如何优化心衰控制.ppt

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,0,100,200,300,400,500,600,700,1960,1980,2000,2020,Millions,165,296,403,649,Chronic Heart Failure A disease state which seldom stops !,Risk factors: diabetes hypertension,Vascular dysfunction,Vascular disease,Tissue injury (MI, stroke),Pathological remodeling,Target organ dysfunction (HF, renal),Sympatikus Angiotensin II aldosterone,-,The Cardiovascular Continuum,Adapted 2003 from Dzau V, Braunwald E. Am Heart J. 1991; Gibbons 1999.,Heart failure,Death,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-,Standard Heart failure care,Extraordinary measure,Risk modification,X,X,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,Morbidity,Prevention,Life quality,No 1,Putting guideline into clinical prctice !,No 2,Evidence based medicine makes difference !,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,Yes,CRT/CRT-D,ESC,CHF,ACEI+BB,Persisting symptoms & sign,Yes,NO,ARB or Aldosterone antagonist,Persisting symptoms,Yes,QRS120 ms,Yes,CRT/CRT-D,NO,LVEF35%,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,Primary Prevention,Diu,Meto,5,10 (y),(n=3 234),Hypertension,50,Cumulative No.,Sudden Death - Risk Reduction with Metoprolol,Secondary Prevention,Plac,Meto,(n=5 474),1,2,3 (y),Post Myocardial infarction,Tertiary Prevention,Plac,Meto CR/XL,6,12,18 (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,Postinfarct - HF,Heart failure at admission,0,1,2,3,4,5,6,Months,0.0,0.1,0.2,0.3,No heart failure at admission,20.7,5.9,12.0,2.9,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) 64 64 Women (%) 21 21 NYHA class (%) II 24 24 III 73 73 IV 3 3 Mean LVEF (%) 28 28 ACE inhibitor (%) 100 100 Beta-blocker (%) 55 56 Spironolactone (%) 17 17,McMurray et al, Lancet 2003,Candesartan Placebo n=1276 n=1272,0,1,2,3,years,0,10,20,30,40,50,Placebo,Candesartan,%,Number at risk Candesartan 1276 1176 1063 948 457 Placebo 1272 1136 1013 906 422,3.5,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 covers more !,Guideline Not dictionary in bookshelf, but concept in your brain !,Paradigm shift: New era to come !,Heart Failure 70-90: Standard therapy with blocker, ACEI,Heart Failure 2000-: Tailored heart failure management on the basis of ACEI/BB Focus on patients well-being,Heat Failure 50-70: Digitalis, Vasodilator, Inotropics,Considering how much at