Geriatrics Resident Rounds

January 9 2012

Jonah Mizzau
PGY-2 Internal Medicine

You are asked to see an 80F in the ER with worsening SOB.

She has a h/o heart problems and is an ex-smoker. When
you examine her she has signs of decompensated heart
failure but a significant wheeze.
You remember hearing the term cardiac asthma and wonder
if it applies to this patient and if so what does that mean for
her treatment and prognosis

Review basics of cardiac asthma (definition,

pathophysiology)
Review characteristics of cardiac asthma in geriatric
population
Review specific treatment options in this setting

1st described in 1832 by James Hope

Multiple definitions, usually asthma-type sx w/out 1 lung
Commonly defined now as wheezing, coughing and
orthopnea due to CHF

Tanabe, T. et al. Cardiac Asthma: New insights into an old disease. Expert Review of Respiratory Medicine. 6.6:705 (2012)

Mechanisms:
1. Bronchial vasc circulation changes
2. Pulmonary edema, blood vol in lungs
3. Airway remodelling
4. Bronchial hyper-responsiveness

Tanabe, T. et al. Cardiac Asthma: New insights into an old disease. Expert Review of Respiratory Medicine. 6.6:705 (2012)

Leading cause of acute SOB in elderly

Approx 10% of pop > 80 have dx HF
Significant in-hospital mortality (13-29%)

Rich M. Heart Failure in the 21st Century: a Cardiogeriatric syndrome. Journal of Gerontology 56A: 88-96 (2001)

Single centre, prospective study to look at incidence, pt

characteristics, tx outcomes
Included:
pts > 65
Acute SOB
CHF (TTE or BNP)
Excluded:
Asthma exacerbation
Jorge, S., et al. Cardiac asthma in elderly patients: incidence, clinical presentation and outcomes. BMC Cardiovascular Disorders 7:16
(2007)

Divided into:
Cardiac asthma (wheeze detected in ED)
Classical CHF (no wheeze)
514 initially included, 212 proven to have HF (by TTE or BNP)
Outcomes were survival (in-hosp, 1 yr) and re-admission

Jorge, S., et al. Cardiac asthma in elderly patients: incidence, clinical presentation and outcomes. BMC Cardiovascular Disorders 7:16
(2007)

Jorge, S., et al. Cardiac asthma in elderly patients: incidence, clinical presentation and outcomes. BMC Cardiovascular Disorders 7:16
(2007)

Jorge, S., et al. Cardiac asthma in elderly patients: incidence, clinical presentation and outcomes. BMC Cardiovascular Disorders 7:16
(2007)

Results:
35% (75) fit cardiac asthma
65% (137) fit classical CHF
BNP/NT-pro-BNP lvls similar
PFTs similar (restrictive) but w distal airway obstruction in
cardiac asthma pts
tobacco use, pH, pCO2 as well

Jorge, S., et al. Cardiac asthma in elderly patients: incidence, clinical presentation and outcomes. BMC Cardiovascular Disorders 7:16
(2007)

Jorge, S., et al. Cardiac asthma in elderly patients: incidence, clinical presentation and outcomes. BMC Cardiovascular Disorders 7:16
(2007)

Concluded:
Higher incidence than previously reported (35%)
Same outcomes btw both groups (despite differences in
presentation)

Jorge, S., et al. Cardiac asthma in elderly patients: incidence, clinical presentation and outcomes. BMC Cardiovascular Disorders 7:16
(2007)

Maybe our lady does fit into this cardiac asthma group, after
all its not uncommon
and her outcomes can be expected to be similar to that of
our classic decompensated HF pts.
how do we treat her?

Best evidence supports conventional therapy for LV systolic

dysfn (provided her HF is systolic):
ACEi/ARB
BB (safe for COPD, maybe even survival benefit)
Spironolactone
Digoxin
Acutely loop diuretic + nitrate

40 pts in Greece w orthopnea, LV sys dysfn (TTE), pulm

edema (CXR)
Measured resp fn sitting to supine, w or w/out SL nitrates
Improved fn while supine w nitrates

Spyratos, D. et al. Assessment of respiratory mechanics by impulse oscillometry in orthopneic patients with acute left ventricular
failure. Heart & Lung 40:97-104 (2011)

-agonists:
may fluid resorption and pulm edema (ex-vivo study,
post-lung resection study)
Meta-analysis 2011 - no reason to withhold (ischemia,
arrhythmia) as acute tx for ?HF but no demonstrated benefit
(physiologically may make sense)

Maak, C., Tabas, J. and McClintock, D. Should acute treatment with inhaled beta agonists be withheld from patients with
dyspnea who may have heart failure? Journal of Emergency Medicine 40:2: 135-145 (2011)

Anti-cholinergics:
Small study in Am J of Cardio, showed statistically sig
difference in PFTs in NYHA 2/3 HF pts txed w ipratropium
Not routinely recommended

Kindman, L. et al. Abnormalities of pulmonary function in patients with congestive heart failure, and reversal with ipratropium
bromide. American Journal of Cardiology 73:258-262 (1994)

Cardiac asthma common presentation of CHF in elderly pts

Challenging diagnosis remember Not all that wheezes is
(bronchial) asthma
Best tx is chronic HF tx

Hunt, S. et al. 2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart
Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice
Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 119(14), 391-479
(2009)
Jorge, S., et al. Cardiac asthma in elderly patients: incidence, clinical presentation and outcomes. BMC Cardiovascular Disorders 7:16
(2007)
Kindman, L. et al. Abnormalities of pulmonary function in patients with congestive heart failure, and reversal with ipratropium bromide.
American Journal of Cardiology 73:258-262 (1994)
Lien C. et al. Heart failure in frail elderly patients: diagnostic difficulties, co-morbidities, polypharmacy and treatment dilemmas.
European Journal of Heart Failure 4:91-98 (2002)
Maak, C., Tabas, J. and McClintock, D. Should acute treatment with inhaled beta agonists be withheld from patients with dyspnea who
may have heart failure? Journal of Emergency Medicine 40:2: 135-145 (2011)
Manzano, L. et al. Diagnosis of elderly patients with heart failure. European Journal of Heart Failure. 14: 1097-1103 (2012)
Rich M. Heart Failure in the 21st Century: a Cardiogeriatric syndrome. Journal of Gerontology 56A: 88-96 (2001)
Spyratos, D. et al. Assessment of respiratory mechanics by impulse oscillometry in orthopneic patients with acute left ventricular failure.
Heart & Lung 40:97-104 (2011)
Tanabe, T. et al. Cardiac Asthma: New insights into an old disease. Expert Review of Respiratory Medicine. 6.6:705 (2012)