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Professor Gary Francis, Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, USA presents this lecture.
Abstract: Congestive heart failure continues to be a major epidemic throughout the western world. Of note, many patients with heart failure have concomitant renal dysfunction. When patients with chronic heart failure are admitted to hospital with acute decompensation, about 30-40% are noted to have abnormal renal function. Some have referred to this as the “cardio-renal syndrome”. However, there is no commonly agreed upon definition. We know that once renal insufficiency occurs in the setting of heart failure, the prognosis is poor.
Data from the United States would suggest that about 25 to 30% of patients admitted to hospital with decompensated heart failure have severe renal insufficiency as manifested by a GFR between 15 and 30 cc/min. This problem occurs in both the setting of impaired systolic function as well as in patients with preserved systolic function. For years it has been assumed that many of the manifestations of the cardio-renal syndrome are related to inadequate flow to the kidney as a consequence of worsening heart failure. Although this is undoubtedly true, there are many pathways whereby the heart and the kidney interact to generate this common syndrome. Clearly, pump dysfunction is not the sole factor.
One can make a case that much of the cardio-renal syndrome is related to elevated venous pressure. Both animal experimentation and clinical observation would suggest that a rise in central venous pressure can be transmitted through the IVC to the renal veins, thus engorging the kidneys and creating heightened intra-renal pressure to the extent that tubular function is impaired. We have also noticed that intra-abdominal pressure, and not low cardiac output, is closely linked to diminishing renal function in patients admitted to the hospital with acute heart failure. Such patients do not necessarily have ascites. Relief of this pressure by paracentesis, ultrafiltration, or dialysis is usually, though not always, associated with improvement in renal function.
The management of the cardio-renal syndrome continues to be problematic, but a constellation of therapies are available including intravenous loop diuretics, intravenous vasodilators such as nitroprusside, aquaretics, adenosine-1 receptor antagonists, ultrafiltration, dialysis, and in some cases inotropic drugs. Each of these therapies will be considered separately with regard to their efficacy and safety in patients with this syndrome. The role of intravenous nesiritide will be discussed in detail. Mechanical means to reduce increased central pressure and venous congestion will also be considered. At this time one can create a rational strategy to manage these complex patients, but there is no single therapy that is uniformly effective. As with all complex disorders, a more refined understanding of the pathophysiology will essentially allow us a better entry toward improved therapy.
Biography: Gary S. Francis, M.D. is Head of Clinical Cardiology Section at the Cleveland Clinic and is Professor of Medicine at the Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, and has an appointment in the Kaufman Center for Heart Failure and the Transplant Center at the Clinic. He was educated at the University of Minnesota, Creighton University, and did advanced training in Chicago and San Diego. He is board certified in Internal Medicine and Cardiovascular Diseases.
Dr. Francis’s main interests are heart failure and acute coronary syndromes. He served as President of the Heart Failure Society of America 2004-2006 and has done extensive research in heart failure. He is a Fellow of the American College of Cardiology, American College of Physicians and the American Heart Association. Dr. Francis is a member of many professional societies and organizations including the Heart Failure Society of America, International Society of Heart and Lung Transplantation, the Central Society for Clinical Research, and the Council of Clinical Cardiology of the American Heart Association. Dr. Francis has current support from two NHLBI SCCOR Grants. He has served or serves on more than 20 editorial boards including Circulation, Journal of the American College of Cardiology, the American Heart Journal and the American Journal of Cardiology and served as an Executive Editor for the Journal of Cardiac Failure from 1994-2000. He is an expert reviewer for more than 30 different journals. Prior to his appointment at the Cleveland Clinic, Dr. Francis was Professor of Medicine at the University of Minnesota and Research Director of the Rasmussen Center for Heart Failure.
Dr. Francis has had a leadership role in many clinical trials at the national and international level, and has served on the Data and Safety Monitoring Boards of 20 large international trials. He has authored or co-authored more than 500 orginal manuscripts, review papers, editorials, and book chapters and has edited or co-edited 17 books. He was co-author of the 1995, 2001 and 2005 and 2008 ACC/AHA guidelines on the treatment of heart failure. He is also a co-author of the 2004 AACL Guidelines on Biomarkers in Heart Disease and the 2007 NACBLM Guidelines on troponin and natriuretic peptides. He has more than 5000 citations by Scopus.
Dr. Francis is repeatedly listed in the “Best Doctors in America” and was named by Good Housekeeping as one of the “Best Heart Doctors in America” in 1996. He was awarded the Mentor Award for teaching by the medical students at the University of Minnesota in 1989 and 1991, received a national “Master” award for teaching by the University of Miami in 1996 and 2002. He received the “Distinguished Teacher of the Year” at the Cleveland Clinic in 2000, and has served as visiting professor or lecturer at more than 90 universities world-wide, including a number of named lectureships. He gave the Laennec Lecture at the AHA meeting in 2006.
In the Chair: Professor Martin Cowie, Chair in Cardiology (Health Services Research), Imperial College London
Vote of Thanks: Professor Philip Poole-Wilson, British Heart Foundation Simon Marks Professor of Cardiology, Imperial College London
A tea/coffee reception will precede the lecture at 17.30 and a drinks reception will follow the lecture, both in the Refectory.
Attendance is free but with registration in advance with Emma Watson, e.watson@imperial.ac.uk.