心力衰竭内科疾病课件

Heart Failure A Disease for the Internist Dr Chris Davidson Sussex Cardiac Centre BRIGHTON UK 1EFIM Beziers 2007 Heart Failure a typical case? nMedical Assessment Unit n78 year old woman nHypertension ; type II Diabetes nAF 110/min, 180/80, JVP+, oedema+ nCXR: cardiomegaly, pulmonary congestion nECG: AF, LBBB Given iv Frusemide 80mg with a good diuresis and feels better today 2EFIM Beziers 2007 Heart Failure A Disease for the Internist nWho looks after patients with Heart Failure? nUse of Evidence-based Treatments nThe problem of Heart Failure with Preserved LV function nCo-Morbidity in Heart Failure nHow do we prevent early relapse? 3EFIM Beziers 2007 EuroHeart Failure Survey 11,327 diagnosis HF Mean age 71 years; 47% women GIM / geriatrics 55%, cardiology 45% CHD 66%, Valve disease 29%, DCM 5% HF principle reason for admission in 40% LVSD in 46%: male female European Heart Journal (2003) 24, 442463 Registry of 46,786 consecutive admissions to general medicine and cardiology wards in 24 European countries over a 6 week period 2001-2 4EFIM Beziers 2007 Heart Failure in France Cohen-Solal et al European Heart Journal (2000) 21, 763769 5EFIM Beziers 2007 HEART FAILURE How Serious? 6EFIM Beziers 2007 Epidemiology of Heart Failure: Framingham Study HypertensionHypertension76%76%79%79% CHDCHD46%46%27%27% RheumaticRheumatic2%2%3%3% OtherOther11%11%17%17% MORTALITYMORTALITY82%82%67%67% (6 Year)(6 Year) MALEMALEFEMALEFEMALE Ho et al Circulation 1993;88:107-115 7EFIM Beziers 2007 MORE MALIGNANT THAN CANCER? Stewart S et al. Eur. J Heart Failure (2001) 3 315-322 Reference: Stewart et al. Eur J Heart Failure 2001 Five year Survival of Patients admitted to Hospital in Scotland 1991 28%28% 8EFIM Beziers 2007 HEART FAILURE What are the recommended treatments? 9EFIM Beziers 2007 HF Trial Evidence nACE inhibitors nVasodilators: Hydrallazine/Nitrate nBeta-Blockers nSpironolactone nAngiotensin Receptor Blockers nExercise Training nBiventricular Pacing / Defibrillators nCardiac Transplantation 10EFIM Beziers 2007 Mortality Benefit of Treatments in Heart Failure 6mo 3.5yr 6mo 1.3yr 1yr 2yr 11EFIM Beziers 2007 Euro Heart Failure Survey: Use of ACEI and BB 12EFIM Beziers 2007 Guidelines for the Treatment of Heart Failure nAmerican Heart Ass. / American College of Cardiology q Chronic Heart Failure 2005 J Am Coll Cardiol 2005; 46:1116-43 nEuropean Society of Cardiology qChronic Heart Failure 2005 EHJ 2005;26:1115-1140 nEuropean Society of Cardiology qAcute Heart Failure 2005 EHJ 2005;26:384-416 ALL THERAPEUTIC GUIDELINES RELATE TO SYSTOLIC DYSFUNCTION 13EFIM Beziers 2007 Heart Failure a typical case? nMedical Assessment Unit n78 year old woman nHT ; type II Diabetes nSR 110/min, 180/80, JVP+, oedema+ nCXR: cardiomegaly, pulmonary congestion nECG: AF, LBBB Given iv Frusemide 80mg with a good diuresis and feels better today Echocardiography : LVH, Ejection Fraction 48% 14EFIM Beziers 2007 HEART FAILURE Systolic vs. Diastolic Dysfunction 15EFIM Beziers 2007 EuroHeart Failure Study: Preserved vs Impaired LV Function (EF men q4 years older qHypertension more common European Heart Journal (2004) 25, 12141220 16EFIM Beziers 2007 Adjusted Survival Curves for Patients with Heart Failure with Reduced or Preserved Ejection Fraction over the Year after the First Hospital Admission Bhatia R et al. N Engl J Med 2006;355:260-269 17EFIM Beziers 2007 PATHO-PHYSIOLOGY OF HEART FAILURE Cardiac OutputCardiac Output BloodBlood PressurePressure VasoVaso- - ConstrictionConstriction Na+ retentionNa+ retention NEURO-ENDOCRINE ACTIVATION RENAL PERFUSION Renin/Angiotensin Sympathetic sys. ANP / BNP 18EFIM Beziers 2007 HEART FAILURE: Diastolic Dysfunction How should we treat these patients? 19EFIM Beziers 2007 CHARM Programme Lancet. 2003; 362: 759-766. n=3025 LVEF 40% ACE inhibitor treated/not treated CHARM Added CHARM Preserved 3 component trials comparing candesartan to placebo CHARM Alternative n=2028 LVEF 40% ACE inhibitor intolerant n=2548 LVEF 40% ACE inhibitor treated Primary outcome: CV death or CHF hosp 20EFIM Beziers 2007 CHARM-Preserved: Primary outcome CV death or CHF hospitalisation 0123years3.5 0 10 20 30 Placebo Candesartan 5 15 25 HR 0.89 (95% CI 0.77-1.03), p=0.118 Adjusted HR 0.86, p=0.051 % 366 (24.3%) 333 (22.0%) RRR=11% Lancet. 2003;362:759-766. 21EFIM Beziers 2007 Heart Failure A Disease for the Internist nWho looks after patients with Heart Failure? nUse of Evidence-based Treatments nThe problem of Heart Failure with Preserved LV function nCo-Morbidity in Heart Failure nHow do we prevent early relapse? 22EFIM Beziers 2007 Co-Morbidity in Heart Failure Survey of 122,630 patients in US Healthcare System Braunstein et al JACC 2003 42; 1226 39% overall had 5 or more co- morbidities; Only 4% had HF alone 23EFIM Beziers 2007 Co-Morbidity in Heart Failure (2) nAnaemia qKosiborod M, Smith GL, Radford MJ, Foody JM, Krumholz HM. The prognostic importance of anaemia in patients with heart failure. Am J Med 2003;114:1129. nChronic Inflammation qElevated circulating levels of tumour necrosis factor in severe chronic heart failure. Levine B, et al M. N Engl J Med 1990;323:23641. qInflammatory biomarkers in heart failure. Pedersen JW, Felker GM. Congest Heart Fail. 2006 Nov- Dec;12(6):324-8. 24EFIM Beziers 2007 Anaemia in a cohort of 12,065 patients with new-onset heart failure. Circulation 2003;107;223-225 25EFIM Beziers 2007 HEART FAILURE: How can we influence early relapses? 26EFIM Beziers 2007 EuroHeart Failure Study 27EFIM Beziers 2007 Copyright 2001 BMJ Publishing Group Ltd. Blue, L. et al. BMJ