digitus)Digitalis purpurea – a common variety1775 – William Withering
![Page 15: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/15.jpg)
CHFIt’s a hemodynamic disease !
Preload
Afterload
Contractility
![Page 16: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/16.jpg)
Preload
• William Stokes (1804-1878) uses Mercuryto treat CHF
• Southey’s tubes• 1919 - Organomercurial diuretics• Rotating tourniquets• 1958 – thiazide diuretics• Oral nitrates improve hemodynamics
AHJ 1975;90:346
![Page 17: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/17.jpg)
CHF
Used into the late 1950’s
Southey’s Tubes
![Page 18: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/18.jpg)
CHFIt’s a hemodynamic disease !
Preload
Afterload
Contractility
![Page 19: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/19.jpg)
Contractility
• Digoxin• Epinephrine• Dopamine• Dobutamine
![Page 20: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/20.jpg)
CHFIt’s a hemodynamic disease !
Preload
Afterload
Contractility
![Page 21: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/21.jpg)
Afterload• Lowered afterload improves hemodynamics in MR
(Ann Int Med 1975;83:312)• Vasodilator therapy in heart failure
(Ann Int Med 1975;83:421)• Hydralazine / Minoxidil in refractory CHF
(Ann Int Med 1976;85:467)• Lowered afterload improves hemodynamics in AI
(Circulation 1976;53:879)• Lowered afterload improves hemodynamics in CHF
(Ann Rev Physiology 1977;39:277• 1987 - CONSENSUS I
![Page 22: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/22.jpg)
CHF
It’s a neurohormonal disease !
• 1963 – Plasma norepinephrine elevated in CHF(NEJM 1963;269:653)
• 1970’s digoxin reduces plasma renin and norepinephrine levels
![Page 23: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/23.jpg)
CHF
• It’s a hemodynamic diseasePreloadContractilityAfterload
• It’s a neurohormonal disease
![Page 24: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/24.jpg)
CHFSystolic vs Diastolic Failure
Kitzman,et al., Am J Cardiol, 2001;87:413-419
45%
55%Diastolic
Systolic
*No valvular or mechanical causes
![Page 25: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/25.jpg)
CHF
Systole = contraction (inotropy)
Diastole = relaxation (lusitropy)
![Page 26: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/26.jpg)
CHF
What is diastolic dysfunction?
![Page 27: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/27.jpg)
CHF
Dilated Normal Hypertrophic
![Page 28: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/28.jpg)
CHF
Normal Heart Enlarged Heart
![Page 29: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/29.jpg)
CHF
Diagnosis
• ClinicalSOB, DOE, CoughOrthopneaEdema
• CxR• BNP• Echo (or equivalent)
![Page 30: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/30.jpg)
CHF
Diagnosis
What is the EF?
Low NormalHigh
![Page 31: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/31.jpg)
CHF
Is there ischemia?
Yes No
Diagnosis
PTCACABGEECP
![Page 32: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/32.jpg)
CHF (systolic dysfunction)
• Preload• Contractility• Afterload• Neurohormonal• Dysrhythmia• Dysynchrony
![Page 33: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/33.jpg)
Emergency Rx CHF
PreloadLasix
Nesiritide
ContractilityInotropes
Digoxin
Afterload Nipride
Neurohormonal N/A
Dysrhythmia Antiarrhythmics
Dysynchrony N/A
![Page 34: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/34.jpg)
Chronic Rx CHF
Preload
+ Lasix
+ Ultrafiltration
+ Nitrates
ContractilityDigoxin
Transplant evaluation / LVAD
AfterloadACE / ARB
Hydralazine
Neurohormonal
Beta blocker
ACE / ARB
Spironolactone / eplerinone
DysrhythmiaICD
+ Antiarrhythmics
Dysynchrony BiV Pacing
![Page 35: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/35.jpg)
Preload
IV diuretics Lasix (20,40,80,160,320) Lasix drip Combination (Lasix / zaroxolyn)Naturetic peptic (nesiritide)Dialysis / UltrafiltrationNitrates
![Page 36: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/36.jpg)
Dialysis / Ultrafiltration
![Page 37: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/37.jpg)
Ultrafiltration
CHF Solutions, Inc.
![Page 38: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/38.jpg)
Contractility
• Dobutamine• Milrinone• Epinephrine• Dopamine• LVAD• Heart transplantation
![Page 39: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/39.jpg)
Ambulatory Infusion Pumps
• Dobutamine• Milrinone
![Page 40: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/40.jpg)
Afterload
• ACE inhibitors• ARB’s• Hydralazine
![Page 41: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/41.jpg)
Neurohormonal
• Beta blocker• Spironolactone / eplerenone• ACE inhibitors• ARB’s
![Page 42: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/42.jpg)
Is there a BEST Beta Blocker?
17% Reduction
![Page 43: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/43.jpg)
Dysrhythmia
• ICD• Antiarrhythmics• Beta blockers
![Page 44: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/44.jpg)
Dysynchrony
• Bi-V pacing
![Page 45: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/45.jpg)
Therapy of CHF
0 10 20 30 40 50 60 70 80 90 100
Ejection Fraction
Normal
Systolic Dysfunction Diastolic Dysfunction
![Page 46: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/46.jpg)
Therapy of CHF
0 10 20 30 40 50 60 70 80 90 100
Ejection Fraction
NormalRange
Systolic Dysfunction Diastolic Dysfunction
• ICD• BiV pacer• Heart transplant
• Aggressive MedRx
![Page 47: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/47.jpg)
Therapy of CHF
0 10 20 30 40 50 60 70 80 90 100
Ejection Fraction
NYHA
CLASS
I
II
III
IV
ACE, Beta, ARB, dig +ACE, Beta, +ARB
ICD, BiV
Transplant
![Page 48: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/48.jpg)
End
![Page 49: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/49.jpg)
CHF
Diagnosis
![Page 50: A History of Dropsy Timothy A. Denton, M.D. Attending Cardiologist High Desert Heart Institute Victorville, CA](https://reader030.vdocuments.us/reader030/viewer/2022032707/56649e0d5503460f94af721e/html5/thumbnails/50.jpg)
CHF
Diagnosis
• Clinical• CxR• BNP• Echo