如何优化心衰控制？.ppt

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Keep guideline in mind,walking your own way!,Michael Fu,MD,PhD,FESC,Professor,Senior Consultant Physician,Head,Heart Failure Center Medicine,Sahlgrenska University Hospital/Sahlgrenska,Gteborg,SWEDEN,How to optimize heart failure management?,Chronic Heart FailureMore common than we believe,!,2%,10%,CHF:A aged population,0,100,200,300,400,500,600,700,1960,1980,2000,2020,Millions,165,296,403,649,Chronic Heart Failure A disease state which seldom stops!,Chronic Heart Failure More malignant than we believe!,CHF:More malignant than most cancer!,Stewart et al.Eur J Heart Failure 2001,3(3):315-,A,Risk factor,Ischemea,Hypertention,Diabetes,B,Heart dysfunction,C,Heart failure,D,Refractory HF,Standard Heart failure care,Extraordinary measure,Risk modification,X,X,diuretic,digoxin,diuretic,digoxin,diuretic,digoxin,ACE-I,diuretic,digoxin,ACE-I,diuretic,digoxin,ACE-I,blocker,diuretic,digoxin,ACE-I,blocker,ACEI (1991),blocker(1999),ARB (2003),ACE-I,blocker,ARB,Evidence-based heart failure medications,One year mortality(%),Worldwide Gteborg,blocker:50%82%,ACEI:64%75%,Age 80 years Worldwide Gteborg,blocker:15%80%,ACEI:35%73%,European heat survey,Heart failure registry in Gteborg,A Gap between Guideline and Clinical Practice,To clarify objectives,of treatment of chronic heart failure,Prognosis,Morbidity,Prevention,Life quality,No 1,Evidence based medicine makes difference!,Beta-blocker ACE inhibitor AT1 receptor blocker Aldosteron receptor antagonist Digitalis Diuretics Antikoagulation,Vasodilator,Antiarytmics,Inotropic agents,Calcium channel blocker,Statin,ASA,TNF-,antagonist,Endothelin antagonist,AVP antagonist,Relieve Slow Prevent,Symptom prpgression SCD,?,?,?,CHF,ACEI+BB,ESC,CHF,ACEI+BB,Persisting symptoms&sign,Yes,ARB or Aldosterone antagonist,Persisting symptoms,Yes,QRS120 ms,Yes,CRT/CRT-D,ESC,CHF,ACEI+BB,Persisting symptoms&sign,Yes,NO,ARB or Aldosterone antagonist,Persisting symptoms,Yes,QRS120 ms,Yes,CRT/CRT-D,NO,LVEF35%,Yes,ICD,ESC,CHF in particular,Sudden death,Sudden Death,“,The major challenge confronting,contemporary cardiology”,Bernard Lown,Most common death in,Hypertension,Post-MI patients,Heart failure,Sudden Death,CHF in particular,Post-MI,Postinfarct-HF,Heart failure at admission,0,1,2,3,4,5,6,Months,0.0,0.1,0.2,0.3,No heart failure at admission,20.7,5.9,12.0,2.9,Heart failure during hospitalisation,25.3,%Mortality,Survival Post-MI:GRACE Registry,Steg et al Circulation 2004,CHF in particular,Doubel RAAS inhibitors,CHARM Programme,0,1,2,3,years,0,10,20,30,40,50,Placebo,Candesartan,%,Number at risk,Candesartan127611761063948457,Placebo127211361013906422,3.5,HR 0.85 (95%CI 0.75-0.96),p=0.011Adjusted HR 0.85,p=0.010,483(37.9%),538(42.3%),McMurray et al,Lancet 2003,CHARM-Added,Primary outcome,CV death or CHF hospitalisation,Effect of Candesartan:,On top of ACEI,BB and Spironolacton,Walking out from misperceptions!,No 3,Beta-blockers should be avoided in diabetic CHF patients,Beta-blockers should be avoided in COPD and CHF patients,Beta-blockers and ACE inhibitors should be avoided in elderly CHF patients,Low dose of beta blocker/ACEI is not meningful,False,False,False,False,False,All beta blockers or ARB have class effects,False,To be creative!,No 4,Hypotension,Bradycardy,Renal dysfunction,Hyperkalaemia,Low compliance,For example,Not easy,but not impossible!,Too much diuretics?,Hypotension,Other vasodilators?,Symptomatic?,Time to re-consider!,Negative chronotropic drug(digitalis,CCB with low vascular selectivity)?,Bradycardy?,Symptomatic?,Time to re-consider !,Daytime?Evening?,At rest?Exercise?,Pacemaker?,What shall we do when guideline does,NOT,exist?,No guideline in most HF patients,Elderly,HFNEF,HFNEF:HF with preserved systolic function,I do as I wish,because there is no guideline,I do my best,as physician,despite there is no guideline,I do nothing,because there is no guideline,Wrong!,Right!,Wrong!,Prevention:BP,Diagnos:NTpro BNP,Heart Failure Outpat Clinic,Self-care:eduction,exercise,Guideline covers more!,Guideline,Not dictionary in bookshelf,but concept in your brain!,Paradigm shift:New era to come!,Heart Failure 70-90:,Standard,therapy with,blocker,ACEI,Heart Failure 2000-:,Tailored heart failure management on the basis of ACEI/BB,Focus on patients well-being,Heat Failure 50-70:,Digitalis,Vasodilator,Inotropics,Considering how much attention has been paid to disease of the heart during the past 20 years,their history and causes might be regarded as nearly complete,George Burrows,1847,Despite nealy 200 years has elapsed,we are still in the start-block in our race to fight with heart filure,Michael Fu,2007,