慢性心力衰竭指南讲义

1、慢性心力衰竭指南讲义ESC-51 COUNTRIESContentDefinition and diagnosisDiagnostic techniquesNon-pharmacological managementPharmacological therapyDevices and surgeryCo-morbidities and special populationsDefinition and diagnosis “The very essence of cardiovacular medicine is the recognition of early heart failure”S

2、ir Thomas Lewis,1933Definition of HFImportantly, it was emphasised that the diagnosis is not dependent on a certain ejection fraction (EF), although it has implications for prognosis.Common clinical manifestationsClinical manifestationsFatigueCoughBreathlessnessSwollen anklesDepressionWeight gainLos

3、s of appetiteNeed to urinate at nightPalpitationSwollen abdomen Classification of HFCommon causes of HFCoronary heart disease Many manifestationsHypertension Often associated with left ventricular hypertrophy and ejection fractionCardiomyopathies Familial/genetic or non-familial/non-genetic (includi

4、ng acquired, e.g. myocarditis) Hypertrophic (HCM), dilated (DCM), restrictive (RCM), arrhythmogenic right ventricular (ARVC), unclassifiedDrugs -Blockers, calcium antagonists, antiarrhythmics, cytotoxic agents Toxins Alcohol, medication, cocaine, trace elements (mercury, cobalt, arsenic) Endocrine D

5、iabetes mellitus, hypo/hyperthyroidism, Cushing syndrome, adrenal insufficiency, excessive growth hormone, phaeochromocytomaNutritional Deficiency of thiamine, selenium, carnitine. Obesity, cachexiaInfiltrative Sarcoidosis, amyloidosis, haemochromatosis, connective tissue diseaseOthers Chagas diseas

6、e, HIV infection, peripartum cardiomyopathy, end- stage renal failureClassification of HF New onset First presentation Acute or slow onsetTransient Recurrent or episodicChronic Persistent Stable, worsening, or decompensated Time is important for various types of heart failure. Diagnostic techniques

7、Clinical examination Diagnosis of HF with natriuretic peptidesAs regards diagnostic tools, the importance of BNP/NT-proBNP was stressed, and it is now recommended not only for excluding heart failure, but also for confirmation of the diagnosis. Diagnostic assessments supporting the presence of HF (B

8、NP) in Differentiating between Dyspnea Alan S. Maisel, N Engl J Med 2002;347:161167. BNP among Patients in Each of the Four NYHA Classifications Alan S. Maisel, N Engl J Med 2002;347:161167. BNPBNP400 pg/mL, NT-proBNP2000 pg/mIncreased ventricular wall stress HF likelyIndication for echoConsider tre

9、atmentBNP100 pg/mL, NT-proBNP40-50%. HF with preserved ejection fraction (HFPEF) is present half the patients with HF.”Epidemiologic studies Solomon SD,Circulation 112:3738- 3744, 2005Assessment of HFPEFPresence of signs and/or symptoms of chronic HF.Presence of normal or only mildly abnormal LV sys

10、tolic function (LVEF45-50%).Evidence of diastolic dysfunction (abnormal LV relaxation or diastolic stiffness).Speckle-tracking echocardiographyA 62-year-old man with a normal heartEF=60%A 78-year-old manDiastolic dysfunctionEF=55% Process underlying HFPEFNon-pharmacological managementA strong relati

11、onship between healthcare professionals and patients as well as sufficient 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 treatment and care

12、Sabate E. Adherence to Long-term Therapies. Evidence for Action. Geneva: WHO;2003.People involved in careThe Players Pharmacological therapyPrognosis:Reduce mortalityMorbidity:Improve quality of life Prevention:Reduce hospitalizationACE inhibitorsUnless contraindicated or not tolerated, an ACEI shou

13、ld be used in all patients with symptomatic HF and a LVEF 40%.Treatment with an ACEI improves ventricular function 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 o

14、f recommendation I, level of evidence ACONSENSUS(1987) and SOLVD-Treatment(1991)Mortality Reductions with ACEI051015202530Relative Risk Reduction (%)CONSENSUSSOLVDSAVEAIREHOPEn = 253n = 4228n = 2231n = 1986n = 3577CONSENSUS: NEJM 1987;316:1429-435, SOLVD: NEJM 1991;325:293-302, SAVE: NEJM 1992;327:6

15、69-677AIRE: Lancet 1993;342:821-828, HOPE: Lancet 2000;355:253-259-BlockersUnless contraindicated or not tolerated, a b-blocker should be used in all patients with symptomatic HF and an LVEF40%. b-Blockade improves ventricular function and patient well-being, reduces hospital admission for worsening

16、 HF, and increases survival. Where possible, in hospitalized patients, treatment with a b-blocker should be initiated cautiously before discharge.Class of recommendation I, level of evidence ACIBIS II(1999), MERIT-HF(2000) and COPERNICUS(2002)Effect of -Blockers on outcomeAldosterone antagonistsUnle

17、ss contraindicated or not tolerated, the addition of a low-dose of an aldosterone antagonist should be considered in all patients with an LVEF35% and severe symptomatic HF, i.e. currently NYHA functional class III or IV, in the absence of hyperkalaemia and significant renal dysfunction. Aldosterone

18、antagonists reduce hospital admission for worsening HF and increase survival when 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 eviden

19、ce BRALES(1999), EPHESUS(2003)Aldosterone antagonists in HFPitt B, N Engl J Med 1999;341:709717Pitt B, N Engl J Med 2003;348:13091321.ARBsUnless contraindicated or not tolerated, an ARB is recommended in patients with HF and an LVEF 40% who remain symptomatic despite optimal treatment with an ACEI a

20、nd b-blocker, unless also taking an aldosterone antagonist. Treatment with an ARB improves ventricular function and patient well-being, and reduces hospital admission for worsening HF.Class of recommendation I, level of evidence AVal-HEFT(2001) and CHARMAdded(2003)CHARM-Alternative trialGranger et a

21、l. Lancet 2003;362:7726.Proportion with event(%)DigoxinIn patients with symptomatic HF and AF, digoxin may be used to slow a rapid ventricular rate. In patients with AF and an LVEF40% it should be used to control heart rate in addition to, or prior to a b-blocker.Class of recommendation I, level of

22、evidence CThe Effect of Digoxin on Mortality and Morbidity in Patients with Heart FailureN Eng1 Med,1997;336:525-533DIG TRAIL-All-cause mortalityPlaceboDigoxinThe Effect of Digoxin on Mortality and Morbidity in Patients with Heart Failure N Eng1 Med,1997;336:525-533Hospital admission for worsening H

23、F28%P0.01PlaceboDigoxinThe Effect of Digoxin on Mortality and Morbidity in Patients with Heart Failure N Eng1 Med,1997;336:525-533DiureticsDiuretics are recommended in patients with HF and clinical signs or symptoms of congestion.Class of recommendation I, level of evidence BIn symptomatic patients

24、with an LVEF 40%, the combination of H-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-blocker, and an ARB or aldosterone antagonist. Tr

25、eatment 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 BV-HeFT-I(1991)and A-HeFT(2004)Other drugs-Statins“In elderly patients with symptomatic chronic HF and systolic dysfunction caused by CAD, st

26、atin treatment may be considered to reduce cardiovascular hospitalization. ”Class of recommendation IIb, level of evidence BTrial 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

27、receive 10 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 : 2193 vs. 2564 (p 0.001), respectively Rosuvastatin in Older Patientswith Systo

28、lic Heart FailureN Engl J Med 2007;357:22482261. Primary Outcome and Death from Any CauseN Engl J Med 2007;357:22482261.N Engl J Med 2007;357:22482261. Hospitalizations for cardiovascular causesP40 days of MI (Class I Level A)Non-ischaemic aetiology (Class I Level B)CRTNYHA Class III/IV and QRS .120

29、 ms (Class I Level A)To improve symptoms/reduce hospitalization (Class I Level A)To reduce mortality (Class I Level A) Class I recommendationsICDICD therapy for primary prevention is recommended to reduce mortality in patients with LV dysfunction due to prior MI who are at least 40 days post-MI, hav

30、e 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 for1 year. (Class of 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 (LVEF35%).Canadian Implantable DefibrillatorStudy. Eur Heart J 2000;21:20712078.Mortality of ICD23%Bardy GH, N Engl J Med 2005;352:225237.CR