如何优化心衰控制课件幻灯

Keep guideline in mind, walking your own way ! Michael Fu, MD, PhD, FESC Professor, Senior Consultant Physician Head, Heart Failure Center Medicine Sahlgrenska University Hospital/Sahlgrenska Gteborg, SWEDEN How to optimize heart failure management ? Chronic Heart Failure More common than we believe ! 2 % 10 % CHF: A aged population 0 100 200 300 400 500 600 700 196019802000 2020 Millions 165 296 403 649 Chronic Heart Failure A disease state which seldom stops ! Risk factors:Risk factors: diabetesdiabetes hypertensionhypertension Vascular Vascular dysfunctiondysfunction Vascular diseaseVascular disease Tissue injuryTissue injury (MI, stroke) (MI, stroke) PathologicalPathological remodelingremodeling Target organ dysfunction Target organ dysfunction (HF, renal)(HF, renal) SympatikusSympatikus AngiotensinAngiotensin II II aldosteronealdosterone - The Cardiovascular Continuum Adapted 2003 from Dzau V, Braunwald E. Am Heart J. 1991; Gibbons 1999. Heart failureHeart failure DeathDeath Chronic Heart Failure More malignant than we believe ! CHF: More malignant than most cancer ! Stewart et al. Eur J Heart Failure 2001, 3(3): 315- A Risk factor Ischemea Hypertention Diabetes B Heart dysfunction C Heart failure D Refractory HF Standard Heart failure care Extraordinary measure Risk modification XX Chronic Heart Failure Worse than we believe in CHF treatment diuretic digoxin diuretic digoxin diuretic digoxin ACE-I diuretic digoxin ACE-I diuretic digoxin ACE-I blocker diuretic digoxin ACE-I blocker ACEI (1991) blocker (1999)ARB (2003) ACE-I blocker ARB Evidence-based heart failure medications One year mortality (%) Worldwide Gteborg blocker: 50 % 82 % ACEI: 64% 75 % Age 80 years Worldwide Gteborg blocker: 15 % 80 % ACEI: 35% 73 % European heat survey, Heart failure registry in Gteborg A Gap between Guideline and Clinical Practice Can we do better ? To clarify objectives of treatment of chronic heart failure Prognosis MorbidityPrevention Life quality No 1 Putting guideline into clinical prctice ! No 2 Evidence based medicine makes difference ! Beta-blocker ACE inhibitor AT1 receptor blocker Aldosteron receptor antagonist Digitalis Diuretics Antikoagulation Vasodilator Antiarytmics Inotropic agents Calcium channel blocker Statin ASA TNF- antagonist, Endothelin antagonist, AVP antagonist Relieve Slow Prevent Symptom prpgression SCD ? ? ? CHF ACEI+BB ESC CHF ACEI+BB Persisting symptoms & sign Yes ARB or Aldosterone antagonist ESC CHF ACEI+BB Persisting symptoms & sign Yes ARB or Aldosterone antagonist Persisting symptoms Yes QRS120 ms YesCRT/CRT-D ESC CHF ACEI+BB Persisting symptoms & sign Yes NO ARB or Aldosterone antagonist Persisting symptoms Yes QRS120 ms YesCRT/CRT-D NOLVEF35% Yes ICD ESC CHF in particular Sudden death Sudden Death “The major challenge confronting contemporary cardiology” Bernard Lown Most common death in Hypertension Post-MI patients Heart failure Sudden Death PrimaryPrimary Prevention Prevention Diu Meto 510 (y) (n=3 234) Hypertension 50 Cumulative No. Sudden Death - Risk Reduction with Metoprolol SecondarySecondary Prevention Prevention Plac Meto (n=5 474) 123 (y) Post Myocardial infarction TertiaryTertiary Prevention Prevention Plac Meto CR/XL 61218 (m) (n=3 991) Heart Failure 12 Cumulative No. 120 Olsson G et al Am J Hypertens 1991 Olsson G et al Eur Heart J 1992 MERIT-HF Study Group, Lancet 1999 Cumulative Per Cent CHF in particular Post-MI PostinfarctPostinfarct - HF - HF Heart failure at admission Heart failure at admission 0 0 1 1 2 2 3 3 4 4 5 5 6 6 MonthsMonths 0.00.0 0.10.1 0.20.2 0.30.3 No heart failure at admissionNo heart failure at admission 20.7 5.9 12.0 2.9 Heart failure during hospitalisation Heart failure during hospitalisation 25.3 % Mortality Survival Post-MI : GRACE Registry Steg et al Circulation 2004 Metoprolol CR in Post-MI HF Janosi et al., Am Heart J 2003, 146(4): 721- CHF in particular Doubel RAAS inhibitors CHARM Programme CHARM-Added Baseline characteristics (1) Mean age (years) 6464 Women (%)2121 NYHA class (%) II 2424 III7373 IV 33 Mean LVEF (%)2828 ACE inhibitor (%)100100 Beta-blocker (%)5556 Spironolactone (%)1717 McMurray et al, Lancet 2003 CandesartanPlacebo n=1276 n=1272 0123years 0 10 20 30 40 50 Placebo Candesartan % Number at risk Candesartan127611761063948457 Placebo127211361013906422 3.5 HR 0.85 (95% CI 0.75-0.96), p=0.011 Adjusted HR 0.85, p=0.010 483 (37.9%) 538 (42.3%) McMurray et al, Lancet 2003 CHARM-Added Primary outcome, CV death or CHF hospitalisation Effect of Candesartan: On top of ACEI, BB and Spironolacton Walking out from misperceptions ! No 3 Beta-blockers should be avoided in diabetic CHF patients Beta-blockers should be avoided in COPD and CHF patients Beta-blockers and ACE inhibitors should be avoided in elderly CHF patients Low dose of beta blocker /ACEI is not meningful False False False False False All beta blockers or ARB have class effects False To be creative ! No 4 Hypotension Bradycardy Renal dysfunction Hyperkalaemia Low compliance For example Not easy, but not impossible ! Too much diuretics ? Hypotension Other vasodilators ? Symptomatic ? Time to re-consider ! Negative chronotropic drug (digitalis, CCB with low vascular selectivity ) ? Bradycardy ? Symptomatic ? Time to re-consider ! Daytime ? Evening ? At rest ? Exercise ? Pacemaker ? What shall we do when guideline does NOT exist ? No guideline in most HF patients Elderly HFNEF HFNEF: HF with preserved systolic function I do as I wish because there is no guideline I do my best as physician despite there is no guideline I do nothing because there is no guideline Wrong ! Right ! Wrong ! Prevention : BP Diagnos: NTpro BNP Heart Failure Outpat Clinic Self-care: eduction, exercise Guideline co