如何优化心衰控制？课幻灯PPT

1、keep guideline in mind, walking your own way !michael fu, md, phd, fescprofessor, senior consultant physicianhead, heart failure center medicinesahlgrenska university hospital/sahlgrenskagteborg, swedenhow to optimize heart failure management ?chronic heart failuremore common than we believe !2 %10

2、% chf: a aged population01002003004005006007001960198020002020millions165296403649chronic heart failure a disease state which seldom stops !-the cardiovascular continuumadapted 2003 from dzau v, braunwald e. am heart j. 1991; gibbons 1999.chronic heart failure more malignant than we believe !chf: mo

3、re malignant than most cancer !stewart et al. eur j heart failure 2001, 3(3): 315- arisk factor ischemea hypertention diabetes bheart dysfunction c heart failure drefractory hfstandard heart failure careextraordinary measurerisk modificationxx chronic heart failure worse than we believe in chf treat

4、mentdiureticdigoxindiureticdigoxindiureticdigoxinace-idiureticdigoxinace-idiureticdigoxinace-i blockerdiureticdigoxinace-i blockeracei (1991) blocker (1999)arb (2003) ace-i blockerarbevidence-based heart failure medicationsone year mortality (%) worldwide gteborg blocker: 50 % 82 %acei: 64% 75 %age

5、80 years worldwide gteborg blocker: 15 % 80 %acei: 35% 73 %european heat survey, heart failure registry in gteborga gap between guideline and clinical practicecan we do better ? to clarify objectives of treatment of chronic heart failureprognosismorbiditypreventionlife qualityno 1putting guideline i

6、nto clinical prctice !no 2evidence based medicine makes difference !beta-blocker ace inhibitor at1 receptor blocker aldosteron receptor antagonist digitalis diuretics antikoagulationvasodilatorantiarytmicsinotropic agentscalcium channel blockerstatinasatnf- antagonist, endothelin antagonist, avp ant

7、agonist relieve slow prevent symptom prpgression scd ? chfacei+bbesc chfacei+bbpersisting symptoms & signyesarb or aldosterone antagonistesc chfacei+bbpersisting symptoms & signyesarb or aldosterone antagonistpersisting symptoms yesqrs120 ms yescrt/crt-d esc chfacei+bbpersisting symptoms &am

8、p; signyesnoarb or aldosterone antagonistpersisting symptoms yesqrs120 ms yescrt/crt-d nolvef35% yesicdescchf in particularsudden deathsudden death“the major challenge confrontingcontemporary cardiology”bernard lownmost common death in hypertension post-mi patients heart failuresudden deathdiumeto51

9、0 (y) (n=3 234)hypertension50cumulative no.sudden death - risk reduction with metoprololplacmeto(n=5 474) 123 (y)post myocardial infarctionplacmetocr/xl61218 (m) (n=3 991)heart failure12cumulative no.120olsson g et alam j hypertens 1991olsson g et al eur heart j 1992merit-hf study group, lancet 1999

10、cumulative per centchf in particularpost-mi 20.75.912.02.925.3% mortalitysurvival post-mi : grace registrysteg et al circulation 2004metoprolol cr in post-mi hf janosi et al., am heart j 2003, 146(4): 721-chf in particulardoubel raas inhibitors charm programmecharm-addedbaseline characteristics (1)m

11、ean age (years) 6464women (%)2121nyha class (%)ii 2424iii7373 iv 33mean lvef (%)2828ace inhibitor (%)100100beta-blocker (%)5556spironolactone (%)1717mcmurray et al, lancet 2003candesartanplacebo n=1276 n=12720123years01020304050placebocandesartan%number at riskcandesartan127611761063948457placebo127

12、2113610139064223.5hr 0.85 (95% ci 0.75-0.96), p=0.011adjusted hr 0.85, p=0.010483 (37.9%)538 (42.3%)mcmurray et al, lancet 2003charm-addedprimary outcome, cv death or chf hospitalisationeffect of candesartan: on top of acei, bb and spironolactonwalking out from misperceptions !no 3 beta-blockers sho

13、uld 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 meningfulfalsefalsefalsefalsefalse all beta blockers or arb have class effectsfalseto be c

14、reative !no 4 hypotension bradycardy renal dysfunction hyperkalaemia low compliance for examplenot easy, but not impossible !too much diuretics ?hypotensionother vasodilators ?symptomatic ?time to re-consider !negative chronotropic drug (digitalis, ccb with low vascular selectivity ) ? bradycardy ?s

15、ymptomatic ?time to re-consider !daytime ? evening ?at rest ? exercise ?pacemaker ?what shall we do when guideline does not exist ?no guideline in most hf patientselderlyhfnefhfnef: hf with preserved systolic function i do as i wish because there is no guideline i do my best as physician despite the

16、re is no guideline i do nothing because there is no guidelinewrong !right !wrong ! prevention : bp diagnos: ntpro bnp heart failure outpat clinic self-care: eduction, exercise guideline covers more !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, aceiheart failure 2000-: tailored heart failure management on the basis of acei/bb focus on patients well-beingheat failure 50-70: digitalis, vasodilator, inotropicsconsidering how much attention has