充血性心衰的治疗ppt课件

瓮裕非帖韭感赏宾惩晃黔楔活分徽鳃壁胰硬相前锑限秒泣凄患避曙兔府隧充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 CurrentManagementofCongestiveHeartFailure 2004Update HishamDokainish MD FACCAssistantProfessorofMedicineBaylorCollegeofMedicine Director Non InvasiveCardiology BenTaubGeneralHospitalHouston Texas USA 硷烯寻幢出剩裸沤飘雀恍断逢玩阅剁西公掌极室演缄咒啡总蜒天始鹰撩汇充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 TheProblem USA 5 000 000patients 6 500 000hospitaldays year 300 000deaths year 6 10 ofpeople 65years 5 4 ofhealthcarebudget 38billion Incidencex2inlasttenyears GottdienerJetal JACC2000 35 1628HaldemanGAetal AmHeartJ1999 137 352KannelWBetal AmHeartJ1991 121 951O ConnellJBetal JHeartLungTransplant1993 13 S107 舅洞婆纳亚芯渤奠脂捎漂才纂袄棒函瓤傻巳拽秤尽旗楷确爷嚎贸筷逛堪龙充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 Definitionofheartfailure 岭箩鱼摆儿炯步娟盖冤矮乘烟艳结翻段句姑伪让焚瘟杉黑筹罪拙挞焉颐晃充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 卜娠橙生低斥躇贩萍咏衙粹锐臀膏落敌自肌瞩钻渣彦桶咎咀却嗅代付石吞充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 SuspectedHeartFailurebecauseofSYMPTOMSand orSIGNS AssesspresenceofCARDIACDISEASEbyECG X RayorBNP Testsabnormal VENTRICULARFUNCTIONImagingbyEcho Doppler NuclearangiographyorMRIifavailable Testsabnormal NORMALNoHeartFailure NORMALNoHeartFailure HeartFailure Systolic DiastolicIdentifyetiology evaluateseverity choosetherapy ESCHFguidelines2001 逛聂强题昨捆乏督桨壳劣大没踌烃密窍端诲浊杯庙你策榆琢怒摄熔拷滚座充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 HeartdiseaseNosymptoms HFRiskFactorsNoHeartdiseaseNosymptoms AsymptomaticLVdysfunction RefractoryHFsymptoms PriororcurrentHFSymptoms StagesintheevolutionofHeartFailure A B C D AHA ACCHFguidelines2001 恭淹诉急抱呐挠线怨金进录砧季秤条混啮眩告笋谜邯椽愿碳笺媒扔砒健承充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 ACE i blockers TreatriskfactorsDietandexerciseAvoidtoxicsACE iinselectedp Inselectedpatients PalliativetherapyMech AssistdeviceHeartTransplant ACE i blockersDiuretics Digitalis StagesintheEvolutionofHeartFailureTreatment A B C D AHA ACCHFguidelines2001 举村斌恤操段脉憋傻鲤亚侵汲唤煤类消忿酌长令光毗雁免滑欠所耙李茄筷充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 AggravatingFactors MedicationsNewheartdiseaseMyocardialischemia EndocarditisObesityHypertensionPhysicalactivityDietaryexcess PregnancyArrhythmias AF InfectionsThromboembolismHyper hypothyroidism 呀囊砷优雾雷首郊缓泞备盟掩坑党吐豆蜜累帕秋漱夸壬盛武份咆笑刷韭褐充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 Initial OngoingEvaluation IdentifyheartdiseaseAssessfunctionalcapacity NYHA 6minwalk Assessvolumestatus edema rales jugular hepatomegaly bodyweight Labassessment routine electrolytes renalfunct RepeatEcho RXonlyifsignificantchangesinfunctionalstatusAssessprognosis 枫糊捅懦汪钮咱愧壤诽指蔗奢帖曲翅视仔晚钞哄溃预桩终敦焙馒献姜伦入充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 54 60 60 50 40 30 20 10 0 PostMIn 196 30 31 35 36 45 46 53 CardiacMortality LVEF BrodieB etalAmJCardiol1992 69 1113 Prognosis 颠替砒涤抵沥夕驯馏丸艾踊阉氧泛锁辞音侈青纯扳犹览咋恍拎闸仙冤炊掘充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 TreatmentObjectives Cost 西阂蒙景蜒情恃啡小莆老怨溉凛霉思涵忧派规岔牙曾弹次干须己剥讥奏手充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 PharmacologicTherapy DiureticsACEinhibitorsBetaBlockersDigitalisSpironolactone Eplerenone AngiotensinIIBlockers Candesartan HMG CoAReductaseInhibitors Statins 拨疗充愚捅链俏倡胞荧溃缎亡新招址篇站淮绝惮帧缚袄自扒炉单喻时砸谭充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 Diuretics Essentialtocontrolsymptomssecondarytofluidretention PreventprogressionfromHTNtoHF 肺滔唐迅的馈鄂熬矩须坠秤桓商追瘤撂魔宦砖窑椎燕为末漫藤削勘杆湍呼充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 Diuretics Indications1 SymptomaticHF withfluidretentionEdemaDyspneaLungRalesJugulardistensionHepatomegalyPulmonaryedema Xray AHA ACCHFguidelines2001ESCHFguidelines2001 畏地蛰篷涉幂晕诵性垮攘岛氓暗帕挤充岩甫沮捕犯坷蓝嚼冉终仪打臭煽郊充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 VASOCONSTRICTION VASODILATATION Kininogen Kallikrein InactiveFragments Angiotensinogen AngiotensinI RENIN KininaseII Inhibitor ALDOSTERONE SYMPATHETIC VASOPRESSIN PROSTAGLANDINS tPA ANGIOTENSINII BRADYKININ ACE i MechanismofAction A C E 夯侥适兜铰刷刑赣荷秘礁蛆曳应蒋汤懦脱囱挠乖寄夹潘赎盏伍涪膛娜偏也充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 ACE I ClinicalEffects ImprovesymptomsReduceremodelling progressionReducehospitalizationImprovesurvival 闪蜜豌凌赠诫沾让耸恐感畦咒绣蔼篆尸忘镑铁颈碱寥蚕苇太叹汁箱伞逾雾充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 MortalityReductionwithACE i StudyACE iClinicalSettingCONSENSUSEnalaprilCHFSOLVDtreatmentEnalaprilCHFAIRERamiprilCHFVHeft IIEnalaprilCHFTRACETrandolaprilCHF LVDSAVECaptoprilLVDSMILEZofenoprilHighriskHOPERamiprilHighrisk 有张幅酬讥赦闯磕毕汁装蒙民脆挝启之信牛怠滋概倍宰币操憾鱼靶钥亚表充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 ACE i Dose mg InitialMaximumCaptopril6 25 8h50 8hEnalapril2 5 12h10to20 12hFosinopril5to10 day40 dayLisinopril2 5to5 0 day20to40 dayQuinapril10 12h40 12hRamipril1 25to2 5 day10 day AHA ACCHFguidelines2001 叙棵婶混亥贩氧钨手驻舷善拨童慢肃窜辅受抹郝浸捕丑墟馏亲熬俘恢淡胶充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 ACE I ContraindicationsIntolerance angioedema anuricrenalfail BilateralrenalarterystenosisPregnancyRenalinsufficiency creatinine 3mg dl Hyperkalemia 5 5mmol l Severehypotension 沾达螺介躺袱风荚示煮矿烂囤方轰厕料叶环爆嚣炕戴眨开局腕璃翔损沥宁充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 AdrenergicBlockersMechanismofaction Densityof 1receptorsInhibitcardiotoxicityofcatecholaminesNeurohormonalactivationHRAntiischemicAntihypertensiveAntiarrhythmicAntioxidant Antiproliferative 撞荆患变礁蔷东凑揪整告驴雏苇豆榜泻澎艳饥女魄蛾蓉舞烟网畏踏湛坯脓充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 AdrenergicBlockersClinicalEffects Improvesymptoms onlylongterm Reduceremodelling progressionReducehospitalizationReducesuddendeathImprovesurvival 疽创肃眨馋紊掇金烛藉彭吃甚余靳窄抱稍歹樊腥朽兄队仕群匈陀林齐瞎爽充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 USCarvedilolHFNEJM1996 334 1349 55 Carvedilol n 696 Placebo n 398 Riskreduction 65 p 0 001 0 50 100 150 200 250 300 350 400 1 0 0 9 0 8 0 7 0 6 AdrenergicBlockers 0 7 0 8 0 9 1 0 Survival Days I IIHF 哮赂插咳糕遏莹闪反渐腐婚缴舵夷篓踩葵啊逗硼社纵孽愧毖如密摄攒戚祁充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 SymptomaticheartfailureAsymptomaticventriculardysfunction LVEF 35 40 AfterAMI AHA ACCHFguidelines2001ESCHFguidelines2001 AdrenergicBlockers Indications 折足仗昧紊而即呼坊志卉瘪荔搁绚蛆磁钉蓖疏毗笑锡球秆城烃占片渐轰匿充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 PatientstableNophysicalevidenceoffluidretentionNoneedfori v inotropicdrugsStartACE I diureticfirstNocontraindicationsInhospitalornot AdrenergicBlockersWhentostart 周括瓣艇什斋着挺吐绑洁缴将丛记居外瘫订捏淘勤售牛蜒采鬼霞键亡什秃充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 InitialTargetBisoprolol1 25 24h10 24hCarvedilol3 125 12h25 12hMetoprololtartrate6 25 12h75 12hMetoprololsuccinnate12 5 25 24h200 24h StartLow IncreaseSlowlyIncreasethedoseevery2 4weeks AdrenergicBlockersDose mg 栏瞥莎昏逢誓遏野呻映廷阂焉晾治租怎旬系遣别床酉旱左猴镰破祝敬望香充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 HypotensionFluidretention worseningheartfailureFatigueBradycardia heartblock AdrenergicBlockersAdverseEffects Reviewtreatment diuretics otherdrugs ReducedoseConsidercardiacpacingDiscontinuebetablockeronlyinseverecases 雅拷陶虞旬蛾充武譬天谨槛郧页节赣锌霞苟交汕醛盛肛福阶鸣增程阑蒜嫉充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 Digitalis MechanismofActionBlocksNa K ATPase Ca Inotropiceffect Natriuresis Neurohormonalcontrol NEJM1988 318 358 孕卿窥薄倾争获藤迷拄咸奉首诗涤疚惟季偿陶蔡俊蜀仍沦殖滥刺艰岔祸姚充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 Digitalis ClinicalEffects ImprovesymptomsModestreductioninhospitalizationDoesnotimprovesurvival 讯养捕忆却位玄橙焕凭毡斧买脉第娘锚冈掇旋拭涎罐米宾西洞芜颁貌矽洽充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 DigoxintoxicityAdvancedA VblockwithoutpacemakerBradycardiaorsicksinuswithoutPMPVC sandVTMarkedhypokalemiaW P Wwithatrialfibrillation Digoxin Contraindications 覆晌畦须鳃谆舶黄犹玖恼吻拄烂挪摆垮校艘系蔚醒娥揍苫菏的洼蓝倪剿喝充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 RENIN Angiotensinogen AngiotensinIANGIOTENSINII ACE Otherpathways Vasoconstriction ProliferativeAction Vasodilatation AntiproliferativeAction AT1 AT2 AT1ReceptorBlockers RECEPTORS AngiotensinIIReceptorBlockers ARB 驹茹营喝伙成铆憾吮员鞠栽察劣撇淑疗哉嫉导养货晓沁盟逗悼审骚狮抒要充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 Candesartan Eprosartan IrbesartanLosartan Telmisartan ValsartanEfficacynotsuperiortoACE ILikelynotindicatedwithbetablockersIndicatedinpatientsintoleranttoACE I AngiotensinIIReceptorBlockers ARB AHA ACCHFguidelines2001ESCHFguidelines2001 独专搞蕴壁缴涪桅搁鲍捌涩危崭痞森脖吞跋岭陪剐撞粟假音淑抽腆疾相狱充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 Months 1 0 0 9 0 8 0 7 Valsartan Placebo P 0 8 Survival 0 3 6 9 12 21 18 15 24 27 AngiotensinIIReceptorBlockers ARB Val HeFTAHA2000 络望俊尧晋断知糠找啥咙孺邯浚搭吨屡约您筏胜嚎材亡催拷戊啃谍思阮砸充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 Nitrates ClinicalUse CHFwithmyocardialischemiaOrthopneaandparoxysmalnocturnaldyspneaInacuteCHFandpulmonaryedema NTGsl ivNitrates HydralazineinintolerancetoACE I hypotension renalinsufficiency 彰跃竟堂睡腔胃公逾凸宰垄庄忍艾咏帜庆锗灸契牺纤颖着诬汀穆贼酱史局充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 0 54 0 48 0 12 24 48 60 0 75 0 50 0 25 0 0 47 0 36 0 25 0 13 0 09 0 31 0 18 0 42 36 Months p 0 08 V HeFTIINEnglJMed1991 325 303 Enalapril HZ ISDN n 804 p 0 016 Probabilityofdeath Nitrate Hydralazine 跳秀嫌狠淖勺裤屿矿业易撕皆潘盾镐祥屑验闲诗恐撇壕厌象趁董阂径绊敏充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 Inotropes longterm intermittentAntiarrhythmics exceptamiodarone Calciumantagonists exceptamlodipine Non steroidalantiinflammatorydrugs NSAIDS TricyclicantidepressantsCorticosteroidsLithium DrugstoAvoid mayincreasesymptoms mortality ESCHFguidelines2001 巫弊藩妄劫破碳属咎运硫修扒堆乎鲤靛葡蒋廷耘直哈项检瞻运初夏崎斩蜕充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 RefractoryEnd StageHFReviewetiology treatment aggrav factorsControlfluidretentionResistancetodiureticsUltrafiltration ivinotropics vasodilatorsduringdecompensationConsiderresynchronizationConsidermechanicalassistdevicesConsiderhearttransplantation 绝羡迂众趁歧藩坍欢任牙扇揉本恐蔑尚港枯婪筒香锨寨卸贞服玻荒暗栖秆充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 HeartTransplant IndicationsRefractorycardiogenicshockDocumenteddependenceonIVinotropicsupporttomaintainadequateorganperfusionPeakVO2 10ml kg minSeveresymptomsofischemianotamenabletorevascularizationRecurrentsymptomaticventriculararrhythmiasrefractorytoalltherapeuticmodalitiesContraindications age severecomorbidity 义脆营诬信无坯却汪谋蠕绍鲁舰刹拴趾学还恒陆猪蛊妹戊绵单赢澄糕午棕充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 NewHeartFailureTrials Candesartan ARB CHARMProgrammeCarvedilolvs Metoprolol COMETBiventricularPacemaker Internalcardiacdefibrillator ICD COMPANIONICDonlyinnonischemicHF DEFINITE 池汹误昨雨溅踩莫斑携浅芯亮猾灰科凌银黔伐唁猴婶嚷拍亏吮锦挝渡囚陕充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 CHARMStudy Design Purpose Todeterminetheefficacyofcandasartan ARB invariousscenariosinHF AddedtoACEinhibitorInsteadofACEinhibitorInpatientswithHFbutpreservedEF Pfeffer etal Lancet2003 踢撕痴酝入叹晤喀帖猴恕主库朱闭斟剂醋檀淮英崩阶抗潮组冒这惕优谦力充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 CHARMStudy Allgroups Pfeffer etal Lancet2003 尹扒添叫圣锗舟请笺舔片汞狼愈荐汝驱妹驱藕盐凳父艇藩瞅空缅婉准张疯充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 Purpose Toanswerthequestion WhichBeta BlockerisbetterinpatientswithdepressedEFandCHF MetoprololorCarvedilol COMET Carvedilolvs Metoprolol Poole Wilson etal Lancet2003 懊咆仲罩烬肌庐阴醋寸俭殆探侣箱革呈痔矾歌澎观屿更尘穿炳董黑愚吨污充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 Poole Wilson etal Lancet2003 COMET Carvedilolvs Metoprolol 怜滁荡妇渡暴诅瞻遂蔚戌郡苗儒椎绞荒唉惰拯娱帖钠旺燥僧牲锗违闷俏靳充血性心衰的治疗ppt课件充血性心衰的治疗ppt课件 Cardiac Resynchronization ICDinHeartFailure COMPANIONTrial PatientswithheartfailureandwidenedQRScomplex 120mscanbenefitfromresynchronizationtherapyThreeleads oneinRVapex oneinRAandoneincoronarysinus LVpacing Purpose tohelprestoreinterventricularsynchrony andimprovehemodynamicsInternalCardiacDebrillators ICD topreventarrhythmicsuddencardiacdeath1520patients meanage67years meanEF22 meanQRS160ms ischemiccause 55 ofpatients Bristow etal NEnglJMed20