充血性心衰的治療課件

1、 Current Management of Congestive Heart Failure: 2004 UpdateHisham Dokainish, MD, FACCAssistant Professor of MedicineBaylor College of Medicine,Director, Non-Invasive Cardiology,Ben Taub General HospitalHouston, Texas, USAAggravating Factors Medications New heart disease Myocardial ischemia Endocard

2、itis Obesity Hypertension Physical activity Dietary excess Pregnancy Arrhythmias (AF) Infections Thromboembolism Hyper/hypothyroidismInitial / Ongoing Evaluation Treatment ObjectivesSurvivalMorbidityExercise capacityQuality of lifeNeurohormonal changes Progression of CHFSymptoms Pharmacologic Therap

3、yDiureticsACE inhibitorsBeta Blockers Digitalis Spironolactone (Eplerenone) Angiotensin II Blockers (Candesartan) HMG-CoA Reductase Inhibitors (“Statins”) VASOCONSTRICTIONVASODILATATION KininogenKallikreinInactive FragmentsAngiotensinogenAngiotensin IRENINKininase IIInhibitorALDOSTERONESYMPATHETICVA

4、SOPRESSINPROSTAGLANDINStPAANGIOTENSIN IIBRADYKININACE-i. Mechanism of ActionA.C.E.ACE-I: Clinical Effects Improve symptoms Reduce remodelling / progression Reduce hospitalization Improve survival Intolerance (angioedema, anuric renal fail.) Bilateral renal artery stenosis Pregnancy Renal insufficien

5、cy (creatinine 3 mg/dl) Hyperkalemia ( 5,5 mmol/l) Severe hypotension-Adrenergic BlockersMechanism of action Density of 1 receptors Inhibit cardiotoxicity of catecholamines Neurohormonal activation HRAntiischemicAntihypertensiveAntiarrhythmicAntioxidant, Antiproliferative -Adrenergic BlockersClinica

6、l Effects Improve symptoms (only long term) Reduce remodelling / progression Reduce hospitalization Reduce sudden death Improve survival1.00.90.80.7 Symptomatic heart failure Asymptomatic ventricular dysfunction- LVEF 120 ms can benefit from resynchronization therapy Three leads: one in RV apex, one

7、 in RA and one in coronary sinus (LV pacing) Purpose: to help restore interventricular synchrony, and improve hemodynamics Internal Cardiac Debrillators (ICD) to prevent arrhythmic sudden cardiac death 1520 patients: mean age 67 years; mean EF 22%; mean QRS 160 ms; ischemic cause 55% of patientsBris

8、tow, et al: N Engl J Med 2004ICD Therapy in Nonischemic Cardiomyopathy: DEFINITE Trial MADIT II trial showed that patients with EF35% after MI have lower mortality with prophylactic ICD therapy 458 patients with nonischemic DCM randomized and PVCs or NSVT to optimum medical therapy +/- internal card

9、iac defibrillator Mean age: 58 years; mean QRS 115 ms; mean EF 21%Kadish, et al: N Engl J Med 2004CHF Treatment Summary1. Make the right diagnosis: Echo is essential2. Diet and exercise are important3. Diuretic for symptoms4. ACE inhibitor for symptoms and survival5. Beta-blocker for symptoms and survival (Carvedilol likely better)CHF Treatment Summary6. Spironolactone (or eplerenone) for Class III or IV heart failure7. Candesart