MOFFITT CARDIOLOGY REPORT PEARLS 4/4/17: Ascites and Baroreflex Activation Therapy!

Hey everyone! Thanks to Muazzum for presenting an interesting mystery case of a middle-aged man with heart failure who developed volume overload but had a low SAAG ascites with a PMN-predominant WBC count of 800! Pearls below on ascites and baroreflex activation therapy (!):

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Top Pearls:

  1. Ascites etiologies can be broken down into high and low SAAG, but also high and low protein (see 2×2 table below).
  2. The differential for ascites PMN count >250 is broader than just SBP!
  3. Baroreflex stimulation devices improve outcomes in HFrEF and resistant hypertension.

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For those who want more info:

Some core topics first, followed by some newfangled craziness… 🙂

Thanks to Jess Beaman for the table below reviewing the general pattern of SAAG and total protein with various causes of ascites:

Total ascites protein

< 2.5 g/dL

Total ascites protein

> 2.5 g/dL

SAAG ≥ 1.1 g/dL Portal hypertension due to cirrhosis Portal hypertension due to hepatic venous outflow obstruction (including right heart failure)
SAAG < 1.1 g/dL Nephrotic syndrome Malignancy, tuberculosis

https://ucsfmed.wordpress.com/2016/01/06/1-6-16-va-ambulatory-report-pearls-ascites-constrictive-pericarditis/

 

Diagnostic criteria for SBP are met if ascites PMN count >250, but Harry reminded us that the differential for PMN >250 is broader than just SBP and also includes:

  • Secondary bacterial peritonitis (perforation)
  • Bloody fluid (trauma or hemorrhage), need to correct 1 PMN per 250 RBCs
  • Foreign body
  • TB (usually mononuclear)
  • Malignancy (usually mononuclear)
  • Serositis (autoimmune/drug-induced, usually mononuclear)

 

Now, onto…baroreflex stimulation devices?!?

Implantable devices that provide electrical stimulation to the carotid baroreceptors, also called “baroreflex activation therapy” (BAT). As Muazzum and Anne Thorson taught us, these devices reduce HR, BP, and afterload, which is beneficial for hypertension and heart failure.

Baroreflex activation therapy has been shown to be safe and effective in improving functional status, quality of life, exercise capacity, and HF hospitalizations in patients with NYHA III HFrEF.

Abraham et al JACC Heart Fail 2015

Zile et al Eur J Heart Fail 2015

It is also safe and effective in reducing blood pressure in patients with resistant chronic hypertension.

De Leeuw et al Hypertension 2017

The device is implanted subcutaneously in the upper chest wall, and carotid sinus leads are placed in contact with the baroreceptors. An external programmer is used to turn the system on/off and regulate the signal level.

X-ray with an implanted BAT device:

Barostim CXR

ECG demonstrating artifact seen with the device’s activity:

ECG

Crazy!! Thanks Muazzum and Anne for introducing us to a brave new world of cardiac devices. 🙂

 

Evernote: https://www.evernote.com/shard/s272/sh/6ef83563-865f-4bf3-80b3-7b5702070ef9/ba2d4f31083b59ae85f9b049f6f1349e

Have a great day everyone!

SamMy

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