老年病学教学课件：05 Chronic Heart Failure in the elderly

ChronicHeartFailure

intheelderlyDefinitionHFisacomplexclinicalsyndromethatcanresultfromanystructuralorfunctionalcardiacdisorderthatimpairstheabilityoftheventricletofillwithorejectblood.≥60yrsChronicClassificationofHeartFailure

intermsoflocationLeft,rightandbiventricularheartfailureintermsofvelocityAcuteandchronicheartfailureintermsofmechanismSystolicordiastolicheartfailureEpidemiology4.6millionHFpatientsintheUnitedStates10millionHFpatientsinEuropeApproximately80percentofallheartfailureadmissionsoccurinpatientsolderthan65HalfofHFpatientswilldiewithin4yearsPatientswithsevereHFwilldiewithin1year

IntheUnitedStates,theestimatedcostsforthemanagementofpatientswithheartfailureexceed$10billionannually.Prevalenceratesofcongestiveheartfailure(CHF)bygenderandageCharacteristicofCHFintheelderlyUndetectablesymptomUntypicalclinicalfeatureEasytobemisdiagnosedComplication(infection,etc)

↑,badprognosisReactiontodrugtherapy↓ADR↑Causesofdisease

HypertensionCADValvularheartdiseaseArrhythmiaAnemiaHyperthyroidismPathophysiologyChronic

myocardialremodelingApoptosisNecrosisFibrosisHypertrophyCardiacContractility↓PeripheralPerfusion↓Harmfuleffectsofneurohormonal,cytokine,andwallstressSymptomClinicalSymptomsFACES...FatigueActivitieslimitedChestcongestionEdemaorankleswellingShortnessofbreathLeft-SideHeartFailureSymptomsSignsApicalSMDiastolicGallop(S3,S4)HR↑S1↓P2↑RalesHydrothoraxShortnessofbreathDyspneaFatigueExertionaldyspneaParoxysmalnocturnaldyspneaOrthopneaCardiacasthmaRight-SideHeartFailureSymptomsSignsEdemaAscites

AnkleswellingAnkleswellingFatigueJugularvenousdistentionAuxiliary

examination

UCG（UltrasonicCardiogram）nuclidemyocardialperfusionimagingX-RayECGCAG(coronary

arteriography)myocardialbiopsyBNPandNT-proBNPBNPSecretedbyventricularmyocytes

differentialdiagnosisindyspnea＜100pg/ml：normal100～400pg/ml：PE，COPD，etc.BNP>400pg/ml:mostofHFpatientsNT-proBNP

N-terminal

pro

BNP，inactivehalf-life

period↑，morestableNT-proBNP<300pg/ml，excludeHF＜200pg/mlaftertreatment，favourable

prognosis6-minutewalktest

Evaluateexercisetolerance，prognosis

walkingdistance＞450m，MildHF；walkingdistance

150～450m，moderateHF；walkingdistance＜150m，severeHF；walkingdistance＜300m,badprognosis

Assesssymptoms&signsHeartDiseases?ECG/BNP/X-Ray?AbnormalEvaluatecardiacfunctionbyechocardiographyHeartfailureCharacterizetypeandseveritySelectedtests,(angio,Haemodynamicmonitoring)ConsiderotherdiagnosisAbnormalNormalNormalSuspectedChronicHeartFailureDifferentialDiagnosisLeft-sideHFRight-sideHFRespiratorySystemDiseaseLiverDiseaseLungDiseasePericardiumDisease

NYHAClassificationClassI—No

limitation:Ordinaryphysicalactivitydoesnotcauseunduefatigue,dyspnea,orpalpitation.ClassII—Slight

limitationofphysicalactivity:

Suchpatientsarecomfortableatrest.Ordinaryphysicalactivityresultsinfatigue,palpitation,dyspnea,orangina.ClassIII—Marked

limitationofphysicalactivity:Althoughpatientsarecomfortableatrest,lessthanordinaryactivitywillleadtosymptoms.ClassIV—Inabilitytocarryonanyphysicalactivitywithoutdiscomfort:Symptomsofcongestivefailurearepresentevenatrest.Withanyphysicalactivity,increaseddiscomfortisexperienced.ProposedStageofHFSTAGEA

AthighriskofHFbutwithoutstructuralheartdiseaseorHFsymptomsSTAGEBStructuralheartdiseasebutwithoutsignsorsymptomsofHFSTAGEC

StructuralheartdiseasewithpriororcurrentHFsymptomsSTAGED

End-stageHF，RefractoryHFrequiringspecializedinterventions(markedsymptomsofHFatrest)Treatment

GeneraltreatmentDrugtreatment

Non-medicinetreatmentTreatmentObjectivesDecreasesymptomsImproveexercisecapacityEnhancequalityoflifeDecreasemorbidityRetardtheprogressionofheartfailureImprovesurvivalGeneraltreatmentremoving

inducedfactorsmonitoring

weightAdjustinglife-style，restrictwaterandsodium，Moderate

exercisepsychologicalandpsychiatrictherapyoxygentherapyMedications

DiureticAngiotensin-ConvertingEnzymeInhibitors（ACEI）AngiotensinReceptorBlocker（ARB）BetablockersDigoxin

Aldosterone

receptor

antagonistAnticoagulantandantiplatelet

drugDiureticssodiumandwaterretentionsymptomsofvolumeoverloadinresistantedema,loopdiuretics,K+-sparingdiuretics,andmetolazoneareindicatedIA→IC(2014ChineseCHFGuideline)+ACEI/ARB+BetablockersAngiotensinConvertingEnzymeInhibitorsPhysiologicBenefits

ArteriovenousVasodilatationpulmonaryarterialdiastolicpressurepulmonarycapillarywedgepressureleftventricularend-diastolicpressuresystemicvascularresistancesystemicbloodpressureAngiotensinConvertingEnzymeInhibitorsPhysiologicBenefitsLVfunctionandcardiacoutputrenal,coronary,cerebralbloodflowNochangeinheartrateormyocardialcontractilitynoneurohormonalactivationAngiotensinConvertingEnzymeInhibitorsPhysiologicBenefitsIncreasesexercisecapacityimprovesfunctionalclassattenuationofLVremodelingpostMIdecreaseintheprogressionofchronicHFdecreasedhospitalizationenhancedqualityoflifeimprovedsurvivalACEIIndication：AllCHFpatients,stageB,

asymptomatic,LVEF＜40%～45%,LifetimeuseACEI+Betablockers，synergistic

effect

ACEIContraindication：severelaryngealedema

，

kidneyfailure（nourineandnodialysis，

pregnantwomen）caution

：

Bilateralrenalarterystenosis

serumcreatinine＞3mg/dl（265.2μmol/L）

hyperpotassemia（＞5.5mmol/L）

hypotension（SBP＜90mmHg）

LVOTO（LeftVentricularOutflowTract

Obstruction）ACEIdosageinitialdosetargetdosecaptopril6.25mg,tid50mg,tidenalapril2.5mg,bid10～20mg,bidperindopril2mg/d4～8mg/dlisinopril2.5～5mg/d30～35mg/dbenazepril2.5mg/d5～10mg,bidramipril2.5mg/d5mg,bid或10mg/dACEImonitor：bloodpressure，serumpotassium，serumcreatinine.1-2weeksafterinitiate

treatmentSCr↑＜30%,expected

,followup.SCr↑＞30%～50%,stoporreduce(2)Don’taddKCLorpotassium-sparingdiuretic(3)serumpotassium＞5.5mmol/L，stopACEIARBindication:

thesameasACEI,StageA：preventHF

patientsintolerantofanACEinhibitor

ARB

dosage

initialdosetargetdosecandesartan*4～8mg/d32mg/dvalsartan*20～40mg/d160mg/dlosartan*25～50mg/d50～100mg/dirbesartan150mg/d300mg/dTelmisartan40mg/d80mg/dOlmesartan10～20mg/d20～40mg/d*havebeenconfirmedbysomeRCTthatcanreducemortalityandinvalidismrateARBContraindication,cautionandmonitor:

thesameasACEILessdrycough

-BlockerPhysiologicBenefitsincreasethedensityof-1receptorsdecreaseneurohormonalactivationdecreaseheartrateprovideantihypertensive,antianginal,andantiarrhythmiceffects-BlockerClinicalBenefitsdecreasesymptomsofHFimproveleftventricularfunctionimproveexercisetoleranceMajorPlaceboControlledTrialsof

-BlockadeinHeartFailure34%CumulativeMortality(%)Days20155010P=.0062(adjusted)MetoprololCR/XL(n=1990)Placebo(n=2001)USCarvedilolTrials1ProbabilityofEvent-freeSurvivalCarvedilol(n=696)Placebo(n=398)DaysP<.0010.0010020030040065%1.0MERIT-HF2Survival(%ofPatients)1009080607006000400300200100DaysCarvedilol(n=1156)Placebo(n=1133)500600040030020010050035%P=.00013COPERNICUS4Days0.02004008001.00.80.6P<.000134%Bisoprolol(n=1327)Placebo(n=1320)CIBIS-II30600Survival051015202530AllPatients(n=2289)Higher-RiskPatients(n=624)NumberofEvents060180AllPatients(n=2289)Higher-RiskPatients(n=624)NumberofEvents8Weeks8WeeksDeathsDeathorHospitalization

forAnyReasonPlaceboCarvedilol

COPERNICUS:EarlyClinicalOutcomes12025191531531346344

Beta-blockerdosage

initialdosetargetdoseMetoprololSuccinate

11.875～23.75mg,qd142.5～190.0mg,qdbisoprolol1.25mg,qd10mg,qdcarvedilol3.125～6.25mg，bid25～50mg，bidmetoprololtartrate6.25mg，bid~tid50mg，bid~tidBeta-blockertargetdosemeansHR55~60bpmadverse

reactions:hypotension,

fluidretention,HFdeteriorate,bradycardiaandAVBaldosteronereceptorantagonistIndication:allEF≤35%,afterACEI/ARBandBeta-blocker,stillhavesymptom(NYHAⅡ-Ⅳ)AfterAMI,LVEF≤40%，havesymptomsofCHForhistoryofdiabetesaldosteronereceptorantagonistcontraind