收缩性和舒张性心衰的治疗课件

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1、ManagementofSystolicvs.DiastolicHeartFailureMichaelWolk,MD,FACCWeill-CornellGreatWallofChinaSymposiumOctober,2004Basicconcepts…TheclinicalsyndromeofheartfailurecanoccurwitheithernormalorreducedLVEFVirtuallyallclinicaltrialsofheartfailuretherapieshaveenrolledonl

2、ypatientswithreducedLVEFThus…ExtrapolatingrecommendedtherapyforHFwithreducedEFtopatientswithHFandnormalEFisnot“automatic”TherapyforHFwithReducedEFEvidencebaseforACEIandbetablockertherapyamongthelargestandmostconsistentinmedicinediureticdigoxindiureticdigoxinACE

3、IdiureticdigoxinACEIdiureticdigoxinACEIBetablockerdiureticdigoxinACEIBetablockerdiureticdigoxinACEIBetablockerARBSOLVD-T(1991)RRR21%CIBIS-2(1999)RRR33%CHARM-Added(2003)(Beta-blockersubgroup)RRR30%ImprovingSurvivalinCHFOne-yearMortalityCVDeath,MI,orHFbyTreatmen

4、tPfeffer,McMurray,Velazquez,etal.NEnglJMed2003;349CaptoprilMonthsValsartanvs.Captopril:HR=0.96;P=0.198Valsartan+Captoprilvs.Captopril:HR=0.97;P=0.36900.10.20.30.4061218243036ProbabilityofEventValsartanValsartan+CaptoprilACE-IinHF-WhoandHow?HFSAPracticeGuideline

5、s2004Allpts(symptomaticandasymptomatic)withLVsystolicdysfunction(LVEF<40%).ACEIshouldbemonitoredcloselyifserumCris>2.0mg/dlorserumpotassiumis>5.0mmol/L.ACEIshouldbetitratedastolerated,inconjunctionwithBBs,totargetdosesusedinclinicaltrials.WeightOfEvidence:-Blo

6、ckadeOver18,000patientsevaluatedinlong-termplacebo-controlledclinicaltrialsImprovementincardiacfunctionandsymptoms;(equivocaleffectsonexercisetolerance)Decreaseinall-causemortalityby30%-35%(P<.0001);effectshownin5individualtrialsDecreaseincombinedriskofdeathand

7、hospitalizationby35%-40%(P<.001);effectshownin7individualtrialsEffectshowninpatientsalreadyreceivingACEinhibitorsTherapyforHFwithReducedEFLifestylechanges:SaltrestrictionAchieveidealweightPursueregularexerciseAvoidsmoking,toxinsTherapyforHFwithReducedEFGeneral

8、considerationsforallpatientsTreatreversibleischemiaManagecontributingarrhythmiaWHATHAVEWELEARNEDABOUTNESIRITIDEINCHF?Asimpleregimen/predictableeffect.Improveshemodynamics.Im