充血性心衰的治疗ppt课件

Current Management of Congestive Heart Failure: 2004 Update Hisham Dokainish, MD, FACC Assistant Professor of Medicine Baylor College of Medicine, Director, Non-Invasive Cardiology, Ben Taub General Hospital Houston, Texas, USA TheThe ProblemProblem (USA) (USA) 5,000,000 patients5,000,000 patients 6,500,000 hospital 6,500,000 hospital daysdays / / yearyear 300,000 deaths / year300,000 deaths / year 6% - 10% of people 65 years6% - 10% of people 65 years 5.4% of health care budget (38 billion)5.4% of health care budget (38 billion) Incidence x 2 in last ten yearsIncidence x 2 in last ten years GottdienerGottdiener J et al. JACC 2000;35:1628 J et al. JACC 2000;35:1628 HaldemanHaldeman GA GA et al.et al. Am Heart J 1999;137:352 Am Heart J 1999;137:352 Kannel WB Kannel WB et al.et al. Am Heart J 1991;121:951 Am Heart J 1991;121:951 OConnell JB OConnell JB et al.et al. J Heart Lung Transplant 1993;13:S107 J Heart Lung Transplant 1993;13:S107 Definition of heart failureDefinition of heart failure AHA / ACC HF guidelines 2001AHA / ACC HF guidelines 2001 Clinical syndrome that can result from any Clinical syndrome that can result from any structural or functional cardiac disorder thatstructural or functional cardiac disorder that impairs the ability of the ventricle to fill with impairs the ability of the ventricle to fill with or eject bloodor eject blood SuspectedSuspected Heart Heart FailureFailure because of SYMPTOMS and/or SIGNSbecause of SYMPTOMS and/or SIGNS Assess presence of CARDIAC DISEASEAssess presence of CARDIAC DISEASE by ECG, X-Ray or by ECG, X-Ray or BNPBNP TestsTests abnormalabnormal VENTRICULAR FUNCTIONVENTRICULAR FUNCTION Imaging by Imaging by Echo-Echo-DopplerDoppler, , Nuclear angiography or MRI if availableNuclear angiography or MRI if available TestsTests abnormalabnormal NORMALNORMAL No Heart FailureNo Heart Failure NORMALNORMAL No Heart FailureNo Heart Failure Heart Heart FailureFailure: : SystolicSystolic / / DiastolicDiastolic IdentifyIdentify etiologyetiology, evaluate , evaluate severityseverity, , choosechoose therapytherapy ESC HF guidelines 2001ESC HF guidelines 2001 Heart Heart diseasedisease No No symptomssymptoms HF HF RiskRisk FactorsFactors No Heart No Heart diseasedisease No No symptomssymptoms AsymptomaticAsymptomatic LV LV dysfunctiondysfunction RefractoryRefractory HF HF symptomssymptoms Prior Prior oror currentcurrent HF HF SymptomsSymptoms StagesStages in in thethe evolutionevolution of Heart of Heart FailureFailure A A B B C C D D AHA / ACC HF guidelines 2001AHA / ACC HF guidelines 2001 ACE-iACE-i blockers blockers TreatTreat riskrisk factorsfactors DietDiet andand exerciseexercise AvoidAvoid toxicstoxics ACE-i in ACE-i in selectedselected p. p. In In selectedselected patientspatients PalliativePalliative therapytherapy MechMech. . AssistAssist devicedevice Heart Heart TransplantTransplant ACE-iACE-i blockers blockers DiureticsDiuretics / / DigitalisDigitalis StagesStages in in thethe EvolutionEvolution of Heart of Heart FailureFailure TreatmentTreatment A A B B C C D D AHA / ACC HF guidelines 2001AHA / ACC HF guidelines 2001 Aggravating Factors Medications New heart disease Myocardial ischemia Endocarditis Obesity Hypertension Physical activity Dietary excess Pregnancy Arrhythmias (AF) Infections Thromboembolism Hyper/hypothyroidism Initial / Ongoing Evaluation Identify heart diseaseIdentify heart disease Assess functional capacity (NYHA, 6 min walk, )Assess functional capacity (NYHA, 6 min walk, ) Assess volume status: (edema, Assess volume status: (edema, ralesrales, jugular, , jugular, hepatomegalyhepatomegaly, body weight), body weight) Lab assessment: routine: electrolytes, renal Lab assessment: routine: electrolytes, renal functfunct. . Repeat Echo, RX only if significant changes in Repeat Echo, RX only if significant changes in functional statusfunctional status Assess prognosisAssess prognosis 8080707060605050404030302020 54-6054-60 6060 5050 4040 3030 2020 1010 0 0 Post MIPost MI n=196n=196 3 mg/dl) Hyperkalemia ( 5,5 mmol/l) Severe hypotension -Adrenergic Blockers Mechanism of action Density of 1 receptors Inhibit cardiotoxicity of catecholamines Neurohormonal activation HR Antiischemic Antihypertensive Antiarrhythmic Antioxidant, Antiproliferative -Adrenergic Blockers Clinical Effects Improve symptoms (only long term) Reduce remodelling / progression Reduce hospitalization Reduce sudden death Improve survival US US CarvedilolCarvedilol HF HF NEJM 1996; 334: 1349-55NEJM 1996; 334: 1349-55 CarvedilolCarvedilol (n=696)(n=696) PlaceboPlacebo (n=398)(n=398) Risk reduction = 65%Risk reduction = 65% p p Ca = Ca+ + + + InotropicInotropic effect effect NatriuresisNatriuresis Neurohormonal controlNeurohormonal control - - PlasmaPlasma NoradrenalineNoradrenaline - - Peripheral nervous system activityPeripheral nervous system activity - - RAAS activity RAAS activity - - VagalVagal tonetone - - Normalizes arterial Normalizes arterial baroreceptorsbaroreceptors NEJM 1988;318:358 NEJM 1988;318:358 Digitalis. Clinical Effects Improve symptoms Modest reduction in hospitalization Does not improve survival Digoxin toxicity Advanced A-V block without pacemaker Bradycardia or sick sinus without PM PVCs and VT Marked hypokalemia W-P-W with atrial fibrillation DigoxinDigoxin. . ContraindicationsContraindications RENIN AngiotensinogenAngiotensin I ANGIOTENSIN II ACE Other pathways VasoconstrictionProliferative Action Vasodilatation Antiproliferative Action AT1 AT2 AT1 Receptor Blockers RECEPTORS Angiotensin II Receptor Blockers (ARB)Angiotensin II Receptor Blockers (ARB) Candesartan, Candesartan, EprosartanEprosartan, , IrbesartanIrbesartan Losartan, Losartan, TelmisartanTelmisartan, Valsartan, Valsartan Efficacy not superior to ACE-IEfficacy not superior to ACE-I Likely not indicated with beta blockersLikely not indicated with beta blockers Indicated in patients intolerant to ACE-IIndicated in patients intolerant to ACE-I Angiotensin II Receptor Blockers (ARB)Angiotensin II Receptor Blockers (ARB) AHA / ACC HF AHA / ACC HF guidelinesguidelines 2001 2001 ESC HF ESC HF guidelinesguidelines 2001 2001 MonthsMonths 1.01.0 0.90.9 0.80.8 0.70.7 ValsartanValsartan PlaceboPlacebo P = 0.8P = 0.8 SurvivalSurvival 0 0 3 3 6 6 9 9 121221211818151524242727 Angiotensin II Receptor Blockers (ARB)Angiotensin II Receptor Blockers (ARB) Val-Val-HeFTHeFT AHA 2000AHA 2000 Nitrates: Clinical Use CHF with myocardial ischemia Orthopnea and paroxysmal nocturnal dyspnea In acute CHF and pulmonary edema:NTG sl / iv Nitrates + Hydralazine in intolerance to ACE-I (hypotension, renal insufficiency) 0,540,54 0,480,48 0 0 121224244848 6060 0.750.75 0.500.50 0.250.25 0 0 0.470.47 0.360.36 0.250.25 0.130.13 0.090.09 0.310.31 0.180.18 0.420.42 3636 MonthsMonths p = 0.08p = 0.08 V-V-HeFTHeFT II II N Engl J Med 1991; 325:303N Engl J Med 1991; 325:303 EnalaprilEnalapril HZ + ISDNHZ + ISDN n = 804n = 804 p = 0.016p = 0.016 ProbabilityProbability ofof deathdeath Nitrate + Nitrate + HydralazineHydralazine Inotropes, long term / intermittentInotropes, long term / intermittent AntiarrhythmicsAntiarrhythmics (except (except amiodaroneamiodarone) ) Calcium antagonists (except Calcium antagonists (except amlodipineamlodipine) ) Non-steroidal Non-steroidal antiinflammatoryantiinflammatory drugs (NSAIDS) drugs (NSAIDS) TricyclicTricyclic antidepressants antidepressants CorticosteroidsCorticosteroids LithiumLithium Drugs to Avoid Drugs to Avoid (may increase symptoms, mortality)(may increase symptoms, mortality) ESC HF ESC HF guidelinesguidelines 2001 2001 Refractory End-Stage HFRefractory End-Stage HF Review etiology, treatment mean EF 22%; mean QRS 160 ms; ischemic cause 55% of patients Bristow, et al: N Engl J Med 2004 ICD