充血性心衰的治疗课件

1、 Current Management of Congestive Heart Failure: 2004 UpdateHisham Dokainish, MD, FACCAssistant Professor of MedicineBaylor College of Medicine,Director, Non-Invasive Cardiology,Ben Taub General HospitalHouston, Texas, USA Current Management of CongestThe Problem (USA) 5,000,000 patients6,500,000 ho

2、spital days / year 300,000 deaths / year 6% - 10% of people 65 years 5.4% of health care budget (38 billion) Incidence x 2 in last ten yearsGottdiener J et al. JACC 2000;35:1628Haldeman GA et al. Am Heart J 1999;137:352Kannel WB et al. Am Heart J 1991;121:951OConnell JB et al. J Heart Lung Transplan

3、t 1993;13:S107The Problem (USA)Gottdiener J Definition of heart failureAHA / ACC HF guidelines 2001Clinical syndrome that can result from any structural or functional cardiac disorder thatimpairs the ability of the ventricle to fill with or eject bloodDefinition of heart failureAHA充血性心衰的治疗课件Suspecte

4、d Heart Failurebecause of SYMPTOMS and/or SIGNSAssess presence of CARDIAC DISEASEby ECG, X-Ray or BNPTests abnormalVENTRICULAR FUNCTION Imaging by Echo-Doppler,Nuclear angiography or MRI if availableTests abnormalNORMALNo Heart FailureNORMALNo Heart FailureHeart Failure: Systolic / DiastolicIdentify

5、 etiology, evaluate severity, choose therapyESC HF guidelines 2001Suspected Heart FailureAssess Heart diseaseNo symptomsHF Risk FactorsNo Heart diseaseNo symptomsAsymptomaticLV dysfunctionRefractoryHF symptomsPrior or currentHF SymptomsStages in the evolutionof Heart FailureABCDAHA / ACC HF guidelin

6、es 2001Heart diseaseHF Risk FactorsAsACE-i blockersTreat risk factorsDiet and exerciseAvoid toxicsACE-i in selected p.In selectedpatientsPalliative therapyMech. Assist deviceHeart TransplantACE-i blockersDiuretics / DigitalisStages in the Evolutionof Heart Failure TreatmentABCDAHA / ACC HF guideline

7、s 2001ACE-iTreat risk factorsIn seleAggravating Factors Medications New heart disease Myocardial ischemia Endocarditis Obesity Hypertension Physical activity Dietary excess Pregnancy Arrhythmias (AF) Infections Thromboembolism Hyper/hypothyroidismAggravating Factors MedicationInitial / Ongoing Evalu

8、ationIdentify heart diseaseAssess functional capacity (NYHA, 6 min walk, )Assess volume status: (edema, rales, jugular, hepatomegaly, body weight)Lab assessment: routine: electrolytes, renal funct. Repeat Echo, RX only if significant changes in functional statusAssess prognosisInitial / Ongoing Eval

9、uationId8070605040302054-606050403020100Post MIn=1966050403020 Treatment ObjectivesSurvivalMorbidityExercise capacityQuality of lifeNeurohormonal changes Progression of CHFSymptoms(Cost) Treatment ObjectivesSurvival Pharmacologic TherapyDiureticsACE inhibitorsBeta BlockersDigitalisSpironolactone (Ep

10、lerenone)Angiotensin II Blockers (Candesartan)HMG-CoA Reductase Inhibitors (“Statins”) Pharmacologic TherapyDiureticDiuretics Essential to control symptomssecondary to fluid retention Prevent progression from HTN to HFDiureticsDiuretics. Indications1.Symptomatic HF, with fluid retention Edema Dyspne

11、a Lung Rales Jugular distension Hepatomegaly Pulmonary edema (Xray)AHA / ACC HF guidelines 2001 ESC HF guidelines 2001Diuretics. IndicationsAHA / AC VASOCONSTRICTIONVASODILATATION KininogenKallikreinInactive FragmentsAngiotensinogenAngiotensin IRENINKininase IIInhibitorALDOSTERONESYMPATHETICVASOPRES

12、SINPROSTAGLANDINStPAANGIOTENSIN IIBRADYKININACE-i. Mechanism of ActionA.C.E. VASOCONSTRICTIONVASODILATATIOACE-I: Clinical Effects Improve symptoms Reduce remodelling / progression Reduce hospitalization Improve survivalACE-I: Clinical Effects ImprovMortality Reduction with ACE-iStudyACE-iClinical Se

13、ttingCONSENSUSEnalaprilCHFSOLVD treatment EnalaprilCHFAIRERamiprilCHFVHeft-IIEnalaprilCHFTRACETrandolaprilCHF / LVDSAVECaptoprilLVDSMILEZofenoprilHigh risk HOPERamiprilHigh risk Mortality Reduction with ACE-iACE-i. Dose (mg) InitialMaximumCaptopril 6.25 / 8h 50 / 8hEnalapril 2.5 / 12 h 10 to 20 / 12

14、hFosinopril 5 to 10 / day 40 / dayLisinopril 2.5 to 5.0 / day 20 to 40 / dayQuinapril 10 / 12 h40 / 12 hRamipril 1.25 to 2.5 / day 10 / dayAHA / ACC HF guidelines 2001 ACE-i. Dose (mg)AHA / ACC HF gACE-I. Contraindications Intolerance (angioedema, anuric renal fail.) Bilateral renal artery stenosis

15、Pregnancy Renal insufficiency (creatinine 3 mg/dl) Hyperkalemia ( 5,5 mmol/l) Severe hypotensionACE-I. Contraindications-Adrenergic BlockersMechanism of action Density of 1 receptors Inhibit cardiotoxicity of catecholamines Neurohormonal activation HRAntiischemicAntihypertensiveAntiarrhythmicAntioxi

16、dant, Antiproliferative-Adrenergic Blockers Density -Adrenergic BlockersClinical Effects Improve symptoms (only long term) Reduce remodelling / progression Reduce hospitalization Reduce sudden death Improve survival -Adrenergic Blockers ImproveUS Carvedilol HFNEJM 1996; 334: 1349-55Carvedilol(n=696)

17、Placebo(n=398)Risk reduction = 65%p0.0010501001502002503003504001.00.90.80.70.6-Adrenergic Blockers0.70.80.91.0Survival%DaysI-II HFUS Carvedilol HFCarvedilolPlac Symptomatic heart failure Asymptomatic ventricular dysfunction- LVEF Ca+ +Inotropic effectNatriuresisNeurohormonal control- Plasma Noradre

18、naline- Peripheral nervous system activity- RAAS activity - Vagal tone- Normalizes arterial baroreceptorsNEJM 1988;318:358 Digitalis: Mechanism of ActionDigitalis. Clinical Effects Improve symptoms Modest reduction in hospitalization Does not improve survivalDigitalis. Clinical Effects Im Digoxin to

19、xicity Advanced A-V block without pacemaker Bradycardia or sick sinus without PM PVCs and VT Marked hypokalemia W-P-W with atrial fibrillationDigoxin. Contraindications Digoxin toxicityDigoxin. Cont RENINAngiotensinogenAngiotensin IANGIOTENSIN II ACEOther pathwaysVasoconstrictionProliferative Action

20、Vasodilatation Antiproliferative ActionAT1 AT2AT1 Receptor BlockersRECEPTORSAngiotensin II Receptor Blockers (ARB) RENINAngiotensinogenAngiotensCandesartan, Eprosartan, IrbesartanLosartan, Telmisartan, ValsartanEfficacy not superior to ACE-ILikely not indicated with beta blockersIndicated in patient

21、s intolerant to ACE-IAngiotensin II Receptor Blockers (ARB)AHA / ACC HF guidelines 2001ESC HF guidelines 2001Candesartan, Eprosartan, IrbesMonths1.00.90.80.7 ValsartanPlaceboP = 0.8Survival0369122118152427Angiotensin II Receptor Blockers (ARB)Val-HeFTAHA 2000Months1.00.90.80.7 ValNitrates: Clinical

22、UseCHF with myocardial ischemia Orthopnea and paroxysmal nocturnal dyspneaIn acute CHF and pulmonary edema:NTG sl / ivNitrates + Hydralazine in intoleranceto ACE-I (hypotension, renal insufficiency)Nitrates: Clinical UseCHF with0,540,480122448600.750.500.2500.470.360.250.130.090.310.180.4236Monthsp

23、= 0.08V-HeFT IIN Engl J Med 1991; 325:303EnalaprilHZ + ISDNn = 804p = 0.016ProbabilityofdeathNitrate + Hydralazine0,540,480122448600.750.500.250Inotropes, long term / intermittentAntiarrhythmics (except amiodarone)Calcium antagonists (except amlodipine)Non-steroidal antiinflammatory drugs (NSAIDS)Tr

24、icyclic antidepressantsCorticosteroidsLithiumDrugs to Avoid (may increase symptoms, mortality) ESC HF guidelines 2001Inotropes, long term / intermiRefractory End-Stage HFReview etiology, treatment & aggrav. factorsControl fluid retention Resistance to diuretics Ultrafiltration ?iv inotropics / vasod

25、ilators during decompensationConsider resynchronizationConsider mechanical assist devicesConsider heart transplantationRefractory End-Stage HFHeart Transplant. IndicationsRefractory cardiogenic shockDocumented dependence on IV inotropic support to maintain adequate organ perfusionPeak VO2 120 ms can

26、 benefit from resynchronization therapyThree leads: one in RV apex, one in RA and one in coronary sinus (LV pacing)Purpose: to help restore interventricular synchrony, and improve hemodynamicsInternal Cardiac Debrillators (ICD) to prevent arrhythmic sudden cardiac death1520 patients: mean age 67 years; mean EF 22%; mean QRS 160 ms; ischemic cause 55% of patientsBristow, et al: N Engl J Med 2004Cardiac-Resynchronization +/- 充血性心衰的治疗课件充血性心衰的治疗课件ICD Therapy in Nonischemic Cardiomyopathy: DEFINITE TrialMA