




版權說明:本文檔由用戶提供并上傳,收益歸屬內容提供方,若內容存在侵權,請進行舉報或認領
文檔簡介
1、慢性心力衰竭指南講義ESC-51 COUNTRIESContentDefinition and diagnosisDiagnostic techniquesNon-pharmacological managementPharmacological therapyDevices and surgeryCo-morbidities and special populationsDefinition and diagnosis “The very essence of cardiovacular medicine is the recognition of early heart failure”S
2、ir Thomas Lewis,1933Definition of HFImportantly, it was emphasised that the diagnosis is not dependent on a certain ejection fraction (EF), although it has implications for prognosis.Common clinical manifestationsClinical manifestationsFatigueCoughBreathlessnessSwollen anklesDepressionWeight gainLos
3、s of appetiteNeed to urinate at nightPalpitationSwollen abdomen Classification of HFCommon causes of HFCoronary heart disease Many manifestationsHypertension Often associated with left ventricular hypertrophy and ejection fractionCardiomyopathies Familial/genetic or non-familial/non-genetic (includi
4、ng acquired, e.g. myocarditis) Hypertrophic (HCM), dilated (DCM), restrictive (RCM), arrhythmogenic right ventricular (ARVC), unclassifiedDrugs -Blockers, calcium antagonists, antiarrhythmics, cytotoxic agents Toxins Alcohol, medication, cocaine, trace elements (mercury, cobalt, arsenic) Endocrine D
5、iabetes mellitus, hypo/hyperthyroidism, Cushing syndrome, adrenal insufficiency, excessive growth hormone, phaeochromocytomaNutritional Deficiency of thiamine, selenium, carnitine. Obesity, cachexiaInfiltrative Sarcoidosis, amyloidosis, haemochromatosis, connective tissue diseaseOthers Chagas diseas
6、e, HIV infection, peripartum cardiomyopathy, end- stage renal failureClassification of HF New onset First presentation Acute or slow onsetTransient Recurrent or episodicChronic Persistent Stable, worsening, or decompensated Time is important for various types of heart failure. Diagnostic techniques
7、Clinical examination Diagnosis of HF with natriuretic peptidesAs 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 (B
8、NP) in Differentiating between Dyspnea 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. BNPBNP400 pg/mL, NT-proBNP2000 pg/mIncreased ventricular wall stress HF likelyIndication for echoConsider tre
9、atmentBNP100 pg/mL, NT-proBNP40-50%. HF with preserved ejection fraction (HFPEF) is present half the patients with HF.”Epidemiologic studies Solomon SD,Circulation 112:3738- 3744, 2005Assessment of HFPEFPresence of signs and/or symptoms of chronic HF.Presence of normal or only mildly abnormal LV sys
10、tolic function (LVEF45-50%).Evidence of diastolic dysfunction (abnormal LV relaxation or diastolic stiffness).Speckle-tracking echocardiographyA 62-year-old man with a normal heartEF=60%A 78-year-old manDiastolic dysfunctionEF=55% Process underlying HFPEFNon-pharmacological managementA strong relati
11、onship 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 decisions regarding treatment and care
12、Sabate E. Adherence to Long-term Therapies. Evidence for Action. Geneva: WHO;2003.People involved in careThe Players Pharmacological therapyPrognosis:Reduce mortalityMorbidity:Improve quality of life Prevention:Reduce hospitalizationACE inhibitorsUnless contraindicated or not tolerated, an ACEI shou
13、ld 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 ACEI should be initiated before discharge.Class o
14、f recommendation I, level of evidence ACONSENSUS(1987) and SOLVD-Treatment(1991)Mortality Reductions with ACEI051015202530Relative Risk Reduction (%)CONSENSUSSOLVDSAVEAIREHOPEn = 253n = 4228n = 2231n = 1986n = 3577CONSENSUS: NEJM 1987;316:1429-435, SOLVD: NEJM 1991;325:293-302, SAVE: NEJM 1992;327:6
15、69-677AIRE: Lancet 1993;342:821-828, HOPE: Lancet 2000;355:253-259-BlockersUnless contraindicated or not tolerated, a b-blocker should be used in all patients with symptomatic HF and an LVEF40%. b-Blockade improves ventricular function and patient well-being, reduces hospital admission for worsening
16、 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 ACIBIS II(1999), MERIT-HF(2000) and COPERNICUS(2002)Effect of -Blockers on outcomeAldosterone antagonistsUnle
17、ss 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, in the absence of hyperkalaemia and significant renal dysfunction. Aldosterone
18、antagonists reduce hospital admission for worsening HF and increase survival when added to existing therapy, including an ACEI. In hospitalized patients satisfying these criteria, treatment with an aldosterone antagonist should be initiated before discharge.Class of recommendation I, level of eviden
19、ce BRALES(1999), EPHESUS(2003)Aldosterone antagonists in HFPitt B, N Engl J Med 1999;341:709717Pitt B, N Engl J Med 2003;348:13091321.ARBsUnless 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 a
20、nd b-blocker, unless also taking an aldosterone antagonist. Treatment with an ARB improves ventricular function and patient well-being, and reduces hospital admission for worsening HF.Class of recommendation I, level of evidence AVal-HEFT(2001) and CHARMAdded(2003)CHARM-Alternative trialGranger et a
21、l. Lancet 2003;362:7726.Proportion with event(%)DigoxinIn patients with symptomatic HF and AF, digoxin may be used to slow a rapid ventricular 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
22、evidence CThe Effect of Digoxin on Mortality and Morbidity in Patients with Heart FailureN Eng1 Med,1997;336:525-533DIG TRAIL-All-cause mortalityPlaceboDigoxinThe Effect of Digoxin on Mortality and Morbidity in Patients with Heart Failure N Eng1 Med,1997;336:525-533Hospital admission for worsening H
23、F28%P0.01PlaceboDigoxinThe Effect of Digoxin on Mortality and Morbidity in Patients with Heart Failure N Eng1 Med,1997;336:525-533DiureticsDiuretics are recommended in patients with HF and clinical signs or symptoms of congestion.Class of recommendation I, level of evidence BIn symptomatic patients
24、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 should be considered in patients with persistent symptoms despite treatment with an ACEI, b-blocker, and an ARB or aldosterone antagonist. Tr
25、eatment with H-ISDN in these patients may reduce the risk of death. Hydralazine and isosorbide dinitrate(H-ISDN)Class of recommendation IIa, level of evidence BV-HeFT-I(1991)and A-HeFT(2004)Other drugs-Statins“In elderly patients with symptomatic chronic HF and systolic dysfunction caused by CAD, st
26、atin treatment may be considered to reduce cardiovascular hospitalization. ”Class of recommendation IIb, level of evidence BTrial design: A total of 5011 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
27、receive 10 mg of rosuvastatin or placebo per dayResults: Primary Outcome: 11.4% with rosuvastatin vs. 12.3% with placebo (p = 0.12)Death from Any Cause : 11.6% vs.12.2% (p = 0.31), respectivelyAny cause Hospitalizations : 2193 vs. 2564 (p 0.001), respectively Rosuvastatin in Older Patientswith Systo
28、lic Heart FailureN Engl J Med 2007;357:22482261. Primary Outcome and Death from Any CauseN Engl J Med 2007;357:22482261.N Engl J Med 2007;357:22482261. Hospitalizations for cardiovascular causesP40 days of MI (Class I Level A)Non-ischaemic aetiology (Class I Level B)CRTNYHA Class III/IV and QRS .120
29、 ms (Class I Level A)To improve symptoms/reduce hospitalization (Class I Level A)To reduce mortality (Class I Level A) Class I recommendationsICDICD therapy for primary prevention is recommended to reduce mortality in patients with LV dysfunction due to prior MI who are at least 40 days post-MI, hav
30、e 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-analyses 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 DefibrillatorStudy. Eur Heart J 2000;21:20712078.Mortality of ICD23%Bardy GH, N Engl J Med 2005;352:225237.CR
溫馨提示
- 1. 本站所有資源如無特殊說明,都需要本地電腦安裝OFFICE2007和PDF閱讀器。圖紙軟件為CAD,CAXA,PROE,UG,SolidWorks等.壓縮文件請下載最新的WinRAR軟件解壓。
- 2. 本站的文檔不包含任何第三方提供的附件圖紙等,如果需要附件,請聯系上傳者。文件的所有權益歸上傳用戶所有。
- 3. 本站RAR壓縮包中若帶圖紙,網頁內容里面會有圖紙預覽,若沒有圖紙預覽就沒有圖紙。
- 4. 未經權益所有人同意不得將文件中的內容挪作商業(yè)或盈利用途。
- 5. 人人文庫網僅提供信息存儲空間,僅對用戶上傳內容的表現方式做保護處理,對用戶上傳分享的文檔內容本身不做任何修改或編輯,并不能對任何下載內容負責。
- 6. 下載文件中如有侵權或不適當內容,請與我們聯系,我們立即糾正。
- 7. 本站不保證下載資源的準確性、安全性和完整性, 同時也不承擔用戶因使用這些下載資源對自己和他人造成任何形式的傷害或損失。
最新文檔
- 2025年鉆采設備專用件合作協(xié)議書
- 摩托車零配件批發(fā)企業(yè)ESG實踐與創(chuàng)新戰(zhàn)略研究報告
- 活頁賬簿企業(yè)縣域市場拓展與下沉戰(zhàn)略研究報告
- 自粘膠粘紙企業(yè)縣域市場拓展與下沉戰(zhàn)略研究報告
- 小五金百貨企業(yè)ESG實踐與創(chuàng)新戰(zhàn)略研究報告
- 工地材料采購協(xié)議
- 2025年度綠色建筑項目土地抵押借款合同
- 二零二五年度餐飲服務業(yè)員工勞務派遣服務協(xié)議
- 二零二五年度公益組織志愿者招聘與公益活動服務合同
- 二零二五年度夫妻債務處理與婚姻穩(wěn)定執(zhí)行協(xié)議
- 2023年考研考博-考博英語-煤炭科學研究總院考試歷年高頻考點真題薈萃帶答案
- 吳階平醫(yī)學基金-廣東省生殖道感染的流行病學調查-王加義-2013-3-22
- 中藥制劑檢驗的依據和程序
- 理性與感性議論文900字(通用范文3篇)
- 【小學語文 】魯濱遜漂流記導讀課(課件)六年級下冊語文部編版
- GB/T 7999-2007鋁及鋁合金光電直讀發(fā)射光譜分析方法
- 收支管理內部控制流程圖
- 《企業(yè)員工培訓國內外文獻綜述》4800字
- 華中科技大學復變函數試題(一)
- 三年級下冊數學教案-速度、時間和路程 滬教版
- 徽派建筑PPT江西婺源
評論
0/150
提交評論