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1、9/98,1,A, B, C, D, Es of the Management of Heart Failure,Nanette Kass Wenger, MDEmory University School of MedicineGrady Memorial HospitalAtlanta, Georgia,Objectives,Understand the cornerstones of therapy angiotensin-converting enzyme inhibitors, diuretics, and digitalis review the role of other the
2、rapies: pharmacotherapeutic as well as nonpharmacotherapeutic approaches,9/98,2,Epidemiology,4.7 million patients in the United States are estimated to have heart failure 470,000 new cases recognized annually Each year, 875,000 hospitalized patients have a primary diagnosis of heart failure. It is t
3、he major hospital discharge diagnosis for patients in the Medicare age group.,9/98,3,Epidemiology,heart failure increases with age half of all heart failure hospitalizations occur in individuals age 65 years. In the United States, the estimated costs for the management of patients with heart failure
4、 exceed $10 billion annually.,9/98,4,Treatment objectives,Decrease symptoms Improve exercise capacity Enhance quality of life Decrease morbidity Retard the progression of heart failure Improve survival,9/98,5,Cornerstones of Therapy,Angiotensin converting enzyme (ACE) inhibitors diuretics digitalis
5、guidelines for the severity-based therapy of heart failure.,9/98,6,Asymptomatic Patients,For asymptomatic patients with left ventricular dysfunction (NYHA class I), typically those with an ejection fraction below 40%, ACE inhibitors are recommended,9/98,7,Symptomatic Patients,NYHA class II ACE inhib
6、itors, mild diuretics, and digoxin, with or without the use of B-blocker therapy NYHA class III add loop diuretics NYHA class IV consider positive inotropic agents surgical therapies may also be applied,9/98,8,A, B, C, D, Es of Heart Failure Therapy,Aangiotensin converting enzyme inhibitorsanticoagu
7、lants, amiodarone, AICD, assistdevices Bbeta blocking drugs Ccalcium channel blocking drugs, coronaryrevascularization, cardiac transplant, cardiomyoplasty, cardiac reduction surgery Ddiet, diuretics, digitalis, dobutamine Eexercise,9/98,9,Angiotensin Converting Inhibitors physiologic benefits,Arter
8、iovenous Vasodilatation pulmonary arterial diastolic pressure pulmonary capillary wedge pressure left ventricular end-diastolic pressure systemic vascular resistance systemic blood pressure maximal oxygen uptake (MVO2),9/98,10,Angiotensin Converting Inhibitors physiologic benefits, LV function and c
9、ardiac output renal, coronary, cerebral blood flow No change in heart rate or myocardial contractility no neurohormonal activation resultant diuresis and natriuresis,9/98,11,Angiotensin Converting Inhibitors clinical benefits,Increases exercise capacity improves functional class attenuation of LV re
10、modeling post MI decrease in the progression of chronic HF decreased hospitalization enhanced quality of life improved survival,9/98,12,Asymptomatic Patients,Enalopril SOLVD Prevention Trial EF35% HF progression, hospitalization Captopril SAVE, GISSI-3, ISIS-4 Post MI, EF 40% overall mortality, re-i
11、nfarction hospitalization, HF progression,9/98,13,Symptomatic Patients,Hydralazine + Isosorbide dinitrate VHeFT-I mortality, improved functional classas compared with use of digoxin and diureticsVHeFT-IIproved less effective than enalopril,9/98,14,Symptomatic Patients,Enalopril + digoxin + diuretics
12、 SOLVD Treatment TrialEF35%, FC III-IV mortality, hospitalizationCONSENSUS-IIFC IV mortality (40%), symptoms, hospitalizationimproved functional class,9/98,15,Symptomatic Patients,Losartan (AT-II inhibitor) ELITE Trial losartan improved the survival of elderly heart failure patients treated compared
13、 with captopril therapy,9/98,16,Guidelines to ACE Inhibitor Therapy,Contraindications Renal artery stenosis Renal insufficiency (relative) Hyperkalemia Arterial hypotension Cough Angioedema Alternatives Hydralazine + ISDN, AT-II inhibitor,9/98,17,Guidelines to ACE Inhibitor Therapy,It is important t
14、o titrate to the dosage regimen used in the clinical trials in the absence of symptoms or adverse effects on end-organ perfusion in very severe heart failure, hydralazine and nitrates added to ACE inhibitor therapy can further improve cardiac output,9/98,18,Anticoagulant Therapy,Recommended for pati
15、ents with NYHA III-IV and EF 30% or ventricular aneurysm or very dilated LV Indicated for patients with heart failure who have atrial fibrillation, a prior embolic episode, identified intracardiac thrombus, left ventricular aneurysm, thrombophlebitis, or prolonged bed rest titrate INR to 2 to 3,9/98
16、,19,Arrhythmias,Sudden death occurs in about 50% of patients with heart failure,9/98,20,Amiodarone,Randomized clinical trials CHF-STAT NYHA II-III patients with ischemic cardiomyopathy - amiodarone had no affect on survival GESICANYHA III-IV patients with more non-ischemic cardiomyopathy - open labeled amiodarone decreased mortality,9/98,21,AICD,Randomized clinical trials AVID amiodarone vs implantable defibrillatorshowed the AICD group had lower mortality AICD should be
