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 mortalityMorbidity: Impro
14、ve 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 worseni
15、ng 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,SOLVD,
16、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 pa
17、tients 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.,Class
18、 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% a
19、nd severe symptomatic HF, i.e. currently NYHA functional class III or IV, in the absence of hyperkalaemia and significant renal dysfunction. Aldosterone antagonists reduce hospital admission for worsening HF and increase survival when added to existing therapy, including an ACEI. In hospitalized pat
20、ients satisfying these criteria, treatment with an aldosterone antagonist should be initiated before discharge.,Class of recommendation I, level of evidence B,RALES(1999), EPHESUS(2003),Aldosterone antagonists in HF,Pitt B, N Engl J Med 1999;341:709717 Pitt B, N Engl J Med 2003;348:13091321.,ARBs,Un
21、less 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 and b-blocker, unless also taking an aldosterone antagonist. Treatment with an ARB improves ventricular function and patient well-being, and
22、reduces hospital admission for worsening HF.,Class of recommendation I, level of evidence A,Val-HEFT(2001) and CHARMAdded(2003),CHARM-Alternative trial,Granger et al. Lancet 2003;362:7726.,Proportion with event(%),Digoxin,In patients with symptomatic HF and AF, digoxin may be used to slow a rapid ve
23、ntricular 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 evidence C,The Effect of Digoxin on Mortality and Morbidity in Patients with Heart Failure N Eng1 Med,1997;336:525-533,DIG TRAIL-All
24、-cause mortality,The Effect of Digoxin on Mortality and Morbidity in Patients with Heart Failure N Eng1 Med,1997;336:525-533,Hospital admission for worsening HF,The Effect of Digoxin on Mortality and Morbidity in Patients with Heart Failure N Eng1 Med,1997;336:525-533,Diuretics,Diuretics are recomme
25、nded in patients with HF and clinical signs or symptoms of congestion.,Class of recommendation I, level of evidence B,In symptomatic patients 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
26、 should be considered in patients with persistent symptoms despite treatment with an ACEI, b-blocker, and an ARB or aldosterone antagonist. Treatment with H-ISDN in these patients may reduce the risk of death.,Hydralazine and isosorbide dinitrate(H-ISDN),Class of recommendation IIa, level of evidenc
27、e B,V-HeFT-I(1991)and A-HeFT(2004),Other drugs-Statins,“In elderly patients with symptomatic chronic HF and systolic dysfunction caused by CAD, statin treatment may be considered to reduce cardiovascular hospitalization. ”,Class of recommendation IIb, level of evidence B,Trial design: A total of 501
28、1 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 receive 10 mg of rosuvastatin or placebo per day Results: Primary Outcome: 11.4% with rosuvastatin vs. 12.3% with placebo (p = 0.12) Death from Any Caus
29、e : 11.6% vs.12.2% (p = 0.31), respectively Any cause Hospitalizations : 2193 vs. 2564 (p 0.001), respectively,Rosuvastatin in Older Patients with Systolic Heart Failure,N Engl J Med 2007;357:22482261.,Primary Outcome and Death from Any Cause,N Engl J Med 2007;357:22482261.,N Engl J Med 2007;357:224
30、82261.,Hospitalizations for cardiovascular causes,P0.001,Statin-mediated effects in endothelial cells and other tissues,Class I recommendations For Drugs,Devices and surgery,ICD Prior resuscitated cardiac arrest (Class I Level A) Ischaemic aetiology and 40 days of MI (Class I Level A) Non-ischaemic
31、aetiology (Class I Level B) CRT NYHA Class III/IV and QRS .120 ms (Class I Level A) To improve symptoms/reduce hospitalization (Class I Level A) To reduce mortality (Class I Level A),Class I recommendations,ICD,ICD therapy for primary prevention is recommended to reduce mortality in patients with LV
32、 dysfunction due to prior MI who are at least 40 days post-MI, have 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-analy
33、ses 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 Defibrillator Study. Eur Heart J 2000;21:20712078.,Mortality of ICD,23%,Bardy GH, N Engl J Med 2005;352:225237.,CRT,T
34、he survival advantage of CRT-D vs. CRT-P has not been adequately addressed. In the CARE-HF trial, CRT-P was associated with a significant reduction of 37% in the composite end-point of total death and hospitalization for major cardiovascular events (P0.001) and of 36% in total mortality (P0.002).,CO
35、MPANION.N Engl J Med 2004;350:21402150. CARE-HF trial. N Engl J Med 2005;352:15391549.,COMPANION All-Cause Death Results,Days from Randomization,Event-Free Survival (%),100,90,80,70,60,50,OPT,CRT,CRT-D,(CRT vs. OPT) P = 0.059 (CRT-D vs. OPT) P = 0.003,Bristow M. N Engl J Med. 2004;350:2140-2150.,90,
36、900,810,720,630,540,360,270,180,0,990,1080,450,Co-morbidities and special populations,Management of arterial hypertension inpatients with HF,Conclusion,the diagnosis of HF with natriuretic peptides(BNP) HF with preserved ejection fraction(HFPEF) Rosuvastatin in Older Patients with Systolic Heart Failure(statin),“The Loop of Knowledge “,Research Clinical Trials,Guidelines,Education based on Guidelines,Evaluation of Practices by Surveys,Thanks For Your Attention!,
