慢性心力衰竭指南解讀-,,

1、慢性心力衰竭最新指南解讀,田野 教授哈爾濱醫(yī)科大學(xué)附屬二院心內(nèi)科,第五屆北方介入心臟病學(xué)暨心血管疾病診療新進(jìn)展國(guó)際研討會(huì) 2009.01.11 哈爾濱,ESC-51 COUNTRIES,Content,Definition and diagnosisDiagnostic techniquesNon-pharmacological managementPharmacological therapyDevices and surg

2、eryCo-morbidities and special populations,Definition and diagnosis,“The very essence of cardiovacular medicine is the recognition of early heart failure”,Sir Thomas Lewis,1933,Definition of HF,Importantly, it was emphas

3、ised that the diagnosis is not dependent on a certain ejection fraction (EF), although it has implications for prognosis.,,Common clinical manifestations,Clinical manifestations,,Classification of HF,Common causes of HF,

4、Coronary heart disease Many manifestationsHypertension Often associated with left ventricular hypertrophy and ejection fractionCardiomyopathies

5、Familial/genetic or non-familial/non-genetic (including acquired, e.g. myocarditis) Hypertrophic (HCM), dilated (DCM), restrictive

6、 (RCM), arrhythmogenic right ventricular (ARVC), unclassifiedDrugs β-Blockers, calcium antagonists, antiarrhythmics, cytotoxic agents Toxins

7、 Alcohol, medication, cocaine, trace elements (mercury, cobalt, arsenic) Endocrine Diabetes mellitus, hypo/hyperthyroidis

8、m, Cushing syndrome, adrenal insufficiency, excessive growth hormone, phaeochromocytomaNutritional Deficiency of thiamine, selenium, carnitine. Obesit

9、y, cachexiaInfiltrative Sarcoidosis, amyloidosis, haemochromatosis, connective tissue diseaseOthers Chagas' diseas

10、e, HIV infection, peripartum cardiomyopathy, end- stage renal failure,,,Classification of HF,? New onset First presentation Acute or slow o

11、nset? Transient Recurrent or episodic? Chronic Persistent Stable, worsening, or decompensated,,,Time is important for various types of heart failure.,Diagnostic

12、 techniques,,Clinical examination,,Diagnosis of HF with natriuretic peptides,As regards diagnostic tools, the importance of BNP/NT-proBNP was stressed, and it is now recommended not only for excluding heart failure, but

13、also for confirmation of the diagnosis.,Diagnostic assessments supporting the presence of HF,(BNP) in Differentiating between Dyspnea,Alan S. Maisel, N Engl J Med 2002;347:161–167.,BNP among Patients in Each of the Four

14、NYHA Classifications,Alan S. Maisel, N Engl J Med 2002;347:161–167.,BNP,BNP>400 pg/mL, NT-proBNP>2000 pg/mIncreased ventricular wall stress HF likelyIndication for echoConsider treatmentBNP<100 pg/mL, NT-pr

15、oBNP<400 pg/mL Normal wall stress Re-evaluate diagnosisHF unlikely if untreated,Maisel AS,et al. N Engl J Med 2002;347:161-167.,B-type natriuretic peptide (BNP),HF with preserved ejection fraction (HFPEF),HFPEF,“Mo

16、st patients with HF have evidence of both systolic and diastolic dysfunction at rest or on exercise. Patients with diastolic HF have symptoms and/or signs of HF and a preserved left ventricular ejection fraction (LVEF)

17、>40-50%. HF with preserved ejection fraction (HFPEF) is present half the patients with HF.”,Epidemiologic studies,Solomon SD,Circulation 112:3738- 3744, 2005,Assessment of HFPEF,Presence of signs and/or symptoms of c

18、hronic HF.Presence of normal or only mildly abnormal LV systolic function (LVEF≧45-50%).Evidence of diastolic dysfunction (abnormal LV relaxation or diastolic stiffness).,Speckle-tracking echocardiography,A 62-year-old

19、 man with a normal heartEF=60%,A 78-year-old manDiastolic dysfunctionEF=55%,Process underlying HFPEF,Non-pharmacological management,,A strong relationship between healthcare professionals and patients as well as suff

20、icient social support from an active social network has been shown to improve adherence to treatment. It is recommended that family members be invited to participate in education programmes and decisions regarding treatm

21、ent and care,Sabate E. Adherence to Long-term Therapies. Evidence for Action. Geneva: WHO;2003.,People involved in care,The Players,,Pharmacological therapy,Prognosis:Reduce mortalityMorbidity:Improve quality of life

22、 Prevention:Reduce hospitalization,ACE inhibitors,Unless contraindicated or not tolerated, an ACEI should be used in all patients with symptomatic HF and a LVEF 40%.Treatment with an ACEI improves ventricular functio

23、n and patient well-being, reduces hospital admission for worsening HF, and increases survival.In hospitalized patients, treatment with an ACEI should be initiated before discharge.,Class of recommendation I, level of e

24、vidence A,CONSENSUS(1987) and SOLVD-Treatment(1991),Mortality Reductions with ACEI,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0,5,10,15,20,25,30,Relative Risk Reduction (%),CONSENSUS,SOLVD,SAVE,AIRE,HOPE,n = 253,n = 4228,n = 22

25、31,n = 1986,n = 3577,CONSENSUS: NEJM 1987;316:1429-435, SOLVD: NEJM 1991;325:293-302, SAVE: NEJM 1992;327:669-677AIRE: Lancet 1993;342:821-828, HOPE: Lancet 2000;355:253-259,β-Blockers,Unless contraindicated or not tole

26、rated, a b-blocker should be used in all patients with symptomatic HF and an LVEF≦40%. b-Blockade improves ventricular function and patient well-being, reduces hospital admission for worsening HF, and increases survival.

27、 Where possible, in hospitalized patients, treatment with a b-blocker should be initiated cautiously before discharge.,Class of recommendation I, level of evidence A,CIBIS II(1999), MERIT-HF(2000) and COPERNICUS(2002),

28、Effect of β-Blockers on outcome,Aldosterone antagonists,Unless contraindicated or not tolerated, the addition of a low-dose of an aldosterone antagonist should be considered in all patients with an LVEF≦35% and severe sy

29、mptomatic HF, i.e. currently NYHA functional class III or IV, in the absence of hyperkalaemia and significant renal dysfunction. Aldosterone antagonists reduce hospital admission for worsening HF and increase survival w

30、hen added to existing therapy, including an ACEI. In hospitalized patients satisfying these criteria, treatment with an aldosterone antagonist should be initiated before discharge.,Class of recommendation I, level of e

31、vidence B,RALES(1999), EPHESUS(2003),Aldosterone antagonists in HF,Pitt B, N Engl J Med 1999;341:709–717Pitt B, N Engl J Med 2003;348:1309–1321.,ARBs,Unless contraindicated or not tolerated, an ARB is recommended in pat

32、ients with HF and an LVEF 40% who remain symptomatic despite optimal treatment with an ACEI and b-blocker, unless also taking an aldosterone antagonist. Treatment with an ARB improves ventricular function and patient w

33、ell-being, and reduces hospital admission for worsening HF.,Class of recommendation I, level of evidence A,Val-HEFT(2001) and CHARMAdded(2003),CHARM-Alternative trial,Granger et al. Lancet 2003;362:772–6.,Proportion with

34、 event(%),Digoxin,In patients with symptomatic HF and AF, digoxin may be used to slow a rapid ventricular rate. In patients with AF and an LVEF≦40% it should be used to control heart rate in addition to, or prior to a b

35、-blocker.,Class of recommendation I, level of evidence C,The Effect of Digoxin on Mortality and Morbidity in Patients with Heart FailureN Eng1 Med,1997;336:525-533,DIG TRAIL--All-cause mortality,The Effect of Digoxin on

36、 Mortality and Morbidity in Patients with Heart Failure N Eng1 Med,1997;336:525-533,Hospital admission for worsening HF,,The Effect of Digoxin on Mortality and Morbidity in Patients with Heart Failure N Eng1 Med,1997;336

37、:525-533,Diuretics,Diuretics are recommended in patients with HF and clinical signs or symptoms of congestion.,Class of recommendation I, level of evidence B,In symptomatic patients with an LVEF 40%, the combination of H

38、-ISDN may be used as an alternative if there is intolerance to both an ACEI and an ARB. Adding the combination of H-ISDN should be considered in patients with persistent symptoms despite treatment with an ACEI, b-blocke

39、r, and an ARB or aldosterone antagonist. Treatment with H-ISDN in these patients may reduce the risk of death.,,Hydralazine and isosorbide dinitrate(H-ISDN),Class of recommendation IIa, level of evidence B,V-HeFT-I(1991

40、)and A-HeFT(2004),Other drugs-Statins,“In elderly patients with symptomatic chronic HF and systolic dysfunction caused by CAD, statin treatment may be considered to reduce cardiovascular hospitalization. ”,Class of recom

41、mendation IIb, level of evidence B,Trial design: A total of 5011 patients at least 60 years of age with New York Heart Association class II, III, or IV ischemic, systolic heart failure were randomly assigned to receive 1

42、0 mg of rosuvastatin or placebo per dayResults: Primary Outcome: 11.4% with rosuvastatin vs. 12.3% with placebo (p = 0.12)Death from Any Cause : 11.6% vs.12.2% (p = 0.31), respectivelyAny cause Hospitalizations : 219

43、3 vs. 2564 (p <0.001), respectively,,Rosuvastatin in Older Patientswith Systolic Heart Failure,N Engl J Med 2007;357:2248–2261.,,Primary Outcome and Death from Any Cause,N Engl J Med 2007;357:2248–2261.,N Engl J Med

44、2007;357:2248–2261.,,Hospitalizations for cardiovascular causes,,P<0.001,Statin-mediated effects in endothelial cells and other tissues,Class I recommendations For Drugs,Devices and surgery,ICDPrior resuscitated card

45、iac arrest (Class I Level A)Ischaemic aetiology and >40 days of MI (Class I Level A)Non-ischaemic aetiology (Class I Level B)CRTNYHA Class III/IV and QRS .120 ms (Class I Level A)To improve symptoms/reduce hospit

46、alization (Class I Level A)To reduce mortality (Class I Level A),,Class I recommendations,ICD,ICD therapy for primary prevention is recommended to reduce mortality in patients with LV dysfunction due to prior MI who are

47、 at least 40 days post-MI, have an LVEF ≦35%, in NYHA functional class II or III, receiving optimal medical therapy, and who have a reasonable expectation of survival with good functional status for>1 year. (Class of

48、recommendation I, level of evidence A)Meta-analyses of primary prevention trials have shown that the benefit on survival with ICDs is highest in the post-MI patients with depressed systolic function (LVEF≦35%).,Canadian

49、 Implantable DefibrillatorStudy. Eur Heart J 2000;21:2071–2078.,Mortality of ICD,23%,,Bardy GH, N Engl J Med 2005;352:225–237.,CRT,The survival advantage of CRT-D vs. CRT-P has not been adequately addressed. In the CAR

50、E-HF trial, CRT-P was associated with a significant reduction of 37% in the composite end-point of total death and hospitalization for major cardiovascular events (P<0.001) and of 36% in total mortality (P<0.002).,

51、COMPANION.N Engl J Med 2004;350:2140–2150.CARE-HF trial. N Engl J Med 2005;352:1539–1549.,COMPANION All-Cause Death Results,,,,,,,,,Days from Randomization,Event-Free Survival (%),100,90,80,70,60,50,OPT,,,CRT,,CRT-D,,,

52、,(CRT vs. OPT) P = 0.059 (CRT-D vs. OPT) P = 0.003,Bristow M. N Engl J Med. 2004;350:2140-2150.,90,,,,,,,,,,,900,810,720,630,540,360,270,180,0,990,,,1080,,450,,Co-morbidities and special populations,Management of arte

53、rial hypertension inpatients with HF,Conclusion,the diagnosis of HF with natriuretic peptides(BNP)HF with preserved ejection fraction(HFPEF)Rosuvastatin in Older Patientswith Systolic Heart Failure(statin),"The L