老年人慢性心力衰竭的处置及社区管理.pptx

老年人慢性心力衰竭的处置老年人慢性心力衰竭的处置及社区管理及社区管理中南大学湘雅二医院中南大学湘雅二医院屈晓冰屈晓冰2心力衰竭定义心力衰竭定义心脏结构或功能的异常心室充盈或心室充盈或射血能力受损射血能力受损症状:呼吸困难乏力体征:肺部湿罗音肺部湿罗音颈静脉压力升高水肿引起心衰的原发病：冠心病冠心病 心肌病心肌病 风湿性风湿性心瓣膜 高血压病高血压病 Prevalence of Heart Failure by Age and Sex in CHSHF is predominantly a disorder of the older adult population and of the greater than 5 million adults with HF in the United States,50%are at least 75 years of age.Heart Failure in Older AdultsCharacteristicOlder AdultsMiddle AgedPrevalence10%4040HFpEFHFpEF患患者者亚亚组组过过去去曾曾有有HF-REFHF-REF。这这些些EFEF改改善善或或恢恢复复的的患患者者临临床床上上与与持持续续保保留留或或EFEF降降低低的的患患者是不同的。者是不同的。SHF与与DHF的特点的特点SHFDHF病理病理心室收缩功能障碍使收缩期排空能力减退而导致心排血量减少心肌舒缓和（或）顺应性降低使心室舒张期充盈障碍而导致心排血量减少特点特点心室腔扩大，收缩末期容积增大和射血分数降低，对洋地黄类药物有一定效果心肌肥厚，心室腔大小和射血分数正常，舒张功能参数异常，对洋地黄类药物反应不佳Diagnosis of HF type by Clinical Signs and Symptoms HFNEFSystolic HFSymptomsDyspnea on exertion85%96%PND55%50%Orthopnea60%73%Physical FindingsJugular venous distension35%46%Rales72%70%Displaced apical impulse50%60%S3 gallop45%65%*S4 gallop55%66%Edema30%40%Zile MR,Brutsaert DL.Circulation 2002;105:1389The clinical signs and symptoms of HFREF and HFNEF are similar.19HF-PEF的新诊断标准：的新诊断标准：1.1.典型的心衰症状及体征典型的心衰症状及体征2.2.心脏（主要是左室）不大，心脏（主要是左室）不大，LVEF LVEF 45%45%3.3.有心脏的结构性改变有心脏的结构性改变 (如左室肥厚、左房增大如左室肥厚、左房增大)和和/或舒或舒张功能障碍。张功能障碍。4.4.符合流行病学特征：老年、女性、高血压、糖尿病、符合流行病学特征：老年、女性、高血压、糖尿病、肥肥胖、房颤。胖、房颤。5.5.BNP/NTproBNPBNP/NTproBNP轻至中度升高，或至少在轻至中度升高，或至少在“灰区值灰区值”之间。之间。射血分数保射血分数保存存性心衰性心衰主主要要表表现现其其他他考考虑虑因因素素Heart Failure with a Preserved Ejection Fraction(EF)is More Common than Heart Failure with a Reduced EF in Older AdultsOlder patients show a particular propensity for developing HF with preserved LV systolic function(HFNEF)and the proportion with HFNEF increases with advancing age.LV Systolic Function in Elderly with HF in CHSMen41%30%29%Women67%21%12%Kitzman DW,Gardin JM,Gottdiener JS,et al.Importance of heart failure with preserved systolic function in patients 65 years of age.CHS Research Group.Cardiovascular Health Study.Am J Cardiol 2001;87:413-9 Population-based reports from several studies suggest that 50%or more of elderly HF patients have HFNEF with a female preponderance in HFNEF.NYHA心功能分级心功能分级分级分级心功能心功能级重体力活动时无气促症状，属心功能正常级中等体力活动时有气促症状，属心功能轻度异常级轻度体力活动时有气促症状，属心功能中度异常级无体力活动时（安静休息时）有气促症状，属心功能重度异常Associations between Exercise Testing Modalities in Chronic HFNYHA ClassVO2 Max(ml/kg/min)MET(MET 3.5ml/kg/min)6-Min Walk(meters)Duke ActivityIndex(range 0-60)I206450 37II14-204-6300-45023-37III10-143-4150-30014-23IV10315014The severity of functional limitation can be evaluated and recorded by metrics,such as NYHA functional class and performance-based measures,including timed and distance walk tests(e.g.,the 6-minute walk test)which have prognostic significance and are especially useful for serial follow-up.24BNP和和NT-pro BNP的新运用的新运用诊断和鉴别诊断：诊断和鉴别诊断：评价严重程度和预后评价严重程度和预后动态监测可作为评估心衰疗效评估的辅助手段BNP/NT-proBNP水平降幅30%治疗有效的标准24急性心衰的排除标准：急性心衰的排除标准：BNP 100 pg/mlBNP 100 pg/ml NT-proBNP 300pg/ml NT-proBNP 300pg/ml慢性心衰的排除标准：慢性心衰的排除标准：BNPBNP 35 pg/ml35 pg/ml NT-proBNP NT-proBNP 125pg/ml125pg/mlBNP Test and AgeSince natriuretic peptide levels increase mildly with aging,are higher in women than in men,and are affected by renal function and obesity,the specificity of the assays is reduced in older patients,especially in the cohort of older women with HFNEF.心功能不全程度评估心功能不全程度评估超声心动图心电图血常规，生化，甲功等胸片BNP，NT-proBNP心脏核磁冠脉造影心肌核素,PET负荷超声、食道超声心肌活检常规检查常规检查必做必做特殊检查特殊检查选择选择29慢性心衰的治疗目标和推荐药物慢性心衰的治疗目标和推荐药物治疗目标 改善症状改善症状:防止和延缓心室重构减少住院改善生存率 *以前关注点都在生存率方面,现在认识到改善症状、提高生活质量，减少住院率对于患者和医疗系统都是非常重要的推荐药物治疗 ACEI/ACEI/ARBARB受体拮抗剂醛固酮受体拮抗剂心衰治疗的金三角心衰治疗的金三角针对心肌重构机制（RAASRAAS和交感兴奋）和交感兴奋）30慢性慢性HF-REFHF-REF（NYHA-IVNYHA-IV级）处理流程级）处理流程有充血症状/体征无充血症状/体征利尿剂+ACEI(或ARB)+受体阻滞剂ACEI(或ARB)+受体阻滞剂仍NYHA-级，LVEF35%加MRA仍NYHA-级LVEF35%窦律且HR70次/分伊伐布雷定仍NYHA-级LVEF45%地高辛31实施慢性实施慢性HF-REFHF-REF新流程的具体建议新流程的具体建议ACEI和受体阻滞剂开始应用的时间ACEI与受体阻断剂谁先谁后的问题尽早形成“金三角”避免发生低血压、高血钾症、肾功能损害避免发生低血压、高血钾症、肾功能损害31两药孰先孰后并不重要，关键是尽早合用两药孰先孰后并不重要，关键是尽早合用过去强调必须应用利尿剂使液体潴留消除后才开始加用。新指南过去强调必须应用利尿剂使液体潴留消除后才开始加用。新指南去掉去掉这要求。对轻中度水肿，尤其住院患者，可与利尿剂同时使这要求。对轻中度水肿，尤其住院患者，可与利尿剂同时使用。用。32慢性心力衰竭的治疗新进展限钠，限水的观念更新 u限钠：限钠：u稳定期限制钠摄入不一定获益，正常饮食可改善预后u心功能III-IV级患者有益。u心衰急性发作伴有容量负荷过重的患者，通常要限制钠摄入65 years0.91(0.78-1.07)0.91(0.78-1.05)US CarvedilolCarvedilol1,09455459 years0.45(0.24-0.86)0.35(0.14-0.88)CIBIS-IIBisoprolol2,64753971 years0.70(0.49-0.99)0.66(0.53-0.82)COPERNICUSCarvedilol2,2891,10265 years0.75(0.58-0.98)0.57(0.41-0.80)MERIT-HFMetoprolol3,9911,330Upper tertile vs.others0.70(0.52-0.95)0.61(0.47-0.80)SENIORSNebivolol2,1281,06475 years0.92(0.75-1.12)0.79(0.63-0.98)*Hazard ratio composite of all-cause mortality or cardiovascular hospital admissionLong-term beta-blockade is beneficial in patients with HFREF and patients up to the age of 80 have been included in these trials with subgroup analyses indicate that beta-blockers are as effective in older as in younger adults适应证适应证（从III/IV及扩大到II级心功能）所有EF35%,已用ACEI/ARB和受体阻滞剂，仍持续有症状(NYHA-级)（I类，A级）。AMI后、LVEF 40%，有心衰症状或既往有糖尿病史，也推荐使用（I类，B级）。37 HF-REF HF-REF的治疗新进展的治疗新进展醛固酮受体拮抗剂醛固酮受体拮抗剂38HF-REF的药物治疗的药物治疗利尿剂利尿剂首选袢利尿剂如呋塞米、托拉塞米适用于有明显液体潴留或伴有肾功能受损噻嗪类适用于有轻度液体潴留、伴有高血压袢利尿剂及噻嗪类常见不良反应：水电解质紊乱保钾利尿剂39新型利尿剂新型利尿剂托伐普坦托伐普坦作用机制血管加压素V2受体拮抗剂特点：排水不排钠适应症常规利尿剂抵抗低钠血症患者顽固性水肿有肾功能损害倾向适应证适应证（a类，B级）已用利尿剂、ACEI（或ARB）、受体阻滞剂和醛固酮受体拮抗剂，而仍持续有症状LVEF45%伴有快速心室率的房颤患者尤为适合应用方法应用方法0.1250.25mg/d，老年或肾功能受损者剂量减半已应用不宜轻易停用。NYHA级不应用40HF-REF的药物治疗的药物治疗地高辛地高辛41 射血分数保留性心衰的治疗射血分数保留性心衰的治疗积极控制血压 收缩压130/80mmHg（类，A级）优选受体阻滞剂、ACEI或ARB。应用利尿剂：消除液体潴留和水肿(类，C级)治疗基础疾病和合并症：控制慢性房颤的心室率(C)改善心肌缺血：应考虑冠脉血运重建术（a类，C级）。治疗是主要针对症状、并存疾病及危险因素的综合性治疗治疗是主要针对症状、并存疾病及危险因素的综合性治疗41Effect of Antihypertensive Therapy on Incident Heart FailureTrialNAge Range(years)Relative Risk Reduction(%)European Working Party(1)8406022%Coope and Warrender(2)88460-7932%Swedish Trial(3)1,62770-8451%SHEP(4)4,7366055%Syst-Eur(5)4,6956036%STONE(6)1,63260-7968%HYVET(7)3,8458064%Effect of Antihypertensive Therapy on Incident HF in Older AdultsAdequate control of systolic hypertension is the single most effective strategy for management and prevention of HF in older persons.HF-REF治疗新进展治疗新进展CRT的适应证的适应证LVEF35%+(NYHA-a)LBBB且QRS150ms（I，A）。LBBB且150msQRS130ms（a，B）。非LBBB但QRS150ms（a，A）常规起搏指针，预计心室起搏40%（a，C)LVEF35%+NYHA II级LBBB且QRS150ms（I，A）。LBBB且150msQRS130ms（a，B）。43LVEFLVEF35%+35%+房颤房颤,需尽可能保证双室起搏（需尽可能保证双室起搏（IIaIIa），如达不到），如达不到90%90%以上的以上的双室起搏，可以考虑消融房室结。双室起搏，可以考虑消融房室结。扩大到扩大到II II级级+严格的限定严格的限定44植入式心脏转复除颤器（植入式心脏转复除颤器（ICDICD）适应证：适应证：二级预防：曾有心脏停搏、心室颤动，或室性心动过速伴血流动力学不稳定(类，A级)。一级预防：缺血性心脏病：MI后至少40天，LVEF35%NYHA 或级（类，A级）非缺血性心肌病：LVEF35%，NYHA 或级（类，B级）44慢性慢性HF-REFHF-REF治疗流程治疗流程非药物治疗部分非药物治疗部分ICD的一级预防仍NYHA-a级且LVEF35%仍NYHA级LVEF35%ICD一级预防LVEF35%窦律，LBBB且QRS130ms窦律、非LBBB且QRS150ms窦律，LBBB且QRS130ms考虑CRT/CRT-D 终末期考虑LVAD和/或心脏移植经优化药物治疗3-6个月*心肾功能处于边缘状态*RAAS、SNS、AVP*水钠过度负荷*贫血（心肾贫血综合征）*双侧肾动脉狭窄 老年HF，双侧8，单侧26容量波动*造影剂*腹泻（抗生素副作用，菌群失调）*过度利尿，利尿剂抵抗*过度限盐心肾衰竭心肾衰竭 失衡状态失衡状态心肾衰竭心肾衰竭 脆弱平衡脆弱平衡*ACEI、ARB、醛固酮拮抗剂*-B*AVP V2受体拮抗剂*适度利尿剂*维持内源性利钠肽*高钾血症、低钠血症*心律失常（VT、VF）、胺碘酮、转复除颤仪*泛滥性肺水肿心肾衰竭心肾衰竭心肾衰竭的治疗心肾衰竭的治疗长期慢性治疗长期慢性治疗 RAASRAAS阻断剂阻断剂 SNSSNS阻断剂阻断剂 阻滞剂阻滞剂 卡地维洛卡地维洛 AVP V2AVP V2受体拮抗剂受体拮抗剂 利钠肽利钠肽 Nesiritide Nesiritide（重组人（重组人BNPBNP）缓慢连续超滤缓慢连续超滤急救治疗急救治疗 水电解质紊乱水电解质紊乱 心律失常（心律失常（VTVT、VFVF）泛滥性肺水肿（泛滥性肺水肿（flood pulmonary edemaflood pulmonary edema）缓慢连续超滤缓慢连续超滤continous renal replacement threapy,CRRTcontinous renal replacement threapy,CRRT*连续性血液净化疗法，主要原理是超滤、弥散和吸附，以替连续性血液净化疗法，主要原理是超滤、弥散和吸附，以替代受损的肾脏功能。代受损的肾脏功能。*纠正水钠过度负荷（纠正水钠过度负荷（24h24h超滤超滤300030004000ml4000ml）减轻前负荷，）减轻前负荷，改善右室功能；影响高压压力受体，调节改善右室功能；影响高压压力受体，调节AVPAVP释放，减轻后释放，减轻后负荷，提高心排血量和水排泄。负荷，提高心排血量和水排泄。*清除细胞因子清除细胞因子TNFTNF、IL-1IL-1、IL-6IL-6水平。水平。*减轻神经体液因素因子的负面效应，减轻神经体液因素因子的负面效应，RAASRAAS、AVPAVP、儿茶酚胺、儿茶酚胺等。等。*存活率存活率7575左右。左右。心衰治疗流程心衰治疗流程 确定慢性收缩性心衰的诊断（左心室心腔增大，LVEF40%）去除或缓解基本病因和诱因（瓣膜性心脏病对手术治疗作出评定）（冠心病、心绞痛或有存活心肌对血运重建作出评定）判断液体潴留情况有液体潴留的症状和体征 无液体潴留的症状和体征 利尿剂 ACEI (应用至病情控制长期维持)（NYHA心功能、级）-受体阻滞剂 地高辛控制症状（主要为NYA 心功能、级）（NYHA心功能、级）ConditionPrevalence in HFPotential Consequences Assessment TechniqueRenal Dysfunction16%:GFR Men 22%Aggravated by medical therapy(diuretics,ACE cough)Bladder diarySensory Impairments24%:Ocular disordersWorsens non-adherence,increases medication errorsHearing loss screener;Snellen eye chartFrailty30-50%Worsens symptoms,prognosis,quality of lifeADLs;IADLs;Frailty Fatigue/AnergiaMild-mod 70%Severe 20%Worsens symptoms,complicates diagnosisAnergia scaleNutritional Deficiencies30%Exacerbated by dietary restrictionsDietary QuestionnairesSpecific vitamin and nutrient levelsPolypharmacy-Almost all.Worsens non-adherence,medication interaction and adverse drug reactionGreater than 4 medicationsCo-Morbid Conditions in Older Adults with Heart FailureComorbid conditions predispose older patients to the development of HF and also increase symptom severity,worsen prognosis,and complicate management.小结：慢性心衰要点小结：慢性心衰要点急行心衰或慢性心衰恶化如Pro-BNP300pg/ml 或BNP100pg/ml:可以除外心衰非急行心衰（心衰稳定期）如Pro-BNP125pg/ml 或BNP35pg/ml：可以排除心衰 2 2、限盐及限水：、限盐及限水：轻中度心衰及心衰稳定期不主张限盐及限水轻中度心衰及心衰稳定期不主张限盐及限水1、BNP和NT-pro BNP对心衰诊断的排除标准52小结：慢性心衰要点小结：慢性心衰要点3、伴液体滞留的心衰患者首选应用利尿剂改善症状（如袢利尿剂）继以ACEI或受体阻滞剂并尽快使两药联用改善预后的三种药物改善预后的三种药物“金三角金三角”（类类)1、ACEI/ARB（I类，A级）2 2、-受体阻滞剂（阻滞剂（I I类，类，A/BA/B级）级）3 3、醛固酮受体拮抗剂（I I类，类，A/BA/B级）级）改善症状的药物改善症状的药物1 1、利尿剂（托伐普坦）（利尿剂（托伐普坦）（I I类，类，C C级）级）2 2、地高辛、地高辛(a/b(a/b类，类，B B级级)3 3、伊伐布雷定、伊伐布雷定(IIa/b(IIa/b类，类，B/CB/C级级)4 4、其他药物 HF-REF HF-REF的的常用药物小结：慢性心衰要点小结：慢性心衰要点降低降低SCD54小结：慢性心衰要点小结：慢性心衰要点醛固酮受体拮抗剂（醛固酮受体拮抗剂（MRAMRA）适应症的扩展）适应症的扩展 心功能由原来III-IV级扩大到II级 推荐窦房结阻滞剂伊伐布雷定 在使用了 ACEI、受体阻滞剂、MRA后：EF 仍35%窦性心率70bpm 仍有症状者小结：慢性心衰要点小结：慢性心衰要点心脏再同步治疗（心脏再同步治疗（CRTCRT）适应证的扩展及限制）适应证的扩展及限制心功能条件放宽心功能条件放宽由由NYHA III-IVNYHA III-IV及扩大到及扩大到 NYHA NYHA IIII级级，EF3535对QRS宽度及形态有更严格的限制，强调LBBB图形LBBB图形：QRS时限130 ms非LBBB图形：QRS150 msACC/AHA Heart Failure Guidelines HFNEFRecommendationClassControl systolic and diastolic hypertensionIVentricular rate control in patients with atrial fibrillation IDiuretics to control congestion and edema ICoronary revascularization is reasonable in patients with symptomatic coronary artery diseaseIIaRestoration and maintenance of sinus rhythm in patients with atrial fibrillation might be useful to improve symptomsIIbBeta-blocking agents,ACE inhibitors,AT II receptor blockers,or calcium antagonists might be effective to minimize symptomsIIbThe use of digitalis is not establishedIIb Hunt et al.ACC/AHA Practice Guidelines JACC 2005;46:1-82问题？