ESC慢性心衰指南課件

1、Relationship between cardiac dysfunction, HF and HF rendered asymptomaticNORMALCARDIAC DYSFUNCTIONCORRECTED OR RESOLVEDCARDIACDYSFUNCTIONSYMPTOMSHEARTFAILURETHERAPYTherapy CANbe withdrawn without recurrenceof symptomsSymptomsrelievedTherapy CANNOTbe withdrawn without recurrenceof symptomsTransientHe

2、artFailureNosymptomsAsymptomaticcardiacdysfunctionSystolicdysfunctionSymptomspersist1Relationship between cardiac dDiagnosisAccording to the Working Group in Heart Failure, Heart Failure is a syndrome where the diagnosis has the following essential components:A combination of: Symptoms, typically br

3、eathlessness or fatigueCardiac dysfunction documented at restThe diagnosis is supported by:Response to treatment directed towards heart failure2DiagnosisAccording to the WorkAssessments in all casesNecessarySupportsOpposesHistory with symptoms+If absentObjective evidence+If absentResponse to treatme

4、nt+Establish diagnosis3Assessments in all casesEstabTestNecessarySupportsOpposesElectrocardiogram+If normalEchocardiography+If normalChest x-rayIf congestionIf normalBlood countIf normalBlood chemistryIf normalTests for Diagnosis4TestTests for Diagnosis4Additional Tests for DiagnosisTestNecessarySup

5、portsOpposesExercise testIf normalNatriuretic peptide If elevatedIf normalCardiac cath.If normal5Additional Tests for DiagnosisTest to Exclude AlternativesChest x-ray (Lung disease)Pulmonary functionBlood chemistry (Renal and hepatic disease)Blood count (Anaemia)Exercise tolerance (if impaired)6Test

6、 to Exclude AlternativesChElectrocardiographyA normal ECG suggests that the diagnosis of heart failure should be carefully reviewed.The predictive value of a normal ECG to exclude LV systolic dysfunction exceeds 90%7ElectrocardiographyA normal ECChest X-rayA high predictive value of X-ray findings i

7、s only achieved by interpreting them in the context of clinical findings and ECG anomalies.It is useful to detect cardiac enlargement and pulmonary congestionIn chronic heart failure, increased cardiac size and pulmonary venous congestion are useful indicators of abnormal cardiac function with decre

8、ased ejection fraction and/or increased LV filling pressureHowever, cardiomegaly is frequently absent in acute heart failure and in cases with diastolic dysfunction8Chest X-rayA high predictive vPulmonary function testsMeasurements of lung function are of little value in diagnosing chronic heart fai

9、lure.However, they are useful in excluding respiratory causes of breathlessness9Pulmonary function testsMeasurExercise testing In clinical practice exercise testing is of limited value for the diagnosis of heart failure.However, a normal maximal exercise test, in a patient not receiving heart failur

10、e treatment, excludes heart failure as a diagnosis10Exercise testing In clinical pInvasive investigationInvasive investigation is generally not required to establish the presence of chronic heart failure, but may be important in elucidating the cause or to obtain prognostic information11Invasive inv

11、estigationInvasiveEchocardiographyAs objective evidence of cardiac dysfunction at rest is mandatory for the diagnosis of heart failure, echocardiography is the preferred method for this documentationThe most important parameter for identifying patients with systolic cardiac dysfunction and those wit

12、h preserved systolic function is the LV ejection fractionWhen the diagnosis of heart failure is confirmed, echocardiography is also helpful in determining its aetiology 12EchocardiographyAs objective eNatriuretic PeptidesThese peptides may be most useful clinically as a “rule out” test due to a cons

13、istent and very high negative predictive values Especially in primary care patients suspected of having heart failure can be selected for further investigation by echocardiography or other tests of cardiac function on the basis of having an elevated plasma concentration of a natriuretic peptideIn th

14、ose in whom the concentrations are normal, other causes of dyspnoea and associated symptoms should be consideredThe added value of natriuretic peptides in this situation has yet to be determined13Natriuretic PeptidesThese peptNatriuretic PeptidesHigh levels of natriuretic peptides identify those at

15、greatest risk of future serious cardiovascular events including deathThere is also recent evidence that adjusting heart failure therapy in order to reduce natriuretic peptides levels in individual patients may improve outcome14Natriuretic Peptides14Other neuroendocrine evaluationsOther tests of neur

16、oendocrine evaluation are not recommended for diagnostic or prognostic purposes15Other neuroendocrine evaluatioSuspected Heart Failurebecause of symptoms and signsTests abnormalTests abnormalAssess presence of cardiac disease by ECG, X-Ray orNatriuretic peptides (where available)NormalHeart Failureu

17、nlikelyImaging by Echocardiography(Nuclear angiography orMRI where available)NormalHeart FailureunlikelyChoose therapyAssess etiology, degree, precipitatingfactors and type of cardiac dysfunctionAlgorithm for Diagnosis of Chronic HFAdditional diagnostic testswhere appropriate (e.g. coronary angiogra

18、phy)16Suspected Heart FailureTests aManagement OutlineEstablish that patient has heart failureIdentify presenting symptomAssess severity of limitationDetermine etiologyExclude or confirm concomitant diseasesPredict prognosisChoose therapyMonitor progress17Management OutlineEstablish thGuidelines Tre

19、atment - ContentsGeneral advice and measuresExercise and exercise trainingPharmacological therapySurgery and devicesSpecial subsections (elderly, diastolic CHF)Care management programmes18Guidelines Treatment - Content1919General Measures and Advice Patient and family education explain heart failure

20、 symptoms what therapy does self-weighing exercise vs rest 20General Measures and Advice PGeneral measures and adviceDiet-salt intake and fluid restriction Smoking-cessationAlcohol-moderate intake permitted Obesity-weight reductionAbnormal weight lossTravellingSexual activity-counselling, reassuranc

21、e patients/partner Vaccinations-influenza, pneumococcal21General measures and adviceDieGeneral measures and advice Drug counselling : Self-management (diuretics) Desired effects and side effects Duration treatment before effects become apparentNeed for slow up-titration Interaction with other drugs2

22、2General measures and advice DrAce-inhibitorsACE inhibitors are recommended as first-line therapy in patients with a reduced LV systolic function (LVEF40-45%) (Level A)In the absence of fluid retention ACE inhibitors should be given first, in the presence of fluid retention together with diuretics (

23、Level B)ACE inhibitors should be up-titrated to the dosages shown to be effective in large trials .They should not be titrated based on symptomatic improvement23Ace-inhibitorsACE inhibitors aThe recommended procedure for starting an ACE inhibitor1. Review the dose of diuretics2. Avoid excessive diur

24、esis before treatment. 3. Start with a low dose and build up to maintenance dosages4. If renal function deteriorates substantially, stop treatment.5. Avoid potassium-sparing diuretics during initiation of therapy. 6. Avoid non-steroidal anti-inflammatory drugs (NSAIDs).7. Check blood pressure, renal

25、 function and electrolytes 1-2 weeks after each dose increment, at 3 months and subsequently at 6 monthly intervals (Level C)24The recommended procedure for Beta-blockade in Heart FailureBeta-blocking agents are recommended for the treatment of all patients with stable mild, moderate and severe hear

26、t failure from ischemic and non-ischemic origin on standard treatment including ACE inhibition and diuretics (level A)Beta-blocking agents are recommended in patients with LV dysfunction with/without heart failure post-MI for survival benefit (level B)25Beta-blockade in Heart FailureInitiation and u

27、ptitration of beta-blockade in heart failurePatients should be on a background therapy of ACE inhibition and diuretics Stable conditionTirate slowly and carefully from low initial dose to target doses used in large RCTPatients may initially worsen or experience adverse effects (hypotension) monitor

28、and adapt other therapy first before changing dose beta-blocker. Consider PDE inhibitor when positive inotropic support is needed 26Initiation and uptitration of Spironolactone in Heart Failure Aldosterone antagonism is recommended in advanced heart failure (NYHA III and IV) in addition to ACE inhib

29、ition to improve survival and morbidity (level B)27 Spironolactone in HeartAdministration and Dosing Considerations with SpironolactoneTo consider when a patient is in advanced CHF despite standard therapyCheck serum potassium (5mmol/L)and creatinine (5-5.5mmol/L - reduce dose by 50%, stop if persis

30、tsIf after 1 month if symptoms are still severe-increase to 50 mg daily and check potassium and creatinine after 1 week28Administration and Dosing ConsLoop Diuretics, Thiazides and MetolazoneDiuretics are essential when fluid load is present and manifest as pulmonary congestion and pulmonary oedema

31、(level A)The reduction of left ventricular filling pressures result in rapid improvement of dyspnea and improved exercise tolerance (level B)29Loop Diuretics, Thiazides and Potassium-sparing DiureticsPotassium-sparing diuretics should only be prescribed if persisting hypokalemia despite ACE inhibito

32、r therapy in mild heart failure (NYHA lII) and ACE inhibition + low-dose spironolactone in NYHA III/IV (level C)Potassium supplements are less effective in this situationMonitor creatinine and potassium every 5-7 days until stable values 30Potassium-sparing DiureticsPotAngiotensin Receptor Blockers

33、(ARB)ARBs could be considered in patients who do not tolerate ACE inhibitors (level C)It has not been proven that they are as effective as ACE inhibitors in mortality reduction (level B)In addition to ACE inhibition ARBs improve symptoms and reduce hospitalisations for heart failure (level B)The add

34、ition of ARBs to ACE inhibition and beta-blockade cannot be recommended at present-needs further investigation (level C)31Angiotensin Receptor Blockers Digitalis GlycosidesCardiac glycosides are recommended in atrial fibrillation and symptomatic CHF in order to improve cardiac function and symptoms

35、(level B)A combination of digitalis and beta-blockade appears superior to either agent alone (level C)In sinus rhythm digoxin may improve the clinical status in persisting heart failure symptoms due to LV systolic dysfunction (level B).32Digitalis GlycosidesCardiac glVasodilatorsVasodilators may be

36、used as adjunctive therapy in heart failure for the relief of angina or acute dyspnoe (nitrates) or concomitant hypertension (DHP calcium antagonists)ARBs better choice than nitrates/hydralazine when intolerance to ACE inhibitors (level B)Alpha-blockers are not recommended for heart failure (level B

37、) DHP calcium antagonists have no effect on survival in CHF due to LV systolic dysfunction (level A)33VasodilatorsVasodilators may bPositive InotropesInotropic agents are commonly used to limit severe episodes of CHF or as a bridge to transplantation (level C). Use of dobutamine insufficiently docum

38、ented - prognosis unclear. Higher incidence of treatment - related complications with milrinone.Prolonged or repeated oral therapy with available agents (cAMP dependent) increases mortality (level A)Short-term levosimendan (calcium sensitiser) appears to be safer than dobutamine. Its long term effec

39、t on mortality needs to be confirmed (level C)34Positive InotropesInotropic agAntiarrhythmics in Heart FailureIn general there is no indication for the use of anti-arrhythmics in CHF. Specific indications: atrial fibrillation, non-sustained or sustained VTClass I agents should be avoided (level C)Be

40、ta-blockers reduce sudden death in CHF (level A)Amiodarone is effective against most common supra-and ventricular arrhythmias (level B), but routine administration in CHF is not justified (level B)There is no specifically defined role for ICD in CHF (level C), but it improves survival in cardiac arr

41、est or sustained VT associated with LV dysfunction (level A)35Antiarrhythmics in Heart FailuAntiarrhythmics in heart failure (contd)Amiodarone is effective against most common supra-and ventricular arrhythmias (level B), but routine administration in CHF is not justified (level B)There is no specifi

42、cally defined role for ICD in CHF (level C), but it improves survival in cardiac arrest or sustained VT associated with LV dysfunction (level A)36Antiarrhythmics in heart failuAnti-thrombotic TherapyLittle evidence that anti-thrombotic therapy modifies the risk of death or vascular events other than

43、 in atrial fibrillation where anticoagulants are firmly indicated (level C)Lack of evidence to support anti-thrombotic agents in sinus rhythmThere is controversy about the role of a potential interaction between aspirin and ACE inhibitors37Anti-thrombotic TherapyLittle PacemakersPacemakers have had

44、no specific role other than convential bradycardia indication. When needed, AV-synchronous pacing should be preferredResynchronization therapy using bi-ventricular pacing may improve symptoms and sub-maximal exercise capacity (level B) but the effect on mortality and morbidity is as yet unknown38Pac

45、emakersPacemakers have had Surgery for Heart FailureNo controlled data to support revascularisation in general. In individuals with heart failure due to ischemic cardiomyopathy revascularisation may lead to improvement of symptoms (level C)Mitral valve surgery in advanced heart failure and severe MI

46、 may improve symptoms (level C)Cardiomyoplasty not recommended (level C)Partial left ventriculotomy (Batista) not recommended (level C)39Surgery for Heart FailureNo coChoice of Pharmacological TherapyIndicatedIndicated(under specialist care)Indicated (combination of diuretics)IndicatedEnd-stage hear

47、t failure (NYHA IV)IndicatedIndicated(under specialist care)Indicated (combination of diuretics)IndicatedWorsening heart failure (NYHA III)Not indicatedIndicatedIndicated if fluid retentionIndicatedSymptomatic heart failure (NYHAII)Not indicatedPost-MINot indicatedIndicatedAsymptomatic LVdysfunction

48、Aldosterone antagonistBeta-blockerDiureticACE inhibitor40Choice of Pharmacological TherChoice of Pharmacological TherapyIf persisting hypokalemia If ACE inhibitors and ARBs not tolerated Possibly for symptoms in sinus rhythmIf ACE inhibitors or beta-blockers not toleratedEnd-stage heart failure (NYH

49、A IV)If persisting hypokalemia If ACE inhibitors and ARBs not tolerated For symptoms in sinus rhythmIf ACE inhibitors or beta-blockers not tolerated Worsening heart failure (NYHA III)If persisting hypokalemiaIf ACE inhibitors and ARBs not toleratedFor symptoms in sinus rhythmIf ACE inhibitors or bet

50、a-blockers not tolerated Symptomatic heart failure (NYHAII)Not indicatedNot indicated Atrial fibrillationNot indicatedAsymptomatic LVdysfunctionPotassium-sparing diureticVasodilatorDigitalis glycosideARB41Choice of Pharmacological TherPharmacological Therapy of Heart Failure due to Systolic Left Ven

51、tricular DysfunctionARB if ACE inhibitor intolerantor ACE inhibitor +ARB if beta-blocker intolerantcontinue ACE inhibitor beta-blocker spironolactone+ diuretics +digitalis+ nitrates/hydralazine + temporary inotropic supportNYHA IVARB if ACE inhibitor intolerant or ACE inhibitor +ARB if beta-blocker

52、intolerant ACEinhibitor and beta- blocker add spironolactone+ diuretics + digitalisIf still symptomatic+ nitrates/hydralazine if toleratedNYHA IIIARB if ACE inhibitor intolerantor ACE inhibitor + ARB if beta-blocker intolerant ACE inhibitor as first-line treatment add beta-blocker +/- diuretic depen

53、ding on fluid retentionNYHA IIcontinue ACE inhibitor add beta-blocker if post-MIreduce / stop diureticNYHA IFor Symptoms if Intolerant to ACE inhibitor or Beta-blockerFor Survival/Morbidity mandatory therapy For Symptoms42Pharmacological Therapy of HeaConclusionsHeart failure is a very serious condi

54、tionDiagnosis of CHF is based on objective evidence of cardiac dysfunctionEchocardiography is recommended when heart failure is suspectedLow plasma concentrations of natriuretic peptides make CHF unlikelyThese tests may help to the diagnosis and monitoring of CHF43ConclusionsHeart failure is a Concl

55、usions (contd)Symptoms as wells as prognosis can be improved by appropriate therapy.Symptom management may include several agents where diuretics are essential to control fluid retention.ACE-inhibitors and beta-blockers are very well documented and should be considered in all patients as survival is

56、 improved.Dose levels should be titrated as in clinical trials 44Conclusions (contd)Symptoms aTask ForceMembers of the Task ForceCo-chairmen: Willem J. Remme , Karl Swedberg .(Ifnot stated otherwise representing WG on Heart Failure):John Cleland, Hull; A. W. Hoes, Utrecht (GeneralPractice);Attilio G

57、avazzi, Bergamo (WG Myocardial and Pericardial diseases); Henry Dargie, Glasgow;Helmut Drexler, Hannover; Ferenc Follath, Zurich (European Federation of Internal Medicine); A. Haverich, Hannover (WG on Cardiovascular Surgery);Tina Jaarsma, Den Haag (WG on Cardiovascular Nursing); Jerczy Korewicki, W

58、arzaw; Michel Komajda, Paris; Cecilia Linde, Stockholm (WG on Pacing); Jose Lopez-Sendon, Madrid; Luc Pirard, Lige (WG onEchocardiography); Markku Nieminen, Helsinki;Samuel Lvy, Marseille (WG on Arrhythmia); LuigiTavazzi, Pavia; Pavlos Toutouzas, Athens.45Task ForceMembers of the Task Working Schedu

59、leTask Force appointed by the Committee for Practice Guidelines and Policy Conferences of the European Society of Cardiology (ESC). First meeting ESC 1999.Draft circulated among the Nucleus of the Working Group on Heart Failure, other Working Groups, and several experts in the field of heart failure.It was updated based on comments received. It was then sent to the Committee and after their input the document was approved for publication.Accepted May 3, published EHJ September 2001Available on ESC Web site 46Working ScheduleTask Force appGuidelines for Heart Failure Treatment based on L