心力衰竭的诊断与治疗面临的选择与挑战.pptx

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,#,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,1/8/2022,#,Click to edit Master title style,心力衰竭的诊断与治疗面临的选择与挑战,心力衰竭的诊断与治疗面临的选择与挑战,第1页,内 容,脑钠肽、,N,端脑钠肽前体在心力衰竭,诊疗和处理中地位,他汀类药品治疗心力衰竭,力不从心？,心力衰竭的诊断与治疗面临的选择与挑战,第2页,在,初级保健,中被误诊为心力衰竭百分比：,-,Framingham:40%(McKee 1971)-Boston:42%(Carlson 1985)-Kuopio:50%(Remes 1991),急诊室,中,25-50%,失代偿心力衰竭病人被误诊,充血性心力衰竭,:,在临床上是否易于诊疗?,三大症状非特异性（气促、踝肿和疲劳）,尤其,对于肥胖、老年和妇女。,心衰体征仅提醒心衰存在,，但仍需有心功效评,价客观证据。,心力衰竭的诊断与治疗面临的选择与挑战,第3页,BNP 100 but 500 HF likely,心力衰竭的诊断与治疗面临的选择与挑战,第4页,NT-proBNP,年纪分层降低了假阳性和假阴性，提升了阳性预测值,ICON,三重界值无需依据肾功效对,NT-proBNP,界值深入调整,83%,55%,92%,73%,85%,1800 pg/ml,全部,75,岁,(n=519),86%,66%,88%,84%,90%,总计,85%,88%,82%,82%,90%,900 pg/ml,全部,50-75,岁,(n=554),95%,99%,76%,93%,97%,450 pg/ml,全部,50,岁,(n=183),准确度,阴性预测值,阳性预测值,特异性,敏感性,适当界值,年纪分层,Januzzi,et al,Eur Heart J,Anwaruddin,et al,JACC,诊疗急性心力衰竭,国际氨基末端脑钠肽原帮助数据,依据年纪分层,NT-proBNP,“,诊疗”界值,心力衰竭的诊断与治疗面临的选择与挑战,第5页,诊疗心衰三大常规,胸片是心衰初步诊疗主要个别,心脏超声是现在“金标准”,（仍不能完全处理急性呼吸困难判别问题）,到当前为止，由美国和欧洲心脏病协会推荐使用,BNP,或,NT-proBNP,是唯一用于诊疗心力衰竭试验室检测指标,胸片、心脏超声和,BNP/NT-proBNP,检测是诊疗心衰三大常规,心力衰竭的诊断与治疗面临的选择与挑战,第6页,Richards et al.,J Am Coll Cardiol,;47:5260,心力衰竭的诊断与治疗面临的选择与挑战,第7页,BNP,和,NT-proBNP,检测分析,NT-proBNP,半衰期相对较长，浓度相对较稳定，含量相对较高（比,BNP,约高,16,20,倍），,检测相对较轻易，是较理想预测标志物,BNP,半衰期相对较短，（,18,分钟），检测血液时间要求高；在了解病人即刻情况时较有价值,BNP,或,NT-proBNP,临床应用价值基础相同,天天或隔天检测,BNP,并无临床价值，治疗,1W,后,BNP,才出现显著改变,Am J Cardiol,;93:1562-1563,Am J Cardiol,;101:3A,心力衰竭的诊断与治疗面临的选择与挑战,第8页,病人因,急性呼吸困难,来急诊,病史采集,体格检验,ECG,胸片+,NTproBNP,充血性心力衰竭,高度不可能,充血性心力衰竭,高度可能,充血性心力衰竭不可能？,可能？其它检验,NTproBNP,450,p,g/mL -,病人 900pg/mL -,病人 50-75 岁,1800pg/mL,病人 75岁,Bayes-Genis A.Rev Esp Cardiol,心力衰竭的诊断与治疗面临的选择与挑战,第9页,体征,OR,95%CI,p-value,咳嗽,0.18,0.06-0.52,0.001,利用袢利尿剂,3.99,1.58-10.1,0.003,夜间阵发性呼吸困难,4.50,1.32-15.4,0.02,颈静脉怒张,3.05,1.06-8.79,0.04,心力衰竭前,2.63,1.02-6.80,0.05,下肢水肿,2.96,0.94-9.31,0.06,第三心音奔马律,10.4,0.82-130.7,0.07,COPD/,哮喘前,0.48,0.20-1.19,0.,11,端坐呼吸,2.06,0.73-5.83,0.17,喘鸣,0.81,0.29-2.22,0.17,灰色区域中心力衰竭独立预测因子,van Kimmenade,et al,AJC,心力衰竭的诊断与治疗面临的选择与挑战,第10页,Acute Heart Failure-BNP levels and risk stratification from the ED to discharge,UNDER 100 HEART FAILURE UNLIKELY CAUSE OF SOB,UNDER 250 PATIENT IS AT LOW RISK AND MAY BE DISCHARGED SAFELY,CONSIDER BNP IN THE CONTEXT OF CLINICAL SYMPTOMS,ABOVE 600 pg/ml PATIENT IS CONSIDERED STILL AT HIGH RISK,ED ADMISSIONINPATIENTDISCHARGE,ARRIVAL(Tiime),1,500,600,250,100,BNP,Values,(pg/ml),600 pg/ml,400/pg/ml,心力衰竭的诊断与治疗面临的选择与挑战,第11页,急性心力衰竭,5000 pg/ml,是短期预后界值,判断急性心力衰竭短期（,60,天）预后,心力衰竭的诊断与治疗面临的选择与挑战,第12页,Januzzi et al.Arch Intern Med,判断,急性心力衰竭,长久（,1,年）预后,对于,1,年危险度分层，最正确界值是,1000 pg/ml,心力衰竭的诊断与治疗面临的选择与挑战,第13页,Van Kimmenade et al.JACC,各种标志物检测:,+,GFR,联合传统标志物，,NT-proBNP,预后价值加强,心力衰竭的诊断与治疗面临的选择与挑战,第14页,BNP,药理作用：治疗急性失代偿性心衰,扩血管（,vasodilator,）,利 钠 （,natriuretic,）,利 尿 （,diuretic,）,抗纤维化（,antifibrotic,）,Nesiritide,（,natrecor,）,心力衰竭的诊断与治疗面临的选择与挑战,第15页,Fitzgerald,ACC,BNP:,-,治疗过程中显著升高，不能反应体内分泌,BNP,浓度,-,治疗结束后,2,小时才低于基线,NT-proBNP -,治疗中,12,小时即能够显著低于基线水平，反应治疗效果,-,治疗结束,24,小时能够到达最大程度降低,在接收奈西立肽治疗心衰患者中 对,BNP,和,NT-proBNP,改变监测,12 hrs,24 hrs Infusion,心力衰竭的诊断与治疗面临的选择与挑战,第16页,Jourdain P et al et al.JACC;49:1733-9,BNP,监测指导治疗,:STARS-BNP,多中心研究,BNP,/NT-proBNP,能够指导治疗吗,?,心力衰竭的诊断与治疗面临的选择与挑战,第17页,内 容,脑钠肽、,N,端脑钠肽前体在心力衰竭,诊疗和处理中地位,他汀类药品治疗心力衰竭,力不从心？,心力衰竭的诊断与治疗面临的选择与挑战,第18页,Beneficial Effects of Statins,Anti-Inflammatory Effects,Antioxidant Effects,Endothelial Function,Effects on Angiogenesis,Cardiac Hypertrophy and LV Remodeling,Neurohormonal Activation,J Am Coll Cardiol.;51(4),心力衰竭的诊断与治疗面临的选择与挑战,第19页,Statins and Risks for Death and Heart Failure,Hospitalisation in 25,000 heart failure patients,Go A et al.,JAMA,;296:21052111,0,5,10,15,20,25,30,35,Rate per 100 person-years,Baseline,CHD,No Baseline,CHD,Overall,Rate of Death,No.,24598,19705,4893,0,5,10,15,20,25,30,35,Baseline,CHD,No Baseline,CHD,Overall,Rate of Hospitalization,No.,24598,19705,4893,No Statin,Statin,心力衰竭的诊断与治疗面临的选择与挑战,第20页,Adjusted mortality among patients,with,ischemic etiology,(n=62,273),Mortality among patients with heart failure,of,nonischemic etiology,(n=31,551),A,B,心力衰竭的诊断与治疗面临的选择与挑战,第21页,既往研究结果使大家对他汀治疗心衰充满希望,然而，这些试验只是产生假说初步研究,他汀类能否深入用于临床心衰治疗,尚需要开展大规模前瞻性研究,率先完成是,CORNOA,试验,心力衰竭的诊断与治疗面临的选择与挑战,第22页,Patients(n=5011),Chronic ischaemic systolic heart failure receiving optimal HF treatment(diuretics,ACE inhibitors,ARBs,beta-blocker therapy),Ejection fraction0.40(NYHA class III/IV)or 0.35(NYHA class II),60 years,rosuvastatin 10 mg(n=2514),placebo(n=2497),End points:,Time to cardiovascular death,non-fatal MI,non-fatal stroke,Total mortality,Visit:,Week:,1,8 to 2,2,4 to 2,3,0,4,6,521,3 monthly,Final,3 y,A Randomized,Double-Blind,Placebo-Controlled Study with Rosuvastatin in Patients with Chronic Symptomatic Systolic Heart Failure,CORONA -Study Design,Eligibility,Optimal HF treatment instituted,Median follow-up 2.7 years,Placebo,run-in,Kjekshus J et al.,Eur J Heart Fail,;7:1059-1069,心力衰竭的诊断与治疗面临的选择与挑战,第23页,Mean age,(years),73 73,75 years,(%),4141,Female sex,(%),2424,NYHA class,(%),II3737,III6261,IV1.61.4,Ejection Fraction0.310.31,Myocardial infarction(%)60 60,Angina pectoris(%)7273,CABG or PCI(%)2626,Hypertension(%)6363,PlaceboRosuvastatinn=2497n=2514,CORONA -Baseline characteristics,Kjekshus J et al.,N Eng J Med,;357 doi 10.1056/NEJMoa0706201,心力衰竭的诊断与治疗面临的选择与挑战,第24页,Total cholesterol(mmol/L)5.35 5.36,LDL cholesterol(mmol/L)3.563.54,hsCRP,median(mg/L)3.53.5,Loop or thiazide diuretic(%)8889,Aldosterone antagonist(%)3939,ACE inhibitor(%)8080,Beta-blocker(%)7575,Antiplatelet or anticoagulant(%)90 90,PlaceboRosuvastatin n=2497n=2514,CORONA -Medical History,Kjekshus J et al.,N Eng J Med,;357 doi 10.1056/NEJMoa0706201,心力衰竭的诊断与治疗面临的选择与挑战,第25页,-50,-40,-30,-20,-10,0,10,LDL-C,HDL-C,TG,CRP,CORONA,Effects on LDL-C,HDL-C,TG and CRP at 3 months;,Absolute difference between rosuvastatin and placebo,Between group difference,from baseline(%),45%,5.0%,20.5%,37.1%,p0.001,p0.001,p0.001,p0.001,Kjekshus J et al.,N Eng J Med,;357 doi 10.1056/NEJMoa0706201,心力衰竭的诊断与治疗面临的选择与挑战,第26页,CORONA-Primary Endpoint,The combined endpoint of cardiovascular,death,or non-fatal MI or non-fatal stroke(time to first event),Hazard ratio=0.92,95%CI 0.83 to 1.02,p=0.12,Months of follow-up,0,36,30,24,18,12,6,0,10,20,30,Placebo,Rosuvastatin 10 mg,No.at risk,Placebo24972315215618511431811,Rosuvastatin251423452207206819321484855,Percent of patients with,primary endpoint,Kjekshus J et al.,N Eng J Med,;357 doi 10.1056/NEJMoa0706201,心力衰竭的诊断与治疗面临的选择与挑战,第27页,Months of follow-up,0,36,30,24,18,12,6,Placebo,Rosuvastatin 10 mg,0,3,6,12,9,15,Hazard ratio=0.84,95%CI 0.70 to 1.00,p=0.05,No.at risk,Placebo24972315215618511431811,Rosuvastatin251423452207206819321484855,Data on File,CORONA,Post hoc analysis of the number fatal/non-fatal MI or stroke in the primary endpoint,Percent of patients with,event,心力衰竭的诊断与治疗面临的选择与挑战,第28页,p=0.01,p=0.007,p0.001,4,074,2,464,1,299,1,510,3,694,2,193,1,109,1,501,0,1,000,2,000,3,000,4,000,Heart failure,All cause,CV cause,Non-CV cause,Placebo(n=2,497),Rosuvastatin 10 mg(n=2,514),CORONA-Secondary Endpoints,Total number of hospitalizations,No.hospitalisations,Kjekshus J et al.,N Eng J Med,;357 doi 10.1056/NEJMoa0706201,心力衰竭的诊断与治疗面临的选择与挑战,第29页,对,CORONA,试验解释,入选患者平均年纪达,73,岁，,63%,患者,NYHA,心功效为,和,级。试图经过改变粥样硬化自然史，影响心血管罹患率和死亡率作用可能有限,在,CORONA,试验亚组分析中，发觉对于那些心衰程度轻，普通情况良好年轻患者，他汀更能凸显其优势。或他汀在年纪相对较年轻轻度心衰患者中可能会得到不一样结果。,同一类药品不等于同一个药品。还不能确定,CORONA,研究局限是瑞舒伐他汀本身问题,还是他汀类治疗老年心衰患者无确切疗效。,心力衰竭的诊断与治疗面临的选择与挑战,第30页,对,CORONA,试验思索,当咱们仔细思索慢性心衰病理生理基础时，就能轻易了解,CORONA,结果。,他汀类药品是“一类神奇药品”，但并不能包治疗百病。,CORONA,主要研究者也认可：“心力衰竭患者对他汀类药品反应与非心力衰竭患者显著不一样。”,咱们需要“还原他汀类药品降脂功效本质”,心力衰竭的诊断与治疗面临的选择与挑战,第31页,GISSI-HF-Effects of n-3 PUFA and Rosuvastatin on Mortality-Morbidity of Patients With Symptomatic CHF,a prospective,multicenter,randomized,double blind,placebo controlled study,rosuvastatin(10 mg daily)or placebo,4624 heart failure patients have been included in the trial,Primary Objectives:All-cause mortality or hospitalizations for cardiovascular reason,Starting date:August ;Last updated:January 12,Eur J Heart Fail;6:635-641.,心力衰竭的诊断与治疗面临的选择与挑战,第32页,Thank you,心力衰竭的诊断与治疗面临的选择与挑战,第33页,