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1、慢性心力衰竭最新指南解读,田野 教授哈尔滨医科大学附属二院心内科,第五届北方介入心脏病学暨心血管疾病诊疗新进展国际研讨会 2009.01.11 哈尔滨,ESC-51 COUNTRIES,Content,Definition and diagnosisDiagnostic techniquesNon-pharmacological managementPharmacological therapyDevices and surgeryCo-morbidities and special populations,Definition and diagnosis,“The very essence
2、of cardiovacular medicine is the recognition of early heart failure”,Sir Thomas Lewis,1933,Definition of HF,Importantly,it was emphasised that the diagnosis is not dependent on a certain ejection fraction(EF),although it has implications for prognosis.,Common clinical manifestations,Clinical manifes
3、tations,Classification of HF,Common causes of HF,Coronary heart disease Many manifestationsHypertension Often associated with left ventricular hypertrophy and ejection fractionCardiomyopathies Familial/genetic or non-familial/non-genetic(including acquired,e.g.myocarditis)Hypertrophic(HCM),dilated(D
4、CM),restrictive(RCM),arrhythmogenic right ventricular(ARVC),unclassifiedDrugs-Blockers,calcium antagonists,antiarrhythmics,cytotoxic agents Toxins Alcohol,medication,cocaine,trace elements(mercury,cobalt,arsenic)Endocrine Diabetes mellitus,hypo/hyperthyroidism,Cushing syndrome,adrenal insufficiency,
5、excessive growth hormone,phaeochromocytomaNutritional Deficiency of thiamine,selenium,carnitine.Obesity,cachexiaInfiltrative Sarcoidosis,amyloidosis,haemochromatosis,connective tissue diseaseOthers Chagas disease,HIV infection,peripartum cardiomyopathy,end-stage renal failure,Classification of HF,Ne
6、w onset First presentation Acute or slow onsetTransient Recurrent or episodicChronic Persistent Stable,worsening,or decompensated,Time is important for various types of heart failure.,Diagnostic techniques,Clinical examination,Diagnosis of HF with natriuretic peptides,As regards diagnostic tools,the
7、 importance of BNP/NT-proBNP was stressed,and it is now recommended not only for excluding heart failure,but also for confirmation of the diagnosis.,Diagnostic assessments supporting the presence of HF,(BNP)in Differentiating between Dyspnea,Alan S.Maisel,N Engl J Med 2002;347:161167.,BNP among Pati
8、ents in Each of the Four NYHA Classifications,Alan S.Maisel,N Engl J Med 2002;347:161167.,BNP,BNP400 pg/mL,NT-proBNP2000 pg/mIncreased ventricular wall stress HF likelyIndication for echoConsider treatmentBNP100 pg/mL,NT-proBNP400 pg/mL Normal wall stress Re-evaluate diagnosisHF unlikely if untreate
9、d,Maisel AS,et al.N Engl J Med 2002;347:161-167.,B-type natriuretic peptide(BNP),HF with preserved ejection fraction(HFPEF),HFPEF,“Most patients with HF have evidence of both systolic and diastolic dysfunction at rest or on exercise.Patients with diastolic HF have symptoms and/or signs of HF and a p
10、reserved left ventricular ejection fraction(LVEF)40-50%.HF with preserved ejection fraction(HFPEF)is present half the patients with HF.”,Epidemiologic studies,Solomon SD,Circulation 112:3738-3744,2005,Assessment of HFPEF,Presence of signs and/or symptoms of chronic HF.Presence of normal or only mild
11、ly abnormal LV systolic function(LVEF45-50%).Evidence of diastolic dysfunction(abnormal LV relaxation or diastolic stiffness).,Speckle-tracking echocardiography,A 62-year-old man with a normal heartEF=60%,A 78-year-old manDiastolic dysfunctionEF=55%,Process underlying HFPEF,Non-pharmacological manag
12、ement,A strong relationship between healthcare professionals and patients as well as sufficient social support from an active social network has been shown to improve adherence to treatment.It is recommended that family members be invited to participate in education programmes and decisions regardin
13、g treatment and care,Sabate E.Adherence to Long-term Therapies.Evidence for Action.Geneva:WHO;2003.,People involved in care,The Players,Pharmacological therapy,Prognosis:Reduce mortalityMorbidity:Improve quality of life Prevention:Reduce hospitalization,ACE inhibitors,Unless contraindicated or not t
14、olerated,an ACEI should be used in all patients with symptomatic HF and a LVEF 40%.Treatment with an ACEI improves ventricular function and patient well-being,reduces hospital admission for worsening HF,and increases survival.In hospitalized patients,treatment with an ACEI should be initiated before
15、 discharge.,Class of recommendation I,level of evidence A,CONSENSUS(1987)and SOLVD-Treatment(1991),Mortality Reductions with ACEI,0,5,10,15,20,25,30,Relative Risk Reduction(%),CONSENSUS,SOLVD,SAVE,AIRE,HOPE,n=253,n=4228,n=2231,n=1986,n=3577,CONSENSUS:NEJM 1987;316:1429-435,SOLVD:NEJM 1991;325:293-30
16、2,SAVE:NEJM 1992;327:669-677AIRE:Lancet 1993;342:821-828,HOPE:Lancet 2000;355:253-259,-Blockers,Unless contraindicated or not tolerated,a b-blocker should be used in all patients with symptomatic HF and an LVEF40%.b-Blockade improves ventricular function and patient well-being,reduces hospital admis
17、sion for worsening HF,and increases survival.Where possible,in hospitalized patients,treatment with a b-blocker should be initiated cautiously before discharge.,Class of recommendation I,level of evidence A,CIBIS II(1999),MERIT-HF(2000)and COPERNICUS(2002),Effect of-Blockers on outcome,Aldosterone a
18、ntagonists,Unless contraindicated or not tolerated,the addition of a low-dose of an aldosterone antagonist should be considered in all patients with an LVEF35%and severe symptomatic HF,i.e.currently NYHA functional class III or IV,in the absence of hyperkalaemia and significant renal dysfunction.Ald
19、osterone antagonists reduce hospital admission for worsening HF and increase survival when added to existing therapy,including an ACEI.In hospitalized patients satisfying these criteria,treatment with an aldosterone antagonist should be initiated before discharge.,Class of recommendation I,level of
20、evidence B,RALES(1999),EPHESUS(2003),Aldosterone antagonists in HF,Pitt B,N Engl J Med 1999;341:709717Pitt B,N Engl J Med 2003;348:13091321.,ARBs,Unless contraindicated or not tolerated,an ARB is recommended in patients with HF and an LVEF 40%who remain symptomatic despite optimal treatment with an
21、ACEI and b-blocker,unless also taking an aldosterone antagonist.Treatment with an ARB improves ventricular function and patient well-being,and reduces hospital admission for worsening HF.,Class of recommendation I,level of evidence A,Val-HEFT(2001)and CHARMAdded(2003),CHARM-Alternative trial,Granger
22、 et al.Lancet 2003;362:7726.,Proportion with event(%),Digoxin,In patients with symptomatic HF and AF,digoxin may be used to slow a rapid ventricular rate.In patients with AF and an LVEF40%it should be used to control heart rate in addition to,or prior to a b-blocker.,Class of recommendation I,level
23、of evidence C,The Effect of Digoxin on Mortality and Morbidity in Patients with Heart FailureN Eng1 Med,1997;336:525-533,DIG TRAIL-All-cause mortality,The Effect of Digoxin on Mortality and Morbidity in Patients with Heart Failure N Eng1 Med,1997;336:525-533,Hospital admission for worsening HF,The E
24、ffect of Digoxin on Mortality and Morbidity in Patients with Heart Failure N Eng1 Med,1997;336:525-533,Diuretics,Diuretics are recommended in patients with HF and clinical signs or symptoms of congestion.,Class of recommendation I,level of evidence B,In symptomatic patients with an LVEF 40%,the comb
25、ination of H-ISDN may be used as an alternative if there is intolerance to both an ACEI and an ARB.Adding the combination of H-ISDN should be considered in patients with persistent symptoms despite treatment with an ACEI,b-blocker,and an ARB or aldosterone antagonist.Treatment with H-ISDN in these p
26、atients may reduce the risk of death.,Hydralazine and isosorbide dinitrate(H-ISDN),Class of recommendation IIa,level of evidence B,V-HeFT-I(1991)and A-HeFT(2004),Other drugs-Statins,“In elderly patients with symptomatic chronic HF and systolic dysfunction caused by CAD,statin treatment may be consid
27、ered to reduce cardiovascular hospitalization.”,Class of recommendation IIb,level of evidence B,Trial design:A total of 5011 patients at least 60 years of age with New York Heart Association class II,III,or IV ischemic,systolic heart failure were randomly assigned to receive 10 mg of rosuvastatin or
28、 placebo per dayResults:Primary Outcome:11.4%with rosuvastatin vs.12.3%with placebo(p=0.12)Death from Any Cause:11.6%vs.12.2%(p=0.31),respectivelyAny cause Hospitalizations:2193 vs.2564(p 0.001),respectively,Rosuvastatin in Older Patientswith Systolic Heart Failure,N Engl J Med 2007;357:22482261.,Pr
29、imary Outcome and Death from Any Cause,N Engl J Med 2007;357:22482261.,N Engl J Med 2007;357:22482261.,Hospitalizations for cardiovascular causes,P0.001,Statin-mediated effects in endothelial cells and other tissues,Class I recommendations For Drugs,Devices and surgery,ICDPrior resuscitated cardiac
30、arrest(Class I Level A)Ischaemic aetiology and 40 days of MI(Class I Level A)Non-ischaemic aetiology(Class I Level B)CRTNYHA Class III/IV and QRS.120 ms(Class I Level A)To improve symptoms/reduce hospitalization(Class I Level A)To reduce mortality(Class I Level A),Class I recommendations,ICD,ICD the
31、rapy for primary prevention is recommended to reduce mortality in patients with LV dysfunction due to prior MI who are at least 40 days post-MI,have an LVEF 35%,in NYHA functional class II or III,receiving optimal medical therapy,and who have a reasonable expectation of survival with good functional
32、 status for1 year.(Class of recommendation I,level of evidence A)Meta-analyses of primary prevention trials have shown that the benefit on survival with ICDs is highest in the post-MI patients with depressed systolic function(LVEF35%).,Canadian Implantable DefibrillatorStudy.Eur Heart J 2000;21:2071
33、2078.,Mortality of ICD,23%,Bardy GH,N Engl J Med 2005;352:225237.,CRT,The survival advantage of CRT-D vs.CRT-P has not been adequately addressed.In the CARE-HF trial,CRT-P was associated with a significant reduction of 37%in the composite end-point of total death and hospitalization for major cardio
34、vascular events(P0.001)and of 36%in total mortality(P0.002).,COMPANION.N Engl J Med 2004;350:21402150.CARE-HF trial.N Engl J Med 2005;352:15391549.,COMPANION All-Cause Death Results,Days from Randomization,Event-Free Survival(%),100,90,80,70,60,50,OPT,CRT,CRT-D,(CRT vs.OPT)P=0.059(CRT-D vs.OPT)P=0.0
35、03,Bristow M.N Engl J Med.2004;350:2140-2150.,90,900,810,720,630,540,360,270,180,0,990,1080,450,Co-morbidities and special populations,Management of arterial hypertension inpatients with HF,Conclusion,the diagnosis of HF with natriuretic peptides(BNP)HF with preserved ejection fraction(HFPEF)Rosuvastatin in Older Patientswith Systolic Heart Failure(statin),The Loop of Knowledge,ResearchClinical Trials,Guidelines,Education based on Guidelines,Evaluation of Practices by Surveys,Thanks For Your Attention!,
