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1、慢性心力衰竭最新指南解读田野 教授 哈尔滨医科大学附属二院心内科第五届北方介入心脏病学暨心血管疾病诊疗新进展国际研讨会 2009.01.11 哈尔滨ESC-51 COUNTRIESContent Definition and diagnosis Diagnostic techniques Non-pharmacological management Pharmacological therapy Devices and surgery Co-morbidities and special populationsDefinition and diagnosis“The very essence
2、of cardiovacular medicine is the recognition of early heart failure”Sir Thomas Lewis,1933Definition of HF Importantly, it was emphasised that the diagnosis is not dependent on a certain ejection fraction (EF), although it has implications for prognosis.Common clinical manifestationsClinical manifest
3、ationsFatigueCoughBreathlessnessSwollen anklesDepressionWeight gainLoss of appetiteNeed to urinate at nightPalpitationSwollen abdomen Classification of HFCommon causes of HFCoronary heart disease Many manifestations Hypertension Often associated with left ventricular hypertrophy and ejection fractio
4、n Cardiomyopathies Familial/genetic or non-familial/non-genetic (including acquired, e.g. myocarditis) Hypertrophic (HCM), dilated (DCM), restrictive (RCM), arrhythmogenic right ventricular (ARVC), unclassified Drugs -Blockers, calcium antagonists, antiarrhythmics, cytotoxic agents Toxins Alcohol, m
5、edication, cocaine, trace elements (mercury, cobalt, arsenic) Endocrine Diabetes mellitus, hypo/hyperthyroidism, Cushing syndrome, adrenal insufficiency, excessive growth hormone, phaeochromocytoma Nutritional Deficiency of thiamine, selenium, carnitine. Obesity, cachexia Infiltrative Sarcoidosis, a
6、myloidosis, haemochromatosis, connective tissue disease Others Chagas disease, HIV infection, peripartum cardiomyopathy, end- stage renal failureClassification of HF New onset First presentation Acute or slow onset Transient Recurrent or episodic Chronic Persistent Stable, worsening, or decompensate
7、d Time is important for various types of heart failure. Diagnostic techniquesClinical examinationDiagnosis of HF with natriuretic peptides As 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 confirmat
8、ion of the diagnosis. Diagnostic assessments supporting the presence of HF (BNP) 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. BNP BNP400 pg/mL, NT-proBNP2000
9、pg/m - Increased ventricular wall stress - HF likely - Indication for echo - Consider treatment BNP40- 50%. HF with preserved ejection fraction (HFPEF) is present half the patients with HF.”Epidemiologic studies Solomon SD,Circulation 112:3738- 3744, 2005Assessment of HFPEF Presence of signs and/or
10、symptoms of chronic HF. Presence of normal or only mildly abnormal LV systolic function (LVEF45- 50%). Evidence of diastolic dysfunction (abnormal LV relaxation or diastolic stiffness).Speckle-tracking echocardiographyA 62-year-old man with a normal heart EF=60%A 78-year-old man Diastolic dysfunctio
11、n EF=55% Process underlying HFPEFNon-pharmacological management A strong relationship 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
12、 participate in education programmes and decisions regarding treatment and careSabate E. Adherence to Long-term Therapies. Evidence for Action. Geneva: WHO;2003.People involved in careThe PlayersPharmacological therapyPrognosis: Reduce mortalityMorbidity: Improve quality of life Prevention: Reduce h
13、ospitalizationACE inhibitors Unless contraindicated or not tolerated, an ACEI should 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 hospit
14、alized patients, treatment with an ACEI should be initiated before discharge.Class of recommendation I, level of evidence ACONSENSUS(1987) and SOLVD-Treatment(1991)Mortality Reductions with ACEI051015202530Relative Risk Reduction (%)CONSENSUSSOLVDSAVEAIREHOPE n = 253n = 4228n = 2231n = 1986n = 3577C
15、ONSENSUS: NEJM 1987;316:1429-435, SOLVD: NEJM 1991;325:293-302, SAVE: NEJM 1992;327:669-677AIRE: Lancet 1993;342:821-828, HOPE: Lancet 2000;355:253-259-Blockers Unless 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 HF, and increases survival. Where possible, in hospit
