如何优化心衰控制.ppt

Keepguidelineinmind,walkingyourownway!,MichaelFu,MD,PhD,FESCProfessor,SeniorConsultantPhysicianHead,HeartFailureCenterMedicineSahlgrenskaUniversityHospital/SahlgrenskaGteborg,SWEDEN,Howtooptimizeheartfailuremanagement?,ChronicHeartFailureMorecommonthanwebelieve!,2%,10%,CHF:Aagedpopulation,0,100,200,300,400,500,600,700,1960,1980,2000,2020,Millions,165,296,403,649,ChronicHeartFailureAdiseasestatewhichseldomstops!,Riskfactors:diabeteshypertension,Vasculardysfunction,Vasculardisease,Tissueinjury(MI,stroke),Pathologicalremodeling,Targetorgandysfunction(HF,renal),SympatikusAngiotensinIIaldosterone,-,TheCardiovascularContinuum,Adapted2019fromDzauV,BraunwaldE.AmHeartJ.1991;Gibbons2019.,Heartfailure,Death,ChronicHeartFailureMoremalignantthanwebelieve!,CHF:Moremalignantthanmostcancer!,Stewartetal.EurJHeartFailure2019,3(3):315-,StandardHeartfailurecare,Extraordinarymeasure,Riskmodification,X,X,ChronicHeartFailureWorsethanwebelieveinCHFtreatment,diureticdigoxin,diureticdigoxin,diureticdigoxinACE-I,diureticdigoxinACE-I,diureticdigoxinACE-Iblocker,diureticdigoxinACE-Iblocker,ACEI(1991),blocker(2019),ARB(2019),ACE-I,blocker,ARB,Evidence-basedheartfailuremedications,Oneyearmortality(%),WorldwideGteborgblocker:50%82%ACEI:64%75%,Age80yearsWorldwideGteborgblocker:15%80%ACEI:35%73%,Europeanheatsurvey,HeartfailureregistryinGteborg,AGapbetweenGuidelineandClinicalPractice,Canwedobetter?,Toclarifyobjectivesoftreatmentofchronicheartfailure,Prognosis,Morbidity,Prevention,Lifequality,No1,Puttingguidelineintoclinicalprctice!,No2,Evidencebasedmedicinemakesdifference!,CHF,ACEI+BB,ESC,CHF,ACEI+BB,Persistingsymptoms&sign,Yes,ARBorAldosteroneantagonist,ESC,CHF,ACEI+BB,Persistingsymptoms&sign,Yes,ARBorAldosteroneantagonist,Persistingsymptoms,Yes,QRS120ms,Yes,CRT/CRT-D,ESC,CHF,ACEI+BB,Persistingsymptoms&sign,Yes,NO,ARBorAldosteroneantagonist,Persistingsymptoms,Yes,QRS120ms,Yes,CRT/CRT-D,NO,LVEF35%,Yes,ICD,ESC,CHFinparticularSuddendeath,SuddenDeath,“Themajorchallengeconfrontingcontemporarycardiology”,BernardLown,MostcommondeathinHypertensionPost-MIpatientsHeartfailure,SuddenDeath,PrimaryPrevention,Diu,Meto,5,10(y),(n=3234),Hypertension,50,CumulativeNo.,SuddenDeath-RiskReductionwithMetoprolol,SecondaryPrevention,Plac,Meto,(n=5474),1,2,3(y),PostMyocardialinfarction,TertiaryPrevention,Plac,MetoCR/XL,6,12,18(m),(n=3991),HeartFailure,12,CumulativeNo.,120,OlssonGetalAmJHypertens1991,OlssonGetalEurHeartJ1992,MERIT-HFStudyGroup,Lancet2019,CumulativePerCent,CHFinparticularPost-MI,Postinfarct-HF,Heartfailureatadmission,0,1,2,3,4,5,6,Months,0.0,0.1,0.2,0.3,Noheartfailureatadmission,20.7,5.9,12.0,2.9,Heartfailureduringhospitalisation,25.3,%Mortality,SurvivalPost-MI:GRACERegistry,StegetalCirculation2019,MetoprololCRinPost-MIHF,Janosietal.,AmHeartJ2019,146(4):721-,CHFinparticularDoubelRAASinhibitors,CHARMProgramme,CHARM-AddedBaselinecharacteristics(1),Meanage(years)6464Women(%)2121NYHAclass(%)II2424III7373IV33MeanLVEF(%)2828ACEinhibitor(%)100100Beta-blocker(%)5556Spironolactone(%)1717,McMurrayetal,Lancet2019,CandesartanPlacebon=1276n=1272,0,1,2,3,years,0,10,20,30,40,50,Placebo,Candesartan,%,NumberatriskCandesartan127611761063948457Placebo127211361013906422,3.5,HR0.85(95%CI0.75-0.96),p=0.011AdjustedHR0.85,p=0.010,483(37.9%),538(42.3%),McMurrayetal,Lancet2019,CHARM-AddedPrimaryoutcome,CVdeathorCHFhospitalisation,EffectofCandesartan:OntopofACEI,BBandSpironolacton,Walkingoutfrommisperceptions!,No3,Beta-blockersshouldbeavoidedindiabeticCHFpatients,Beta-blockersshouldbeavoidedinCOPDandCHFpatients,Beta-blockersandACEinhibitorsshouldbeavoidedinelderlyCHFpatients,Lowdoseofbetablocker/ACEIisnotmeningful,False,False,False,False,False,AllbetablockersorARBhaveclasseffects,False,Tobecreative!,No4,HypotensionBradycardyRenaldysfunctionHyperkalaemiaLowcompliance,Forexample,Noteasy,butnotimpossible!,Toomuchdiuretics?,Hypotension,Othervasodilators?,Symptomatic?,Timetore-consider!,Negativechronotropicdrug(digitalis,CCBwithlowvascularselectivity)?,Bradycardy?,Symptomatic?,Timetore-consider!,Daytime?Evening?,Atrest?Exercise?,Pacemaker?,WhatshallwedowhenguidelinedoesNOTexist?,NoguidelineinmostHFpatients,Elderly,HFNEF,HFNEF:HFwithpreservedsystolicfunction,IdoasIwishbecausethereisnoguideline,Idomybestasphysiciandespitethereisnoguideline,Idonothingbecausethereisnoguideline,Wrong!,Right!,Wrong!,Prevention:BPDiagnos:NTproBNPHeartFailureOutpatClinicSelf-care:eduction,exercise,Guidelinecoversmore!,GuidelineNotdictionaryinbookshelf,butconceptinyourbrain!,Paradigmshift:Neweratocome!,HeartFailure70-90:Standardtherapywithblocker,ACEI,HeartFailure2000-:TailoredheartfailuremanagementonthebasisofACEI/BBFocusonpatientswell-being,HeatFailure50-70:Digitalis,Vasodilator,Inotropics,Consideringho