舒张性心力衰竭

Toranomon Hospital 第第 1回日中心血管回日中心血管 Clinical Aspects of Diastolic Heart Failure Shin-ichi Momomura, MD Cardiovascular Center Toranomon Hospital Tokyo, Japan Toranomon Hospital 第第 1回日中心血管回日中心血管 Incidence of Heart Failure Framingham Heart Study J Am Coll Cardiol 1993;22:6A13A Male Female Toranomon Hospital 第第 1回日中心血管回日中心血管 Distribution of Left Ventricular Ejection Fraction: EuroHeart Failure Survey European Heart Journal (2003) 24, 442463 Toranomon Hospital 第第 1回日中心血管回日中心血管 What is Diastolic Heart Failure? Diastolic (Heart) Failure Heart failure due to diastolic dysfunction Heart Failure with Preserved or Normal Systolic Function Cf) Systolic Heart Failure Toranomon Hospital 第第 1回日中心血管回日中心血管 Toranomon Hospital 第第 1回日中心血管回日中心血管 Causes of Diastolic Dysfunction Left ventricular hypertrophy (common) Aortic stenosis Chronic hypertension Hypertrophic cardiomyopathy (with/wothout outflow tract obstruction) Acute episodic myocardial ischemica (common) Pericardial disease (rare) Tamponade Constriction Constrictive-effusive disease due to prior radiation therapy Restrictive cardiomyopathy (rare) Amyloid disease Idiopathic restrictive cardiomyopathy Toranomon Hospital 第第 1回日中心血管回日中心血管 Mechanism of DHF LV diastolicdysfunction CO Neurohormnal activity Exersional dyspnea stroke volume Sodium/water retension LV filling pressure edema Pulmonary edema Pulmonary congestioncAcute elevation of BP Toranomon Hospital 第第 1回日中心血管回日中心血管 Epidemiology of DHF Toranomon Hospital 第第 1回日中心血管回日中心血管 Prevalence of DHF Diagnostic Criteria Evaluation of LV function Prevalence Ghali FHS FS24% (UCG) 28% Taffet FHS EF45% (RNV) 43% Takarada FHS FS30% (UCG) 24% Vasan FHS EF50% (UCG) 51% Toranomon Hospital 第第 1回日中心血管回日中心血管 Distribution of the severity of left ventricular systolic dysfunction by qualitative assessment Women Men European Heart Journal (2003) 24, 442463 Toranomon Hospital 第第 1回日中心血管回日中心血管Prognosis of DHF and SHF (1) EF 50% EF 50% 78 59 58 44 51 35 44 32 36 29 16 15 1.0 0.8 0.6 0.4 0.0 0 1 2 3 4 5 6 0.2 Expected EF 50% EF 50% Survival Years Senni M. et al.：Circulation,98,2282,1998. P=0.279 Toranomon Hospital 第第 1回日中心血管回日中心血管 Prognosis of DHF and SHF (2) Smith GL. JACC 2003;41:1510-8 Toranomon Hospital 第第 1回日中心血管回日中心血管 Characteristics: Demographic Preserved EF (n=200) Depressed EF (n=213) p Value Age 73 + 11 70 + 11 0.004 Male gender 74(37%) 139(65%) 0.001 White race 158(79%) 159(75%) 0.30 Smith GL. JACC 2003;41:1510-8 Toranomon Hospital 第第 1回日中心血管回日中心血管 Characteristics: Cardiac History Preserved EF (n=200) Depressed EF (n=213) p Value EF 60 + 8 28 + 10 0.0001 HF 128 (64%) 169 (79%) 0.001 Previous.hospitalization for HF 60 (30%) 94 (45%) 0.002 Years of HF 2.4 + 5.4 3.3 + 5.5 0.002 Hypertension 160 (80%) 139 (65%) 0.001 Arrhythmia 77 (39%) 112 (53%) 0.004 Pacemaker placement 20 (10%) 40 (19%) 0.01 Smith GL. JACC 2003;41:1510-8 Toranomon Hospital 第第 1回日中心血管回日中心血管 Characteristics: Cardiac History Preserved EF (n=200) Depressed EF (n=213) p Value Chronic stable angina 66 (33%) 91 (43%) 0.04 Myocardial infarction 78 (39%) 118 (55%) 0.001 Cardiac catheterization 75 (38%) 123 (58%) 0.001 CABG 39 (20%) 67 (31%) 0.006 PCI 19 (10%) 32 (15%) 0.09 Coronary artery disease 56 (24%) 176 (76%) 0.0001 Aortic stenosis 9 (9%) 14 (9%) 0.86 Smith GL. JACC 2003;41:1510-8 Toranomon Hospital 第第 1回日中心血管回日中心血管 Characteristics: Non-cardiac History Preserved EF (n=200) Depressed EF (n=213) p Value Renal insufficiency 72 (36%) 74 (35%) 0.79 Respiratory disease 61 (31%) 56 (26%) 0.34 CVA/stroke 30 (15%) 33 (15%) 0.89 Diabetes 95 (48%) 102 (48%) 0.94 Smith GL. JACC 2003;41:1510-8 Toranomon Hospital 第第 1回日中心血管回日中心血管 DHF in Japan All (n=172) Preserved Systolic Function (n=61) Intermediate Systolic Function (n=38) Depressed Systolic Function (n=73) Age (yrs) (mean + SD) 68 + 14 69 + 16 69 + 9 67 + 14 Men 105 (61%) 30 (49%) 23 (61%) 52 (71%)* Previous admission for CHF 60 (35%) 15 (25%) 13 (34%) 31 (44%)* Cause of CHF Ischemic 75 (44%) 26 (43%) 16 (42%) 33 (45%) Hypertensive 45 (26%) 20 (33%) 11 (29%) 14 (19%) Cardiomyopathic 43 (25%) 7 (12%) 9 (24%) 27 (37%) Tsutsui H et al. Am J Cardiol 2001;88:230-33 * p40% 25th European Society of Cardiology Annual Congress (2003) CHARM Added CHARM Preserved CHARM Alternative CHARM: Design Toranomon Hospital 第第 1回日中心血管回日中心血管 CHARM：Characeteristics CHARM Alternative Added Preserved n 2,028 2,548 3,025 Age 67 64 67 Female (%) 32 21 40 NYHA (%) 48 24 61 NYHA (%) 49 73 38 mean LVEF (%) 30 28 54 Treatment ACEIs 0 100 18 Diuretics 85 90 75 Digitalis 46 58 28 -blockers 54 55 56 Spironolactone 25 17 12 Eur J Heart Failure 2001; 3 Suppl 1: S17-18 Toranomon Hospital 第第 1回日中心血管回日中心血管 P=0.118 Hazard Ratio 0.8925 20 15 10 5 0 0 1 2 3 3.5 30 Placebo 366 (24.3%) Candesafrtan 333 (22.0%) Time (years) (%) CHARM preserved: Primary Endpoint: Time to cardiovascular death or admission for heart failure Lancet 2003; 362: 77781 Proportion with cardiovascular death or hospital admission for CHF (%) Toranomon Hospital 第第 1回日中心血管回日中心血管 700 600 300 200 0 p=0.014 (%) 25 20 15 10 5 0 Placebo Candesartan p0.017 500 100 400 Placebo Candesartan CHARM preserved: Admission for HF Total number of admissions for CHF Number of patients who were admitted to hospital for CHF from Lancet 2003; 362: 77781 Toranomon Hospital 第第 1回日中心血管回日中心血管 ACC/AHA Guidelines 4.3.2. Patients With HF and Normal LVEF Class I 1. Physicians should control systolic and diastolic hypertension in patients with HF and normal LVEF, in accordance with published guidelines. (Level of Evidence: A) 2. Physicians should control ventricular rate in patients with HF and normal LVEF and atrial fibrillation. (Level of Evidence: C) 3. Physicians should use diuretics to control pulmonary congestion and peripheral edema in patients with HF and normal LVEF. (Level of Evidence: C) Circulation. 2005;112:1825-1852 Toranomon Hospital 第第 1回日中心血管回日中心血管 ACC/AHA Guidelines 4.3.2. Patients With HF and Normal LVEF (cont.) Class IIa Coronary revascularization is reasonable in patients with HF and normal LVEF and coronary artery disease in whom symptomatic or demonstrable myocard