ESC慢性心衰指南课件

DiagnosisAccordingtotheWorkingGroupinHeartFailure,HeartFailureisasyndromewherethediagnosishasthefollowingessentialcomponents:Acombinationof:Symptoms,typicallybreathlessnessorfatigueCardiacdysfunctiondocumentedatrestThediagnosisissupportedby:ResponsetotreatmentdirectedtowardsheartfailureDiagnosisAccordingtotheWorkAssessmentsinallcases

Necessary Supports OpposesHistorywithsymptoms +++ IfabsentObjectiveevidence +++ IfabsentResponsetotreatment ++ EstablishdiagnosisAssessmentsinallcases EstabTest

Necessary Supports OpposesElectrocardiogram ++ IfnormalEchocardiography +++ IfnormalChestx-ray Ifcongestion IfnormalBloodcount IfnormalBloodchemistry IfnormalTestsforDiagnosisTestTestsforDiagnosisAdditionalTestsforDiagnosisTest Necessary Supports OpposesExercisetest IfnormalNatriureticpeptide Ifelevated IfnormalCardiaccath. IfnormalAdditionalTestsforDiagnosisTesttoExcludeAlternativesChestx-ray(Lungdisease)PulmonaryfunctionBloodchemistry(Renalandhepaticdisease)Bloodcount(Anaemia)Exercisetolerance(ifimpaired)TesttoExcludeAlternativesChElectrocardiographyAnormalECGsuggeststhatthediagnosisofheartfailureshouldbecarefullyreviewed.ThepredictivevalueofanormalECGtoexcludeLVsystolicdysfunctionexceeds90%ElectrocardiographyAnormalECChestX-rayAhighpredictivevalueofX-rayfindingsisonlyachievedbyinterpretingtheminthecontextofclinicalfindingsandECGanomalies.ItisusefultodetectcardiacenlargementandpulmonarycongestionInchronicheartfailure,increasedcardiacsizeandpulmonaryvenouscongestionareusefulindicatorsofabnormalcardiacfunctionwithdecreasedejectionfractionand/orincreasedLVfillingpressureHowever,cardiomegalyisfrequentlyabsentinacuteheartfailureandincaseswithdiastolicdysfunctionChestX-rayAhighpredictivevPulmonaryfunctiontestsMeasurementsoflungfunctionareoflittlevalueindiagnosingchronicheartfailure.However,theyareusefulinexcludingrespiratorycausesofbreathlessnessPulmonaryfunctiontestsMeasurExercisetesting

Inclinicalpracticeexercisetestingisoflimitedvalueforthediagnosisofheartfailure.However,anormalmaximalexercisetest,inapatientnotreceivingheartfailuretreatment,excludesheartfailureasadiagnosisExercisetestingInclinicalpInvasiveinvestigationInvasiveinvestigationisgenerallynotrequiredtoestablishthepresenceofchronicheartfailure,butmaybeimportantinelucidatingthecauseortoobtainprognosticinformationInvasiveinvestigationInvasiveEchocardiographyAsobjectiveevidenceofcardiacdysfunctionatrestismandatoryforthediagnosisofheartfailure,echocardiographyisthepreferredmethodforthisdocumentationThemostimportantparameterforidentifyingpatientswithsystoliccardiacdysfunctionandthosewithpreservedsystolicfunctionistheLVejectionfractionWhenthediagnosisofheartfailureisconfirmed,echocardiographyisalsohelpfulindeterminingitsaetiologyEchocardiographyAsobjectiveeNatriureticPeptidesThesepeptidesmaybemostusefulclinicallyasa“ruleout”testduetoaconsistentandveryhighnegativepredictivevaluesEspeciallyinprimarycarepatientssuspectedofhavingheartfailurecanbeselectedforfurtherinvestigationbyechocardiographyorothertestsofcardiacfunctiononthebasisofhavinganelevatedplasmaconcentrationofanatriureticpeptideInthoseinwhomtheconcentrationsarenormal,othercausesofdyspnoeaandassociatedsymptomsshouldbeconsideredTheaddedvalueofnatriureticpeptidesinthissituationhasyettobedeterminedNatriureticPeptidesThesepeptNatriureticPeptidesHighlevelsofnatriureticpeptidesidentifythoseatgreatestriskoffutureseriouscardiovasculareventsincludingdeathThereisalsorecentevidencethatadjustingheartfailuretherapyinordertoreducenatriureticpeptideslevelsinindividualpatientsmayimproveoutcomeNatriureticPeptidesOtherneuroendocrineevaluationsOthertestsofneuroendocrineevaluationarenotrecommendedfordiagnosticorprognosticpurposesOtherneuroendocrineevaluatioSuspectedHeartFailurebecauseofsymptomsandsignsTestsabnormalTestsabnormalAssesspresenceofcardiacdiseasebyECG,X-RayorNatriureticpeptides(whereavailable)NormalHeartFailure

unlikelyImagingbyEchocardiography(Nuclearangiographyor

MRIwhereavailable)NormalHeartFailure

unlikelyChoosetherapyAssessetiology,degree,precipitating

factorsandtypeofcardiacdysfunctionAlgorithmforDiagnosisofChronicHFAdditionaldiagnostictests

whereappropriate(e.g.coronaryangiography)SuspectedHeartFailureTestsaManagementOutlineEstablishthatpatienthasheartfailureIdentifypresentingsymptomAssessseverityoflimitationDetermineetiologyExcludeorconfirmconcomitantdiseasesPredictprognosisChoosetherapyMonitorprogressManagementOutlineEstablishthGuidelinesTreatment-ContentsGeneraladviceandmeasuresExerciseandexercisetrainingPharmacologicaltherapySurgeryanddevicesSpecialsubsections(elderly,diastolicCHF)CaremanagementprogrammesGuidelinesTreatment-ContentESC慢性心衰指南课件GeneralMeasuresandAdvice

Patientandfamilyeducationexplainheartfailuresymptoms–whattherapydoesself-weighingexercisevsrest

GeneralMeasuresandAdvicePGeneralmeasuresandadviceDiet-saltintakeandfluidrestrictionSmoking-cessationAlcohol-moderateintakepermittedObesity-weightreductionAbnormalweightlossTravellingSexualactivity-counselling,reassurancepatients/partnerVaccinations-influenza,pneumococcalGeneralmeasuresandadviceDieGeneralmeasuresandadvice

Drugcounselling:Self-management(diuretics)DesiredeffectsandsideeffectsDurationtreatmentbeforeeffectsbecomeapparentNeedforslowup-titrationInteractionwithotherdrugsGeneralmeasuresandadviceDrAce-inhibitorsACEinhibitorsarerecommendedasfirst-linetherapyinpatientswithareducedLVsystolicfunction (LVEF<40-45%)(LevelA)IntheabsenceoffluidretentionACEinhibitorsshouldbegivenfirst,inthepresenceoffluidretentiontogetherwithdiuretics(LevelB)ACEinhibitorsshouldbeup-titratedtothedosagesshowntobeeffectiveinlargetrials.TheyshouldnotbetitratedbasedonsymptomaticimprovementAce-inhibitorsACEinhibitorsaTherecommendedprocedureforstartinganACEinhibitor1.Reviewthedoseofdiuretics2.Avoidexcessivediuresisbeforetreatment.3.Startwithalowdoseandbuilduptomaintenancedosages4.Ifrenalfunctiondeterioratessubstantially,stoptreatment.5.Avoidpotassium-sparingdiureticsduringinitiationoftherapy.6.Avoidnon-steroidalanti-inflammatorydrugs(NSAIDs).7.Checkbloodpressure,renalfunctionandelectrolytes1-2weeksaftereachdoseincrement,at3monthsandsubsequentlyat6monthlyintervals(LevelC)TherecommendedprocedureforBeta-blockadeinHeartFailureBeta-blockingagentsarerecommendedforthetreatmentofallpatientswithstablemild,moderateandsevereheartfailurefromischemicandnon-ischemicorigin…onstandardtreatmentincludingACEinhibitionanddiuretics(levelA)Beta-blockingagentsarerecommendedinpatientswithLVdysfunctionwith/withoutheartfailurepost-MIforsurvivalbenefit(levelB)Beta-blockadeinHeartFailureInitiationanduptitrationof

beta-blockadeinheartfailurePatientsshouldbeonabackgroundtherapyofACEinhibitionanddiureticsStableconditionTirateslowlyandcarefullyfromlowinitialdosetotargetdosesusedinlargeRCTPatientsmayinitiallyworsenorexperienceadverseeffects(hypotension)–monitorandadaptothertherapyfirstbeforechangingdosebeta-blocker.ConsiderPDEinhibitorwhenpositiveinotropicsupportisneeded

Initiationanduptitrationof

SpironolactoneinHeartFailure

Aldosteroneantagonismisrecommendedinadvancedheartfailure(NYHAIIIandIV)inadditiontoACEinhibitiontoimprovesurvivalandmorbidity(levelB)SpironolactoneinHeartAdministrationandDosingConsiderationswithSpironolactoneToconsiderwhenapatientisinadvancedCHFdespitestandardtherapyCheckserumpotassium(<5mmol/L)andcreatinine(<250μmol/L)Add25mgspironolactonedailyandcheckpotassiumandcreatinineafter4-6daysIfpotassium>5-5.5mmol/L-reducedoseby50%,stopifpersistsIfafter1monthifsymptomsarestillsevere-increaseto50mgdailyandcheckpotassiumandcreatinineafter1weekAdministrationandDosingConsLoopDiuretics,ThiazidesandMetolazoneDiureticsareessentialwhenfluidloadispresentandmanifestaspulmonarycongestionandpulmonaryoedema(levelA)Thereductionofleftventricularfillingpressuresresultinrapidimprovementofdyspneaandimprovedexercisetolerance(levelB)LoopDiuretics,ThiazidesandPotassium-sparingDiureticsPotassium-sparingdiureticsshouldonlybeprescribedifpersistinghypokalemiadespiteACEinhibitortherapyinmildheartfailure(NYHAlII)andACEinhibition+low-dosespironolactoneinNYHAIII/IV(levelC)PotassiumsupplementsarelesseffectiveinthissituationMonitorcreatinineandpotassiumevery5-7daysuntilstablevalues

Potassium-sparingDiureticsPotAngiotensinReceptorBlockers(ARB)ARBscouldbeconsideredinpatientswhodonottolerateACEinhibitors(levelC)IthasnotbeenproventhattheyareaseffectiveasACEinhibitorsinmortalityreduction(levelB)InadditiontoACEinhibitionARBsimprovesymptomsandreducehospitalisationsforheartfailure(levelB)TheadditionofARBstoACEinhibitionandbeta-blockadecannotberecommendedatpresent-needsfurtherinvestigation(levelC)AngiotensinReceptorBlockersDigitalisGlycosidesCardiacglycosidesarerecommendedinatrialfibrillationandsymptomaticCHF…inordertoimprovecardiacfunctionandsymptoms…(levelB)Acombinationofdigitalisandbeta-blockadeappearssuperiortoeitheragentalone(levelC)InsinusrhythmdigoxinmayimprovetheclinicalstatusinpersistingheartfailuresymptomsduetoLVsystolicdysfunction(levelB).DigitalisGlycosidesCardiacglVasodilatorsVasodilatorsmaybeusedasadjunctivetherapyinheartfailureforthereliefofanginaoracutedyspnoe(nitrates)orconcomitanthypertension(DHPcalciumantagonists)ARBsbetterchoicethannitrates/hydralazinewhenintolerancetoACEinhibitors(levelB)Alpha-blockersarenotrecommendedforheartfailure(levelB)

DHPcalciumantagonistshavenoeffectonsurvivalinCHFduetoLVsystolicdysfunction(levelA)VasodilatorsVasodilatorsmaybPositiveInotropesInotropicagentsarecommonlyusedtolimitsevereepisodesofCHForasabridgetotransplantation(levelC). Useofdobutamineinsufficientlydocumented-prognosisunclear.Higherincidenceoftreatment-relatedcomplicationswithmilrinone.Prolongedorrepeatedoraltherapywithavailableagents(cAMPdependent)increasesmortality(levelA)Short-termlevosimendan(calciumsensitiser)appearstobesaferthandobutamine.Itslongtermeffectonmortalityneedstobeconfirmed(levelC)PositiveInotropesInotropicagAntiarrhythmicsinHeartFailureIngeneralthereisnoindicationfortheuseofanti-arrhythmicsinCHF.Specificindications:atrialfibrillation,non-sustainedorsustainedVTClassIagentsshouldbeavoided(levelC)Beta-blockersreducesuddendeathinCHF(levelA)Amiodaroneiseffectiveagainstmostcommonsupra-andventriculararrhythmias(levelB),butroutineadministrationinCHFisnotjustified(levelB)ThereisnospecificallydefinedroleforICDinCHF(levelC),butitimprovessurvivalincardiacarrestorsustainedVTassociatedwithLVdysfunction(levelA)AntiarrhythmicsinHeartFailuAntiarrhythmicsinheartfailure(cont´d)Amiodaroneiseffectiveagainstmostcommonsupra-andventriculararrhythmias(levelB),butroutineadministrationinCHFisnotjustified(levelB)ThereisnospecificallydefinedroleforICDinCHF(levelC),butitimprovessurvivalincardiacarrestorsustainedVTassociatedwithLVdysfunction(levelA)AntiarrhythmicsinheartfailuAnti-thromboticTherapyLittleevidencethatanti-thrombotictherapymodifiestheriskofdeathorvasculareventsotherthaninatrialfibrillationwhereanticoagulantsarefirmlyindicated(levelC)Lackofevidencetosupportanti-thromboticagentsinsinusrhythmThereiscontroversyabouttheroleofapotentialinteractionbetweenaspirinandACEinhibitorsAnti-thromboticTherapyLittlePacemakersPacemakershavehadnospecificroleotherthanconventialbradycardiaindication.Whenneeded,AV-synchronouspacingshouldbepreferredResynchronizationtherapyusingbi-ventricularpacingmayimprovesymptomsandsub-maximalexercisecapacity(levelB)buttheeffectonmortalityandmorbidityisasyetunknownPacemakersPacemakershavehadSurgeryforHeartFailureNocontrolleddatatosupportrevascularisationingeneral.Inindividualswithheartfailureduetoischemiccardiomyopathyrevascularisationmayleadtoimprovementofsymptoms(levelC)MitralvalvesurgeryinadvancedheartfailureandsevereMImayimprovesymptoms(levelC)Cardiomyoplastynotrecommended(levelC)Partialleftventriculotomy(Batista)notrecommended(levelC)SurgeryforHeartFailureNocoChoiceofPharmacologicalTherapyIndicatedIndicated(underspecialistcare)Indicated(combinationofdiuretics)IndicatedEnd-stageheartfailure(NYHAIV)IndicatedIndicated(underspecialistcare)Indicated(combinationofdiuretics)IndicatedWorseningheartfailure(NYHAIII)NotindicatedIndicatedIndicatediffluidretentionIndicatedSymptomaticheartfailure(NYHAII)NotindicatedPost-MINotindicatedIndicatedAsymptomaticLVdysfunctionAldosteroneantagonistBeta-blockerDiureticACEinhibitorChoiceofPharmacologicalTherChoiceofPharmacologicalTherapyIfpersistinghypokalemiaIfACEinhibitorsandARB’snottoleratedPossiblyforsymptomsinsinusrhythmIfACEinhibitorsorbeta-blockersnottoleratedEnd-stageheartfailure(NYHAIV)IfpersistinghypokalemiaIfACEinhibitorsandARB’snottoleratedForsymptomsinsinusrhythmIfACEinhibitorsorbeta-blockersnottoleratedWorseningheartfailure(NYHAIII)IfpersistinghypokalemiaIfACEinhibitorsandARB’snottoleratedForsymptomsinsinusrhythmIfACEinhibitorsorbeta-blockersnottoleratedSymptomaticheartfailure(NYHAII)NotindicatedNotindicatedAtrialfibrillationNotindicatedAsymptomaticLVdysfunctionPotassium-sparingdiureticVasodilatorDigitalisglycosideARBChoiceofPharmacologicalTherPharmacologicalTherapyofHeartFailureduetoSystolicLeftVentricularDysfunctionARBifACEinhibitorintolerantorACEinhibitor+ARBifbeta-blockerintolerantcontinueACEinhibitorbeta-blockerspironolactone+diuretics+digitalis+nitrates/hydralazine+temporaryinotropicsupportNYHAIVARBifACEinhibitorintolerantorACEinhibitor+ARBifbeta-blockerintolerant

ACEinhibitorandbeta-blockeraddspironolactone+diuretics+digitalisIfstillsymptomatic+nitrates/hydralazineiftoleratedNYHAIIIARBifACEinhibitorintolerantorACEinhibitor+ARBifbeta-blockerintolerant

ACEinhibitorasfirst-linetreatment

addbeta-blocker+/-diureticdependingonfluidretentionNYHAIIcontinueACEinhibitor–addbeta-blockerifpost-MIreduce/stopdiureticNYHAIForSymptomsifIntoleranttoACEinhibitororBeta-blockerForSurvival/Morbidity

mandatorytherapy

ForSymptomsPharmacologicalTherapyofHeaConclusionsHeartfailureisaveryseriousconditionDiagnosisofCHFisbasedonobjectiveevidenceofcardiacdysfunctionEchocardiographyisrecommendedwhenheartfailureissuspectedLowplasmaconcentrationsofnatriureticpeptidesmakeCHFunlikelyThesetestsmayhelptothediagnosisandmonitoringofCHFConclusionsHeartfailureisaConclusions(cont´d)Symptomsaswellsasprognosiscanbeimprovedbyappropriatetherapy.Symptommanagementmayincludeseveralagentswherediureticsareessentialtocontrolfluidretention.ACE-inhibitorsandbeta-blockersareverywelldocumentedandshouldbeconsideredinallpatientsassurvivalisimproved.DoselevelsshouldbetitratedasinclinicaltrialsConclusions(cont´d)SymptomsaTaskForceMembersoftheTaskForceCo-chairmen:WillemJ.Remme,KarlSwedberg.(IfnotstatedotherwiserepresentingWGonHeartFailure):JohnCleland,Hull;A.W.Hoes,Utrecht(GeneralPractice);AttilioGavazzi,Bergamo(WGMyocardialandPericardialdiseases);HenryDargie,Glasgow;HelmutDrexler,Hannover;FerencFollath,Zurich(EuropeanFederationofInternalMedicine);A.Haverich,Hannover(WGonCardiovascularSurgery);TinaJaarsma,DenHaag(WGonCardiovascularNursing);JerczyKorewicki,Warzaw;MichelKomajda,Paris;CeciliaLinde,Stockholm(WGonPacing);JoseLopez-Sendon,Madrid;LucPiérard,Liège(WGonEchocardiography);MarkkuNieminen,Helsinki;SamuelLévy,Marseille(WGonArrhythmia);LuigiTavazzi,Pavia;PavlosToutouzas,Athens.TaskForceMembersoftheTaskWorkingScheduleTaskForceappointedbytheCommitteeforPracticeGuidelinesandPolicyConferencesoftheEuropeanSocietyofCardiology(ESC).FirstmeetingESC1999.DraftcirculatedamongtheNucleusoftheWorkingGrouponHeartFailure,otherWorkingGroups,andseveralexpertsinthefieldofheartfailure.Itwasupdatedbasedoncommentsreceived.ItwasthensenttotheCommitteeandaftertheirinputthedocumentwasapprovedforpublication.AcceptedMay3,publishedEHJSeptember2001AvailableonESCWebsiteWorkingScheduleTaskForceappGuidelinesforHeartFailureTreatment

basedonLevelofEvidenceLevelA:atleast2randomisedtrialssupportingrecommendationLevelB:atleastonerandomisedtrialormeta-analysis,supportingrecommendationLevelC:consensusopinionofexpertsbasedupontrialevidenceandclinicalexperienceGuidelinesforHeartFailureTNatriureticPeptidesThesepeptidesmaybemostusefulclinicallyasa“ruleout”testduetoaconsistentandveryhighnegativepredictivevaluesNatriureticPeptidesNatriureticPeptidesThesepeptidesmaybemostusefulclinicallyasa“ruleout”testduetoaconsistentandveryhighnegativepredictivevaluesEspeciallyinprimarycarepatientssuspectedofhavingheartfailurecanbeselectedforfurtherinvestigationbyechocardiographyorothertestsofcardiacfunctiononthebasisofhavinganelevatedplasmaconcentrationofanatriureticpeptideNatriureticPeptidesThesepeptNatriureticPeptidesThesepeptidesmaybemostusefulclinicallyasa“ruleout”testduetoaconsistentandveryhighnegativepredictivevaluesEspeciallyinprimarycarepatientssuspectedofhavingheartfailurecanbeselectedforfurtherinvestigationbyechocardiographyorothertestsofcardiacfunctiononthebasisofhavinganelevatedplasmaconcentrationofanatriureticpeptideInthoseinwhomtheconcentrationsarenormal,othercausesofdyspnoeaandassociatedsymptomsshouldbeconsideredNatriureticPeptidesThesepeptConclusionsHeartfailureisaveryseriousconditionDiagnosisofCHFisbasedonobjectiveevidenceofcardiacdysfunctionEchocardiographyisrecommendedwhenheartfailureissuspectedLowplasmaconcentrationsofnatriureticpeptidesmakeCHFunlikelyThesetestsmayhelptodiagnoseCHFandmonitoring

ConclusionsHeartfailureisaSuspectedHeartFailurebecauseofsymptomsandsignsAssesspresenceofcardiacdiseasebyECG,X-RayorNatriureticpeptides

(whereavailable)NormalHeartFailureunlikelyAlgorithmforDiagnosisofChronicHFSuspectedHeartFailureAssessDiagnosisAccordingtotheWorkingGroupinHeartFailure,HeartFailureisasyndromewherethediagnosishasthefollowingessentialcomponents:Acombinationof:Symptoms,typicallybreathlessnessorfatigueCardiacdysfunctiondocumentedatrestThediagnosisissupportedby:ResponsetotreatmentdirectedtowardsheartfailureDiagnosisAccordingtotheWorkAssessmentsinallcases

Necessary Supports OpposesHistorywithsymptoms +++ IfabsentObjectiveevidence +++ IfabsentResponsetotreatment ++ EstablishdiagnosisAssessmentsinallcases EstabTest

Necessary Supports OpposesElectrocardiogram ++ IfnormalEchocardiography +++ IfnormalChestx-ray Ifcongestion IfnormalBloodcount IfnormalBloodchemistry IfnormalTestsforDiagnosisTestTestsforDiagnosisAdditionalTestsforDiagnosisTest Necessary Supports OpposesExercisetest IfnormalNatriureticpeptide Ifelevated IfnormalCardiaccath. IfnormalAdditionalTestsforDiagnosisTesttoExcludeAlternativesChestx-ray(Lungdisease)PulmonaryfunctionBloodchemistry(Renalandhepaticdisease)Bloodcount(Anaemia)Exercisetolerance(ifimpaired)TesttoExcludeAlternativesChElectrocardiographyAnormalECGsuggeststhatthediagnosisofheartfailureshouldbecarefullyreviewed.ThepredictivevalueofanormalECGtoexcludeLVsystolicdysfunctionexceeds90%ElectrocardiographyAnormalECChestX-rayAhighpredictivevalueofX-rayfindingsisonlyachievedbyinterpretingtheminthecontextofclinicalfindingsandECGanomalies.ItisusefultodetectcardiacenlargementandpulmonarycongestionInchronicheartfailure,increasedcardiacsizeandpulmonaryvenouscongestionareusefulindicatorsofabnormalcardiacfunctionwithdecreasedejectionfractionand/orincreasedLVfillingpressureHowever,cardiomegalyisfrequentlyabsentinacuteheartfailureandincaseswithdiastolicdysfunctionChestX-rayAhighpredictivevPulmonaryfunctiontestsMeasurementsoflungfunctionareoflittlevalueindiagnosingchronicheartfailure.However,theyareusefulinexcludingrespiratorycausesofbreathlessnessPulmonaryfunctiontestsMeasurExercisetesting

Inclinicalpracticeexercisetestingisoflimitedvalueforthediagnosisofheartfailure.However,anormalmaximalexercisetest,inapatientnotreceivingheartfailuretreatment,excludesheartfailureasadiagnosisExercisetestingInclinicalpInvasiveinvestigationInvasiveinvestigationisgenerallynotrequiredtoestablishthepresenceofchronicheartfailure,butmaybeimportantinelucidatingthecauseortoobtainprognosticinformationInvasiveinvestigationInvasiveEchocardiographyAsobjectiveevidenceofcardiacdysfunctionatrestismandatoryforthediagnosisofheartfailure,echocardiographyisthepreferredmethodforthisdocumentationThemostimportantparameterforidentifyingpatientswithsystoliccardiacdysfunctionandthosewithpreservedsystolicfunctionistheLVejectionfractionWhenthediagnosisofheartfailureisconfirmed,echocardiographyisalsohelpfulindeterminingitsaetiologyEchocardiographyAsobjectiveeNatriureticPeptidesThesepeptidesmaybemostusefulclinicallyasa“ruleout”testduetoaconsistentandveryhighnegativepredictivevaluesEspeciallyinprimarycarepatientssuspectedofhavingheartfailurecanbeselectedforfurtherinvestigationbyechocardiographyorothertestsofcardiacfunctiononthebasisofhavinganelevatedplasmaconcentrationofanatriureticpeptideInthoseinwhomtheconcentrationsarenormal,othercausesofdyspnoeaandassociatedsymptomsshouldbeconsideredTheaddedvalueofnatriureticpeptidesinthissituationhasyettobedeterminedNatriureticPeptidesThesepeptNatriureticPeptidesHighlevelsofnatriureticpeptidesidentifythoseatgreatestriskoffutureseriouscardiovasculareventsincludingdeathThereisalsorecentevidencethatadjustingheartfailuretherapyinordertoreducenatriureticpeptideslevelsinindividualpatientsmayimproveoutcomeNatriureticPeptidesOtherneuroendocrineevaluationsOthertestsofneuroendocrineevaluationarenotrecommendedfordiagnosticorprognosticpurposesOtherneuroendocrineevaluatioSuspectedHeartFailurebecauseofsymptomsandsignsTestsabnormalTestsabnormalAssesspresenceofcardiacdiseasebyECG,X-RayorNatriureticpeptides(whereavailable)NormalHeartFailure

unlikelyImagingbyEchocardiography(Nuclearangiographyor

MRIwhereavailable)NormalHeartFailure

unlikelyChoosetherapyAssessetiology,degree,precipitating

factorsandtypeofcardiacdysfunctionAlgorithmforDiagnosisofChronicHFAdditionaldiagnostictests

whereappropriate(e.g.coronaryangiography)SuspectedHeartFailureTestsaManagementOutlineEstablishthatpatienthasheartfailureIdentifypresentingsymptomAssessseverityoflimitationDetermineetiologyExcludeorconfirmconcomitantdiseasesPredictprognosisChoosetherapyMonitorprogressManagementOutlineEstablishthGuidelinesTreatment-ContentsGeneraladviceandmeasuresExerciseandexercisetrainingPharmacologicaltherapySurgeryanddevicesSpecialsubsections(elderly,diastolicCHF)CaremanagementprogrammesGuidelinesTreatment-ContentESC慢性心衰指南课件GeneralMeasuresandAdvice

Patientandfamilyeducationexplainheartfailuresymptoms–whattherapydoesself-weighingexercisevsrest

GeneralMeasuresandAdvicePGeneralmeasuresandadviceDiet-saltintakeandfluidrestrictionSmoking-cessationAlcohol-moderateintakepermittedObesity-weightreductionAbnormalweightlossTravellingSexualactivity-counselling,reassurancepatients/partnerVaccinations-influenza,pneumococcalGeneralmeasuresandadviceDieGeneralmeasuresandadvice

Drugcounselling:Self-management(diuretics)DesiredeffectsandsideeffectsDurationtreatmentbeforeeffectsbecomeapparentNeedforslowup-titrationInteractionwithotherdrugsGeneralmeasuresandadviceDrAce-inhibitorsACEinhibitorsarerecommendedasfirst-linetherapyinpatientswithareducedLVsystolicfunction (LVEF<40-45%)(LevelA)IntheabsenceoffluidretentionACEinhibitorsshouldbegivenfirst,inthepresenceoffluidretentiontogetherwithdiuretics(LevelB)ACEinhibitorsshouldbeup-titratedtothedosagesshowntobeeffectiveinlargetrials.TheyshouldnotbetitratedbasedonsymptomaticimprovementAce-inhibitorsACEinhibitorsaTherecommendedprocedureforstartinganACEinhibitor1.Reviewthedoseofdiuretics2.Avoidexcessi