舒张性心力衰竭.ppt

Clinical Aspects of Diastolic Heart Failure,Shin-ichi Momomura, MD Cardiovascular Center Toranomon Hospital Tokyo, Japan,Incidence of Heart Failure Framingham Heart Study,J Am Coll Cardiol 1993;22:6A13A,Male,Female,Distribution of Left Ventricular Ejection Fraction: EuroHeart Failure Survey,European Heart Journal (2003) 24, 442463,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,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,Mechanism of DHF,LV diastolicdysfunction,CO,Neurohormnal activity,Exersional dyspnea,stroke volume,Sodium/water retension,LV filling pressure,edema,Pulmonary edema,Pulmonary congestionc,Acute elevation of BP,Epidemiology of DHF,Prevalence of DHF,Distribution of the severity of left ventricular systolic dysfunction by qualitative assessment,Women,Men,European Heart Journal (2003) 24, 442463,Prognosis of DHF and SHF (1),EF50% EF50%,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 EF50% EF50%,Survival,Years,Senni M. et al.：Circulation,98,2282,1998.,P=0.279,Prognosis of DHF and SHF (2),Smith GL. JACC 2003;41:1510-8,Characteristics: Demographic,Smith GL. JACC 2003;41:1510-8,Characteristics: Cardiac History,Smith GL. JACC 2003;41:1510-8,Characteristics: Cardiac History,Smith GL. JACC 2003;41:1510-8,Characteristics: Non-cardiac History,Smith GL. JACC 2003;41:1510-8,DHF in Japan,Tsutsui H et al. Am J Cardiol 2001;88:230-33,* p0.05, p0.01 vs. preserved systolic function values,DHF in Japan,Tsutsui H et al. Am J Cardiol 2001;88:230-33, p0.01 vs. preserved systolic function values,DHF in Japan,Tsutsui H et al. Am J Cardiol 2001;88:230-33,p0.05, p0.01 vs. preserved systolic function values; p0.05 vs. intermediate systolic function values,DHF in Japan：Mortality and Readmission,Tsutsui H et al. Am J Cardiol 2001;88:230-33,Chronic Heart Failure Analysis Registry in Tohoku District (CHART),Circ J 2003; 67: 431 436,Diagnosis of DHF,Sign and symptoms of heart failure Non-cardiac disease are excluded Normal or preserved LV contraction Documented diastolic dysfunction Elevated plasma BNP,Definite DHF,Probable DHF,Possible DHF,Circulation. 2000;101:2118-2121,Diagnostic Criteria of DHF,Evaluation of LV diastolic function,Indexes of isovolumic relaxation Peak negative dP/dt, Time constant (Tau) IRT Indexes of passive distensibility Stiffness constant of diastolic PV relation End-diastolic P/V ratio Indexes of LV filling Peak filling rate, Deceleration time, E, E/A,Indexes of LV isovolumic relaxation,Peak negative dP/dt,P(t)=(P0-PB)e-/t + PB,LV pressure (mmHg),LV dP/dt,time,Doppler Criteria for Classification of Diastolic Function Participants,Redfield: JAMA, Volume 289(2).January 8, 2003.194202,BNP levels in patients with normal function and with diastolic dyfunction,Lubien: Circulation 2002; 105:595-601,BNP values and three diastolic patterns,Lubien: Circulation 2002; 105:595-601,Treatment,Randomized Clinical Trials on the Treatment of Chronic Heart Failure,SHF CONSENSUS SOLVD VHeFT II ELITRE II Val-HeFT CHARM alternative CHARM added US Carvedilol MERIT-HF CBIS II COPERNICUS COMET RALES DIG,DHF CHARM preserved? i-preserve (on-going) Hong Kong Diastolic Heart Failure study (on-going) PEP-CHF (on-going),Each Study：Cardiovascular death or admission for heart failure Overall：All cause death,Primary Endpoint,Symptomatic Heart Failure Candesartan or Placebo,n=2028 EF 40% ACE intolerant,n=2548 EF 40% ACE tolerant,n=3025 EF40%,25th European Society of Cardiology Annual Congress (2003),CHARM Added,CHARM Preserved,CHARM Alternative,CHARM: Design,CHARM：Characeteristics,Eur J Heart Failure 2001; 3 Suppl 1: S17-18,P=0.118,Hazard Ratio 0.89,25,20,15,10,5,0,0,1,2,3,3.5,30,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 (%),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,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,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 myocardial ischemia is judged to be having an adverse effect on cardia