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Asthma of Cardiac Origin in a 66-Year Old Male LAPORAN KASUS Asthma of Cardiac Origin in a 66-Year Old Male Kevin Wibawa Research Associates, Siloam Heart Insititute, Jakarta, Indonesia Abstract Heart failure is a disease with high morbidity and mortality. Wheezing, suggesting cardiac asthma, is one of the signs of heart failure. Treatment of cardiac asthma is different from bronchial asthma. An accurate history and physical examination may lead to appropriate diagnosis and treatment. Keywords: Acute heart failure, cardiac asthma, wheezing Abstract Gagal jantung adalah penyakit dengan morbiditas dan mortalitas tinggi. Mengi, yang menandakan asma kardial, adalah salah satu tanda gagal jantung. Tatalaksana asma kardial berbeda dari asma bronkial. Anamnesis dan pemeriksaan fisik yang tepat, didukung pemeriksaan penunjang, dapat membimbing klinisi untuk diagnosis dan tatalaksana yang tepat. Kevin Wibawa. Asma Kardial pada Laki-laki Usia 66 tahun Keywords: Asma kardial, gagal jantung akut, mengi Introduction associated comorbidity.2,4 (LVEDP); this increased left ventricle pressure Asthma is one of the most prevalent diseases is transmitted into the left atrium (LA), and LA found in the world; it is estimated that Pathophysiology of Cardiac Asthma undergoes a structural change to compensate around 20 million individuals in the world Impaired left ventricular (LV) function in the increasing pressure.9 have asthma.1 Asthma is usually treated by a heart failure results in symptoms and signs general physician in primary care. However, of HF. Elevated LV diastolic pressure increases In response to the increasing pressure in LA, asthma signs do not always come from the the pressure in the pulmonary veins.4 As the pulmonary vein (PV) compensate by respiratory tract.2 a consequence, the bronchial veins and increasing its pressure to prevent pulmonary pulmonary tissues are congested. The edema. However, as the pressure in the Cardiac asthma is a condition marked by congested bronchial veins increase airway left ventricle and LA continues to increase, wheezing, coughing, and orthopnea due thickness that results in wheezing.2,7,8 the change in PV cannot prevent the to congestive heart failure.2 This term was pulmonary edema.4 The capillary pressure first introduced by James Hope in 1832.2 The human body has several compensatory begins to rise, followed by fluid transudation Based on National Health Interview Survey, mechanisms toward HF. At the initial and accumulation, causing pulmonary National Center for Health Statistics, CDC, the stages, the Frank-Starling mechanism, congestion.8 The increasing PV pressure can prevalence of cardiac asthma in individuals neurohormonal change, and ventricular be transmitted to bronchial veins. Bronchial more than 65 years old is 7.5%.2 remodelling serve as an adaptive mechanism veins become congested and reduce the toward decreasing cardiac output (CO). bronchial diameter. Both the pulmonary and Wheezing is one of the signs of heart failure However, the compensatory mechanism bronchial veins congestion contribute to the (HF).3 Cardiac asthma with wheezing is one transforms into a maladaptive mechanism as development of wheezing.2,9 sign that may alert the physician to the HF progress.7,8 LV remodelling is a response possibility of HF.4 Since the pathophysiology toward increasing preload. The remodelling Treatment is different, it is important to distinguish process serves as a response to reduce wall The treatment of cardiac asthma is aimed between bronchial and cardiac asthma. tension and to preserve contraction. As heart to improve cardiac contractility and to Generally, the conventional treatment for HF failure worsen, the hypertrophic ventricle alleviate symptoms.2,4 Bronchodilator use can be used to treat cardiac asthma; loop pumps lower stroke volume.7,8 Residual blood for cardiac asthma has small evidence and is diuretic, beta blocker, and nitrate can be in the left ventricle increases end systolic usually used to determine the coexistence given to alleviate symptoms.3 Patient must volume (ESV), end diastolic volume (EDP), of bronchial asthma and heart disease.2 be encouraged to routinely check for HF and and left ventricular end diastolic pressure Treatment modalities for cardiac asthma Alamat Korespondensi email: [email protected] 336 CDK-295/ vol. 48 no. 6 th. 2021 CDK-295/ vol. 48 no. 6 th. 2021 337 LAPORAN KASUS involve the treatment for acute heart failure act primarily in veins, while ACE Inhibitors must be lowered or stopped temporarily in (AHF), such as diuretics, nitrates, inotropic and ARBs act in both veins and arteries.7 patients with cardiogenic shock and/or severe agents, angiotensin converting enzyme (ACE) Nitrates in oral forms, such as nitroglycerine decompensation because BBs may worsen inhibitors, and angiotensin receptor blockers and isosorbide dinitrate, can be given the haemodynamic.11 Another study from (ARB).2,3,9 initially. Nitrates have a rapid onset of action. Jondeau G, et al, showed a continuation of Intravenous nitroglycerine (starting at 10- BBs in ADHF patients did not delay or reduce Diuretics can be given as an initial treatment to 20 µg/min, up to 200 µg/min) or isosorbide the clinical improvement. Therefore, there is a reduce fluid congestion. The most common is dinitrate (starting at 1 mg/h, up to 10 mg/h) possibility to continue BBs treatment in some furosemide, a loop diuretic. Furosemide acts in can be given according to clinical response AHF patients.12 dense ascending loop of Henle. Furosemide is and judgement.3 a powerful diuretic since it can excrete 20-25% Case sodium. Intravenous preparation is preferred Beta-blockers (BBs) are not usually used for A 66-year-old male was admitted to the for rapid onset of action in congested the treatment of AHF. The negative inotropic emergency room (ER) with worsening patients.7,10 For naïve-furosemide patients, an effect of BBs is contraindicated to patients shortness of breath since yesterday. The initial doses of 20-40 mg IV boluses can be with systolic dysfunction.3,7 However, as patient had experienced shortness of breath given. Patients with a history of diuretic use maintenance therapy, many RCTs showed BBs for 14 days; the symptom worsened and may need a higher dose. If the congestion reduce mortality and morbidity in patients became troublesome for 1 day. The shortness persists, doses of 5-40 mg/h IV infusion may with HFrEF. But, the benefit of BBs in AHF of breath was felt during mild physical activity be given.3,10 is still uncertain. Some AHF patients have and resolved during rest. He had experienced BBs as a routine medical treatment; in this the same symptom when heart disease was Vasodilators such as nitrates, ACE Inhibitors, subset of patients, it is still uncertain whether first diagnosed by a cardiologist. However, and ARBS can be given to reduce the preload to stop or to continue the BBs treatment.3 the patient did not remember the type of and/or afterload. Vasodilators such as nitrates A study from Meuwese et al showed BBs heart disease. The patient also complained of frequent urination at night during the last 6 Table 1. The New York Heart Association (NYHA) classification 1 month. Class Symptoms I HF does not cause limitations to physical activity; ordinary physical activity does not cause symptoms The patient had a history of hypertension, II HF cause slight limitations to physical activity; the patients are comfortable at rest, but ordinary physical diabetes mellitus, and heart disease. He activity results in HF symptoms denied any history of bronchial asthma. The III HF cause marked limitations to physical activity; the patients are comfortable at rest, but less than ordinary physical activity results in HF symptoms patient stopped smoking 20 years ago. He IV HF patients are unable to carry on any physical activity without HF symptoms or have symptoms when at rest did not engage in routine physical activity. His routine medications are glimepiride 3 mg 3 Table 2. Symptoms of heart failure o.d, bisoprolol 5 mg o.d, isosorbide dinitrate Symptoms 5 mg b.i.d, digoxin 0.25 mg o.d, ivabradine Typical Atypical 5 mg b.i.d, and antacid 400 mg t.i.d. Patient Breathless Nocturnal cough compliance was poor even though he did Orthopnea Wheezing not experience any side effects. The routinely Paroxysmal nocturnal dyspnea Bloated feeling consumed drugs were isosorbide dinitrate Reduced exercise tolerance Loss of appetite Fatigue, tiredness, increased time to recover after exercise Confusion (especially in elderly) and glimepiride. Bisoprolol is consumed Ankle swelling Depression when he felt a headache. The rest of the medications was never consumed. His last visit Table 3. Signs of heart failure3 to a cardiologist was 4 months ago. COVID-19 Signs pandemic and insurance problem made him More specific Less specific reluctant to come to the hospital. Elevated jugilar venous pressure Weight gain (>2kg/week) Hepatojugular reflux Weight loss (in advanvance HF) Third heart sound (gallop rhythm) Tissue wasting (cachexia) At initial presentation, he was obese with body Laterally displaced apical impulse Cardiac murmur weight 78 kg, body height 169 cm, body mass Peripheral oedema (ankle, sacral, scrotal) index of 27.31 kg/m2, and appeared dyspneic. Pulmonary crepitations Reduced air entry and dullness to percussion at lung His vital signs were: fully awake, blood bases (pleural effusion) pressure 160/90 mmHg, heart rate 100 bpm, Tachycardia Irregular pulse respiratory rate 27 x/min; body temperature Tachypnoea 36.3 °C, and oxygen saturation 90% at room Cheyne Stokes respiration Hepatomegaly air. Other findings included slightly increased Ascites jugular vein pressure, normal cardiac sounds, Cold extremities no cardiac murmur, cardiomegaly, wheezing Oliguria Narrow pulse pressure all over the lung field, warm extremities, and 336 CDK-295/ vol. 48 no. 6 th. 2021 CDK-295/ vol. 48 no. 6 th. 2021 337 LAPORAN KASUS capillary refill time <2 seconds. ECG showed sinus rhythm and incomplete left bundle branch block.
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