慢性心力衰竭最新指南解读-课件,幻灯,PPT.ppt
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1、慢性心力衰竭最新指南解读,田野 教授 哈尔滨医科大学附属二院心内科,第五届北方介入心脏病学暨心血管疾病诊疗新进展国际研讨会 2009.01.11 哈尔滨,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 es
2、sence of cardiovacular medicine is the recognition of early heart failure”,Sir 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,Clinica
3、l manifestations,Classification of HF,Common causes of HF,Coronary heart disease 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
4、 (HCM), dilated (DCM), restrictive (RCM), arrhythmogenic right ventricular (ARVC), unclassified Drugs -Blockers, calcium antagonists, antiarrhythmics, cytotoxic agents Toxins Alcohol, medication, cocaine, trace elements (mercury, cobalt, arsenic) Endocrine Diabetes mellitus, hypo/hyperthyroidism, Cu
5、shing syndrome, adrenal insufficiency, excessive growth hormone, phaeochromocytoma Nutritional Deficiency of thiamine, selenium, carnitine. Obesity, cachexia Infiltrative Sarcoidosis, amyloidosis, haemochromatosis, connective tissue disease Others Chagas disease, HIV infection, peripartum cardiomyop
6、athy, end- stage renal failure,Classification of HF, New onset First presentation 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 H
7、F 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 also for confirmation of the diagnosis.,Diagnostic assessments supporting the presence of HF,(BNP) in Differentiating between Dys
8、pnea,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.,BNP,BNP400 pg/mL, NT-proBNP2000 pg/m Increased ventricular wall stress HF likely Indication for echo Consider treatment BNP100 pg/mL, NT-proBNP
9、400 pg/mL Normal wall stress Re-evaluate diagnosis HF 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,“Most patients with HF have evidence of both systolic and diastolic dysfunction at rest or on
10、 exercise. Patients with diastolic HF have symptoms and/or signs of HF and a 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
11、HFPEF,Presence of signs and/or symptoms of chronic HF. Presence of normal or 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-
12、year-old man Diastolic dysfunction EF=55%,Process underlying HFPEF,Non-pharmacological 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
13、 that family members be invited to participate in education programmes and decisions 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: Impr
14、ove quality of life 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 function and patient well-being, reduces hospital admission for worsen
15、ing HF, and increases survival. In hospitalized patients, treatment with an ACEI 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,SOLV
16、D,SAVE,AIRE,HOPE,n = 253,n = 4228,n = 2231,n = 1986,n = 3577,CONSENSUS: NEJM 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
17、patients with symptomatic HF and an LVEF40%. b-Blockade improves ventricular 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.,Cla
18、ss of recommendation I, level of evidence A,CIBIS II(1999), MERIT-HF(2000) and 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%
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