充血性心力衰竭ppt课件.ppt

CongestiveHeartFailureCollaborative October14 2004 PreventingReadmissionsKennethA LaBresh MD FAHA FACCV P MedicalAffairsandQualityImprovement MassPROClinicalAssociateProfessor BrownUniversity 天马行空官方博客 ACC AHAGuidelinesforEvaluationandManagementofChronicHeartFailure2001 HFcanbepreventedHFhasestablishedriskfactorsHFisaprogressiveconditionwithasymptomaticandsymptomaticstagesHFmorbidityandmortalitycanbereducedbystagespecifictreatments Hunt etal JAmCollCardiol 2001 38 2101 2113 ACC AHAProposedStagesofHF STAGEAHighriskfordevelopingHFSTAGEBAsymptomaticLVdysfunctionSTAGECPastorcurrentsymptomsofHFSTAGEDEnd stageHF Hunt etal JAmCollCardiol 2001 38 2101 2113 NeurohormonalActivationinHeartFailure Hypertrophy apoptosis ischemia arrhythmias remodeling fibrosis AngiotensinII Norepinephrine MorbidityandMortality CNSsympatheticoutflow Cardiacsympatheticactivity Renalsympatheticactivity Sodiumretention MyocytehypertrophyMyocyteinjuryIncreasedarrhythmias Diseaseprogression 1 b1 b1 b2 1 Vascularsympatheticactivity Vasoconstriction 1 ActivationofRAS AdrenergicPathwayinHeartFailureProgression Beta blockerTherapyinHeartFailure PotentialBeneficialEffects ProtectionfromCatecholamineToxicity ReninAngiotensinSystem ReversalofRemodeling Up regulationofb adrenergicReceptors AncillaryFactors MajorPlaceboControlledTrialsof BlockadeinHeartFailure 34 CumulativeMortality Days 20 15 5 0 10 P 0062 adjusted MetoprololCR XL n 1990 Placebo n 2001 USCarvedilolTrials1 ProbabilityofEvent freeSurvival Carvedilol n 696 Placebo n 398 Days P 001 0 0 0 100 200 300 400 65 1 0 0 8 0 7 0 9 MERIT HF2 Survival ofPatients 100 90 80 60 70 0 600 0 400 300 200 100 Days Carvedilol n 1156 Placebo n 1133 500 600 0 400 300 200 100 500 35 P 00013 COPERNICUS4 Days 0 0 200 400 800 1 0 0 8 0 6 P 0001 34 Bisoprolol n 1327 Placebo n 1320 CIBIS II3 0 600 Survival 1PackerMetal NEnglJMed 1996 334 1349 1355 2MERIT HFStudyGroup Lancet 1999 253 2001 2007 3CIBIS IIInvestigators Lancet 1999 353 9 13 4PackerMetal NEnglJMed 2001 344 1651 1658 COPERNICUS All CauseMortality Survival PackerMetal NEnglJMed 2001 344 1651 1658 900 600 300 0 P 0012 P 0002 P 0001 Forany reason Forcardiovascular reason Forheart failure Placebo Carvedilol 29 33 600 400 200 0 450 300 150 8 20 COPERNICUS NumberofHospitalizations PackerMetal Circulation 2002 106 2194 2199 0 5 10 15 20 25 30 AllPatients n 2289 Higher RiskPatients n 624 NumberofEvents KrumHetal JAMA 2003 289 712 718 0 60 180 AllPatients n 2289 Higher RiskPatients n 624 NumberofEvents 8Weeks 8Weeks Deaths DeathorHospitalizationforAnyReason Placebo Carvedilol COPERNICUS EarlyClinicalOutcomes 120 25 19 15 3 153 134 63 44 DoesSubspecialtyCareAffectCHFOutcome SUPPORT1298HospitalizedPatients743 57 Cardiolgist C 555 43 PrimaryCare P CPAge6371Male71 52 EFknown69 47 EF 20 52 39 SUPPORTResults Cardiologistsvs PrimaryCare RHC2 9timesmorelikelyCoronaryangio3 9timesmorelikelyHospitalcosts43 higherACE I64 INBOTHgroupsShorttermmortalitysimilar4 6yearfollowupmortality20 lowerforcardiologists rr0 80 0 66 0 96 Aurebachad AIM2000 132 191 200 ImpactofSubspecialityCare UpstateNewYork10hospitalsThreepatientgroupsINoncardiologistn 977IICardiologistAttendingn 419IIICardiologyConsultn 1058GroupImoreNH morecomorbiditymorefemales lessB Blockeruse UpstateNewYorkResults Results cont PhilbinE CHEST116 2 346 354 HospitalBasedCHFClinic Retrospectiveanalysisbefore n 407 andafter n 357 implementationofaCHFprogramin1994ElementsoftheProgramMultidisiplinaryteamInpatientandoutpatienttreatmentprotocolsPatientandfamilyeducationFollowuptelephonecallsOutpatientinfusioncenter Outcomes HFManagementMetaAnalysis McAlisterFA etal JACC2004 44 810 819 29studiesinvolving5 039patients Conclusions HFmanagementprogramsdecreaseHFhospitalizationsinawidevarietyofformatsMultidisciplinaryapproaches particularlyHFclinicshavebeendemonstratedtoreducemortalityaswell150f18studiesthatevaluatedcostsdemonstratecostsavingsaswell SPAN CHF SpecializedPrimaryandNetworkedCareinHeartFailure Kimmelsteiletal Circ2004 110 1450 1455 CharacteristicsoftheSystem 1 FocusonpatientswhohavearesentHFhospitalization2 AdministeredbynursesascasemanagerswithstrongexpertiseinHFwiththesupportofHFphysiciansactingasconsultantstothenurses TelephonemonitoringandlimitedhomevisitsCommunicationbetweenthenurseandthePCP5 Providedathree month activeintervention followedbysurveillanceoutto1year Hypothesis Auniformdiseasemanagementprogramwill ReducethecostofmedicalcareIncreasethetimetohospitalizationordeathDecreasethefrequencyofadmissionforHF IncreasethetotalnumberofdaysaliveoutofhospitalImproveindicesofhealth relatedqualityoflife CharacteristicsoftheStudyPopulation InclusionPatientsd cwithaprimarydiagnosisofheartfailureEtiologyofHFmayinclude IHD DilatedCMP correctedvalvediseaseorregurgitantvalvediseasedeemeduncorrectableduetosevereLVdysfunction hypertension orhypertrophicdiseaseoftheelderlyLVEFwithin6monthsshowingnonsystolicHFPatientcareprovidedbyaphysicianotherthanaSPAN CHFprovider PatientCharacteristics SPAN CHF EVENTFREESURVIVAL SPAN CHF HFHospitalizations HospitalDays Patient YearAliveinInitial90Days RR 0 48P 0 027 RR 0 54P 0 001 SPAN CHF HFHospitalizations HospitalDays Patient YearAlive1Year RR 1 02P 0 93 RR 0 87P 0 07 CONCLUSIONS CHFisadevastatingresultofcardiovasculardiseasewhichcontinuestoincreaseMultipleeffectivestrategiesareavailabletodealwiththisepidemicbutnotroutinelydeliveredtopatientsDiseasemanagementstrategiesresultincosteffectiveimprovementinpatientsoutcomes Spread TootherpartsofthehospitalTootherhospitalsinthes