管理充血性心力衰竭ppt课件

Congestive Heart Failure Collaborative, October 14, 2004 Preventing Readmissions Kenneth A. LaBresh, MD, FAHA, FACC V.P., Medical Affairs and Quality Improvement, MassPRO Clinical Associate Professor, Brown University ACC/AHA Guidelines for Evaluation and Management of Chronic Heart Failure 2001 HF can be prevented HF has established risk factors HF is a progressive condition with asymptomatic and symptomatic stages HF morbidity and mortality can be reduced by stage specific treatments Hunt, et al. J Am Coll Cardiol. 2001; 38:2101-2113. ACC/AHA Proposed Stages of HF STAGE ASTAGE A High risk for developing HF High risk for developing HF STAGE BSTAGE B Asymptomatic LV dysfunction Asymptomatic LV dysfunction STAGE CSTAGE C Past or current symptoms of HF Past or current symptoms of HF STAGE DSTAGE D End-stage HF End-stage HF Hunt, et al. J Am Coll Cardiol. 2001; 38:2101-2113. Neurohormonal Activation in Heart Failure Hypertrophy, apoptosis, ischemia, arrhythmias, remodeling, fibrosis Angiotensin IINorepinephrine Morbidity and Mortality CNS sympathetic outflow Cardiac sympathetic activity Renal sympathetic activity Sodium retention Myocyte hypertrophy Myocyte injury Increased arrhythmias Disease progression 11121 Vascular sympathetic activity Vasoconstriction 1 Activation of RAS Adrenergic Pathway in Heart Failure Progression Beta-blocker Therapy in Heart Failure Potential Beneficial EffectsPotential Beneficial Effects Protection fromProtection from CatecholamineCatecholamine ToxicityToxicity Renin Renin Angiotensin Angiotensin SystemSystem Reversal of Reversal of RemodelingRemodeling Up-regulationUp-regulation of of - -adrenergicadrenergic ReceptorsReceptors AncillaryAncillary FactorsFactors Major Placebo Controlled Trials of -Blockade in Heart Failure 34% Cumulative Mortality (%) Days 20 15 5 0 10 P=.0062 (adjusted) Metoprolol CR/XL (n=1990) Placebo (n=2001) US Carvedilol Trials1 Probability of Event-free Survival Carvedilol (n=696) Placebo (n=398) Days P.001 0.0 0100200300400 65% 1.0 0.8 0.7 0.9 MERIT-HF2 Survival (% of Patients) 100 90 80 60 70 0 6000400300200100 Days Carvedilol (n=1156) Placebo (n=1133) 500 6000400300200100500 35% P=.00013 COPERNICUS4 Days 0.0 200400800 1.0 0.8 0.6 P.0001 34% Bisoprolol (n=1327) Placebo (n=1320) CIBIS-II3 0600 Survival 1Packer M et al. N Engl J Med. 1996;334:13491355. 2MERIT-HF Study Group. Lancet. 1999;253:20012007. 3CIBIS-II Investigators. Lancet. 1999;353:913. 4Packer M et al. N Engl J Med. 2001;344:16511658. COPERNICUS: All-Cause Mortality % Survival 100 90 80 60 70 50 2402016128428 Months All patients Risk Reduction 35% P=.00013 Carvedilol (n=1156) Placebo (n=1133) Packer M et al. N Engl J Med. 2001;344:16511658. 900 600 300 0 P=.0012P=.0002P.0001 For any reason For cardiovascular reason For heart failure Placebo Carvedilol 29% 33% 600 400 200 0 450 300 150 8 20% COPERNICUS: Number of Hospitalizations Packer M et al. Circulation. 2002;106:21942199. 0 5 10 15 20 25 30 All Patients (n=2289) Higher-Risk Patients (n=624) Number of Events Krum H et al. JAMA. 2003;289:712718. 0 60 180 All Patients (n=2289) Higher-Risk Patients (n=624) Number of Events 8 Weeks8 Weeks Deaths Death or Hospitalization for Any Reason PlaceboCarvedilol COPERNICUS: Early Clinical Outcomes 120 25 19 15 3 153 134 63 44 Does Subspecialty Care Affect CHF Outcome SUPPORT 1298 Hospitalized Patients 743 (57%) Cardiolgist (C) 555 (43%) Primary Care (P) C P Age 63 71 Male 71% 52% EF known 69% 47% EF 20% 52% 39% SUPPORT Results Cardiologists vs. Primary Care: RHC 2.9 times more likely Coronary angio 3.9 times more likely Hospital costs 43% higher ACE-I 64% IN BOTH groups Short term mortality similar 4.6 year follow up mortality 20% lower for cardiologists (rr 0.80 (0.66 - 0.96) Aurebach Aurebach ad, AIM 2000;132:191-200ad, AIM 2000;132:191-200 Impact of Subspeciality Care Upstate New York 10 hospitals Three patient groups I Noncardiologist n = 977 II Cardiologist Attending n = 419 III Cardiology Consult n = 1058 Group I more NH, more comorbidity more females, less B-Blocker use Upstate New York Results Results (cont.) Philbin Philbin E, CHEST 116:2, 346 - 354E, CHEST 116:2, 346 - 354 Hospital Based CHF Clinic Retrospective analysis before (n = 407) and after (n = 357) implementation of a CHF program in 1994 Elements of the Program Multidisiplinary team Inpatient and outpatient treatment protocols Patient and family education Follow up telephone calls Outpatient infusion center Outcomes HF Management Meta Analysis McAlister FA, et al., JACC 2004;44:810-819 29 studies involving 5,039 patients Conclusions HF management programs decrease HF hospitalizations in a wide variety of formats Multidisciplinary approaches, particularly HF clinics have been demonstrated to reduce mortality as well 15 0f 18 studies that evaluated costs demonstrate cost savings as well SPAN-CHF Specialized Primary and Networked Care in Heart Failure Kimmelsteil et al., Circ 2004;110:1450-1455 Characteristics of the System 1.Focus on patients who have a resent HF hospitalization 2. Administered by nurses as case managers with strong expertise in HF with the support of HF physicians acting as consultants to the nurses. 3. Telephone monitoring and limited home visits 4. Communication between the nurse and the PCP 5. Provided a three-month “active intervention”followed by surveillance out to 1 year Hypothesis A uniform disease management program will: Reduce the cost of medical care Increase the time to hospitalization or death Decrease the frequency of admission for HF. Increase the total number of days alive out of hospital Improve indices of health-related quality of life Characteristics of the Study Population Inclusion Patients d/c with a primary diagnosis of heart failure Etiology of HF may include: IHD, Dilated CMP, corrected valve disease or regurgitant valve disease deemed uncorrectable due to severe LV dysfunction, hypertension, or hypertrophic disease of the elderly LVEF within 6 months showing nonsystolic HF Patient care provided by a physician other than a SPAN- CHF provider Patient Characteristics Intervention (n=97) Control (n=103)P Age (mean + SD)70.3 + 12.273.9 + 10.70.05 Female Gender, %42.341.7NS Ischemic CMP, %57.764.1NS Hypertension, %68.070.9NS Diabetes47.449.5NS EF mean0.30 + 140.31 + 12NS Medications, %NS ACE76.172.8 ARB16.717.5 ACE or ARB92.890.3 B-blocker50.063.1 Diuretics96.994.2 Days 180150120906030 0 Cumulative Event Free Survival 1.0 .9 .8 .7 .6 .5 Treatment intervention control SPAN-CHF: SPAN-CHF: EVENT FREE SURVIVALEVENT FREE SURVIVAL SPAN-CHF: HF Hospitalizations, Hospital Days / Patient-Year Alive in Initial 90 Days RR=0.48 P=0.027 RR=0.54 P 0.001 # # SPAN-CHF: HF Hospitalizations, Hospital Days / Patient-Year