2018年慢性心力衰竭最新指南解读-课件,幻灯,PPT-文档资料.ppt
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1、ESC-51 COUNTRIES,Content,Definition and diagnosis Diagnostic techniques Non-pharmacological management Pharmacological therapy Devices and surgery Co-morbidities and special populations,Definition and diagnosis,“The very essence of cardiovacular medicine is the recognition of early heart failure”,Si
2、r Thomas Lewis,1933,Definition of HF,Importantly, it was emphasised 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,Coronary heart dise
3、ase Many manifestations Hypertension Often associated with left ventricular hypertrophy and ejection fraction Cardiomyopathies Familial/genetic or non-familial/non-genetic (including acquired, e.g. myocarditis) Hypertrophic (HCM), dilated (DCM), restrictive (RCM), arrhythmogenic right ventricular (A
4、RVC), unclassified Drugs -Blockers, calcium antagonists, antiarrhythmics, cytotoxic agents Toxins Alcohol, medication, cocaine, trace elements (mercury, cobalt, arsenic) Endocrine Diabetes mellitus, hypo/hyperthyroidism, Cushing syndrome, adrenal insufficiency, excessive growth hormone, phaeochromoc
5、ytoma Nutritional Deficiency of thiamine, selenium, carnitine. Obesity, cachexia Infiltrative Sarcoidosis, amyloidosis, haemochromatosis, connective tissue disease Others Chagas disease, HIV infection, peripartum cardiomyopathy, end- stage renal failure,Classification of HF, New onset First presenta
6、tion Acute or slow onset Transient Recurrent or episodic Chronic Persistent Stable, worsening, or decompensated,Time is important for various types of heart failure.,Diagnostic techniques,Clinical examination,Diagnosis of HF with natriuretic peptides,As regards diagnostic tools, the importance of BN
7、P/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,(BNP) in Differentiating between Dyspnea,Alan S. Maisel, N Engl J Med 2002;347:161167.,BNP among Patients in Each
8、 of the Four NYHA Classifications,Alan S. Maisel, N Engl J Med 2002;347:161167.,BNP,BNP400 pg/mL, NT-proBNP2000 pg/m Increased ventricular wall stress HF likely Indication for echo Consider treatment BNP100 pg/mL, NT-proBNP400 pg/mL Normal wall stress Re-evaluate diagnosis HF unlikely if untreated,M
9、aisel AS,et al. N Engl J Med 2002;347:161-167.,B-type natriuretic peptide (BNP),HF with preserved ejection fraction (HFPEF),HFPEF,“Most 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
10、preserved left ventricular ejection fraction (LVEF) 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 chronic HF. Presence of normal or
11、only mildly abnormal LV systolic function (LVEF45-50%). Evidence of diastolic dysfunction (abnormal LV relaxation or diastolic stiffness).,Speckle-tracking echocardiography,A 62-year-old man with a normal heart EF=60%,A 78-year-old man Diastolic dysfunction EF=55%,Process underlying HFPEF,Non-pharma
12、cological management,A strong relationship 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 de
13、cisions regarding treatment 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 mortality Morbidity: Improve quality of life Prevention: Reduce hospitalization,ACE inhibitors,Unless
14、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 function and patient well-being, reduces hospital admission for worsening HF, and increases survival. In hospitalized patients, treatment with an A
15、CEI should be initiated before discharge.,Class of recommendation I, level of evidence 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 = 2231,n = 1986,n = 3577,CONSENSUS: NEJM
16、1987;316:1429-435, SOLVD: NEJM 1991;325:293-302, SAVE: NEJM 1992;327:669-677 AIRE: Lancet 1993;342:821-828, HOPE: Lancet 2000;355:253-259,-Blockers,Unless contraindicated or not tolerated, a b-blocker should be used in all patients with symptomatic HF and an LVEF40%. b-Blockade improves ventricular
17、function and patient well-being, reduces hospital admission for worsening 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 A,CIBIS II(1999), MERIT-HF(2000) an
18、d COPERNICUS(2002),Effect of -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 LVEF35% and severe symptomatic HF, i.e. currently NYHA functional class III or IV, i
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