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1、Heart Failure Definition of Heart FailureHF is a complex clinical syndrome, in which patients have typical symptoms (e.g. breathlessness呼吸急促呼吸急促, ankle swlling and fatigue疲劳疲劳) and signs (e.g. elevated jugular venous pressure, pulmonary crackles) resulting from an abnormality of cardiac structure or
2、 function.General ConsiderationsSystolic function of the heart is governed by four major determinants:Contractile state of the myocardiumPreload of the ventricleAfterload applied to the ventriclesHeart rateUnderlining Causes of Heart failure-from a clinical viewpoint (1)Underlying causes, comprising
3、 the structural abnormalitiescongenital or acquiredthat affect the peripheral and coronary vessels, myocardium, or cardiac valves and lead to the increased hemodynamic burden, increased myocardial stress, or coronary insufficiency responsible for heart failure.Underlining Causes of Heart failure-fro
4、m a clinical viewpoint (1)Underlying causes:Systemic hypertensionCoronary artery diseaseCardiomyopathyValvular heart diseaseDiabetesBeriberiUnderlining Causes of Heart failure-from a clinical viewpoint (2)Precipitating causes, including the specific caused or incidents that precipitate worsening hea
5、rt failure in 50 to 90 percent of episodes of clinical heart failure.Precipitating Causes of Heart failureInfection, especially pulmonary infections.Arrhythmias, most commonly atrial fibrillation, marked bradycardia.Myocardial ischemia or infarctionPulmonary embolismPrecipitating Causes of Heart fai
6、lurePhysical and emotional stressInappropriate reduction of therapyAdministration of myocardial depressant or salt-retaining drugsClinical Classification1Acute Versus Chronic Heart Failure2Right-Sided Versus Left-Sided Failure3Systolic Versus Diastolic Heart Failure Chronic Heart FailureCauses of HF
7、 in Western WorldFor a substantial proportion of patients, causes are:1. Coronary artery disease2. Hypertension3. Dilated cardiomyopathyClinical ManifestationsLeft-sided heart failureNew York Heart Association Functional ClassificationClass I Patients with cardiac disease but without resulting limit
8、ations of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain.New York Heart Association Functional ClassificationClass II Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Or
9、dinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain.New York Heart Association Functional ClassificationClass III Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary physical activity resul
10、ts in fatigue, palpitation, dyspnea, or anginal pain.New York Heart Association Functional ClassificationClass IV Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of cardiac insufficiency of of the anginal syndrome may be present eve
11、n at rest. If any physical activity is undertaken, discomfort is increased. Stages of Heart FailureAt Risk for Heart Failure:STAGE A High risk for developing HFSTAGE B Asymptomatic LV dysfunctionHeart Failure:STAGE C Past or current symptoms of HFSTAGE D End-stage HFStages of Heart FailureCOMPLEMENT
12、, DO NOT REPLACE NYHA CLASSESNYHA Classes - shift back/forth in individual patient (in response to Rx and/or progression of disease)Stages - progress in one direction due to cardiac remodelingRespiratory DistressNYHA Classes, as discussed above. Orthopnea, develops in the recumbent position and is r
13、elieved by elevation of the head with pillows.Respiratory DistressParoxysmal nocturnal dyspnea： dyspnea usually occurs at night. The patient awakens, often quite suddenly and with a feeling of severe anxiety and suffocation, sits bolt upright, and gasps for breathe.Other SymptomsCough may be caused
14、by pulmonary congestion.Fatigue and weaknessUrinary symptoms includes nocturia and oliguria.Physical Findings with left-sided heart failurePulmonary rales. Moist rales heard over the lung bases are characteristic of left ventricular failure.Gallop sounds. Physical Findings with left-sided heart fail
15、urePulsus alternans. This sign is characterized by a regular rhythm with alternating strong and weak beats. Right-sided heart failureSymptoms of predominant right-sided heart failureBreathlessness is not as prominent in isolated right ventricular failure because pulmonary congestion is usually absen
16、t.Congestive hepatomegaly may produce discomfort in the right upper quadrant.Symptoms of predominant right-sided heart failureOther gastrointestinal symptoms, including anorexia（食欲减退）（食欲减退）, nausea, bloating（饱胀）（饱胀）, a sense of fullness after meals, and constipation（便秘）（便秘）, are due to congestion of
17、 the liver and gastrointestinal tract.Physical Findings with right-sided heart failureHepatojugular reflux. A positive test is expansion of jugular veins while the right upper quadrant is compressed. Physical Findings with right-sided heart failureCongestive hepatomegaly.Edema.Pleural effusion.Ascit
18、es.Laboratory findingsBrain natriuretic peptide (BNP) and N-terminal pro-BNP EchocardiogramSystolic dysfunction: ejection fraction(EF) 40%Diastolic dysfunction: E/A ratio (1.2)Laboratory findingsChest x-raySize and shape of the cardiac silhouetteKerler lines (i.e., sharp, linear densities of interlo
19、bular interstitial edema) “Butterfly” pattern (a cloud-like appearance and concentration of the fluid around the hili) TreatmentGoals of Drugs in the Treatment of Heart FailureTreatment of chronic stable HFEnhance survivalMinimize symptoms and disabilityImprove functional capacityDelay disease progr
20、essionClasses of Drugs Used to treat Heart FailureDrugs Class Diuretics “Loop” diuretics ThiazidesVasodilators Nitrovasodilators Natriuretic peptides (nesiritide)Classes of Drugs Used to treat Heart FailureDrugs Class Positive Inotropic Agents Digitalis derivatives Beta-adrenergic receptor agonists
21、Phosphodiesterase inhibitorsClasses of Drugs Used to treat Heart FailureNeurohormonal Inhibitors Angiotensin-converting enzyme inhibitors (ACEIs) Angiotensin receptor blockers (ARBs) Beta-adrenergic receptor blocking compoundsClass I Benefit RiskProcedure/ Treatment SHOULD be performed/ administered
22、Class IIa Benefit RiskAdditional studies with focused objectives neededIT IS REASONABLE to perform procedure/administer treatmentClass IIb Benefit RiskAdditional studies with broad objectives needed; Additional registry data would be helpfulProcedure/Treatment MAY BE CONSIDERED Class III Risk Benefi
23、tNo additional studies neededProcedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFULshouldis recommendedis indicatedis useful/effective/ beneficialis reasonablecan be useful/effective/ beneficialis probably recommended or indicatedmay/might be consideredma
24、y/might be reasonableusefulness/effectiveness is unknown /unclear/uncertain or not well established is not recommendedis not indicatedshould notis not useful/effective/beneficialmay be harmfulApplying Classification of Recommendations and Level of Evidence Level AMultiple (3-5) population risk strat
25、a evaluatedGeneral consistency of direction and magnitude of effectClass I Recommen-dation that procedure or treatment is useful/ effective Sufficient evidence from multiple randomized trials or meta-analysesClass IIa Recommen-dation in favor of treatment or procedure being useful/ effective Some co
26、nflicting evidence from multiple randomized trials or meta-analysesClass IIb Recommen-dations usefulness/ efficacy less well established Greater conflicting evidence from multiple randomized trials or meta-analysesClass III Recommen-dation that procedure or treatment not useful/effective and may be
27、harmful Sufficient evidence from multiple randomized trials or meta-analysesApplying Classification of Recommendations and Level of Evidence Level BLimited (2-3) population risk strata evaluatedClass I Recommen-dation that procedure or treatment is useful/effective Limited evidence from single rando
28、mized trial or non-randomized studiesClass IIa Recommen-dation in favor of treatment or procedure being useful/ effective Some conflicting evidence from single randomized trial or non-randomized studiesClass IIb Recommen-dations usefulness/ efficacy less well established Greater conflicting evidence
29、 from single randomized trial or non-randomized studiesClass III Recommen-dation that procedure or treatment not useful/effective and may be harmful Limited evidence from single randomized trial or non-randomized studiesApplying Classification of Recommendations and Level of Evidence Applying Classi
30、fication of Recommendations and Level of Evidence Level C Very limited (1-2) population risk strata evaluatedClass I Recommen-dation that procedure or treatment is useful/ effective Only expert opinion, case studies, or standard-of-careClass IIa Recommen-dation in favor of treatment or procedure bei
31、ng useful/effective Only diverging expert opinion, case studies, or standard-of-careClass IIb Recommen-dations usefulness/ efficacy less well established Only diverging expert opinion, case studies, or standard-of-careClass III Recommend-ation that procedure or treatment not useful/effective and may
32、 be harmful Only expert opinion, case studies, or standard-of-carePharmacological treatmentsAn An ACEIACEI is recommended, in addition to beta- is recommended, in addition to beta-blocker, for all patients with blocker, for all patients with EFEF40%40% to to reduce the reduce the risk of HF hospital
33、ization and the risk of HF hospitalization and the risk of prmature death.risk of prmature death.IAA beta-blocker is recommended, in addtion to an ACEI (or ARB if AECI not tolerated), for all patients with an EF40% to reduce the to reduce the risk of HF hospitalization and the risk of risk of HF hos
34、pitalization and the risk of prmature death.prmature death.IAAn MRA is recommended for all patients with persisting syptoms（NYHA IIIV）and anEF35%, despite treatment with an ACEI (or ARB if AECI not tolerated) and a beta-blocker, to reduce the to reduce the risk of HF risk of HF hospitalization and t
35、he risk of prmature hospitalization and the risk of prmature death.death.IAPharmacological treatmentsARBRecommended to reduce the risk of HF hospitalization and the risk of premature death in patients with an EF40% and unable to tolerate an ACEI because of cough (patients should also receive a beta-
36、blocker and an MRA).IARecommended to reduce the risk of HF hospitalization in patients with an EF40% and persisting syptoms (NYHA II-IV) despite treatment with an ACEI and a -blocker who are unable to olerate an MRA.IAPharmacological treatmentsDigoxinDigoxinMay be consided to reduce the risk of HF h
37、ospitalization in patients in sinus rhythm with an EF45% who are unable to tolerate a beta-blocker. Patients shoule also receive an ACEI (or ARB) and an MRA (or ARB). IIb BMay be consided to reduce the risk of HF hospitalization in patients with an EF45% and persisting symptoms（NYHA IIIV）despite tre
38、atment with a -blcker, ACEI(or ARB) and an MRA (or ARB). IIb BPharmacological treatmentsDiuretics: although diuretics have not been shoun to reduce mortality or hospitalizations, they relieve dyspnoea and oedema and are a key treatment for HF. The aim is to use the minimum dose necessary to restore and maintain euvolaemia.Thanks for your attention
