充血性心衰的治疗课件

PPT
  • 阅读 66 次
  • 下载 0 次
  • 页数 49 页
  • 大小 961.500 KB
  • 2023-04-25 上传
  • 收藏
  • 违规举报
  • © 版权认领
下载文档20.00 元 加入VIP免费下载
此文档由【小橙橙】提供上传,收益归文档提供者,本网站只提供存储服务。若此文档侵犯了您的版权,欢迎进行违规举报版权认领
充血性心衰的治疗课件
可在后台配置第一页与第二页中间广告代码
充血性心衰的治疗课件
可在后台配置第二页与第三页中间广告代码
充血性心衰的治疗课件
可在后台配置第三页与第四页中间广告代码
充血性心衰的治疗课件
充血性心衰的治疗课件
还剩10页未读,继续阅读
【这是免费文档,您可以免费阅读】
/ 49
  • 收藏
  • 违规举报
  • © 版权认领
下载文档20.00 元 加入VIP免费下载
文本内容

【文档说明】充血性心衰的治疗课件.ppt,共(49)页,961.500 KB,由小橙橙上传

转载请保留链接:https://www.ichengzhen.cn/view-246639.html

以下为本文档部分文字说明:

CurrentManagementofCongestiveHeartFailure:2004UpdateHishamDokainish,MD,FACCAssistantProfessorofMedicineBaylorCollegeofMedicine,Director,N

on-InvasiveCardiology,BenTaubGeneralHospitalHouston,Texas,USATheProblem(USA)•5,000,000patients•6,500,000hospitaldays/yea

r•300,000deaths/year•6%-10%ofpeople>65years•5.4%ofhealthcarebudget(38billion)•Incidencex2inlasttenyearsGottdienerJetal.JACC2000;3

5:1628HaldemanGAetal.AmHeartJ1999;137:352KannelWBetal.AmHeartJ1991;121:951O’ConnellJBetal.JHeartLungTra

nsplant1993;13:S107DefinitionofheartfailureAHA/ACCHFguidelines2001Clinicalsyndromethatcanresultfromanystructuralorfunctionalcardiacd

isorderthatimpairstheabilityoftheventricletofillwithorejectbloodSuspectedHeartFailurebecauseofSYMPTOMSand/orSIGNSAssesspresenceof

CARDIACDISEASEbyECG,X-RayorBNPTestsabnormalVENTRICULARFUNCTIONImagingbyEcho-Doppler,NuclearangiographyorMRIifava

ilableTestsabnormalNORMALNoHeartFailureNORMALNoHeartFailureHeartFailure:Systolic/DiastolicIdentifyetiology,evaluatese

verity,choosetherapyESCHFguidelines2001HeartdiseaseNosymptomsHFRiskFactorsNoHeartdiseaseNosymptomsAsymptoma

ticLVdysfunctionRefractoryHFsymptomsPriororcurrentHFSymptomsStagesintheevolutionofHeartFailureABCDAHA/ACCHFguidelines2001ACE-iblockersTre

atriskfactorsDietandexerciseAvoidtoxicsACE-iinselectedp.InselectedpatientsPalliativetherapyMech.AssistdeviceHeartTransplantACE-ib

lockersDiuretics/DigitalisStagesintheEvolutionofHeartFailureTreatmentABCDAHA/ACCHFguidelines2001AggravatingFactors•Medications•Newheartdisea

se•Myocardialischemia•Endocarditis•Obesity•Hypertension•Physicalactivity•Dietaryexcess•Pregnancy•Arrhyth

mias(AF)•Infections•Thromboembolism•Hyper/hypothyroidismInitial/OngoingEvaluation•Identifyheartdisease•Assessfunction

alcapacity(NYHA,6minwalk,…)•Assessvolumestatus:(edema,rales,jugular,hepatomegaly,bodyweight)•Labassessment:routine:electrolytes,renalfunct.RepeatEc

ho,RXonlyifsignificantchangesinfunctionalstatus•Assessprognosis8070605040302054-60>6050403020100PostMIn=196<3031-3536-4546-53CardiacMortality%L

VEFBrodieB.etalAmJCardiol1992;69:1113PrognosisTreatmentObjectivesSurvivalMorbidityExercisecapacityQualityoflifeNeurohormonalchangesProgressio

nofCHFSymptoms(Cost)PharmacologicTherapy•Diuretics•ACEinhibitors•BetaBlockers•Digitalis•Spironolactone(Eplerenone)•An

giotensinIIBlockers(Candesartan)•HMG-CoAReductaseInhibitors(“Statins”)Diuretics•Essentialtocontrolsymptomssecondarytoflui

dretention•PreventprogressionfromHTNtoHFDiuretics.Indications1.SymptomaticHF,withfluidretention•Edema•Dyspnea•LungRales•Jugulardistension•

Hepatomegaly•Pulmonaryedema(Xray)AHA/ACCHFguidelines2001ESCHFguidelines2001VASOCONSTRICTIONVASODILATATIONKininogenKallikreinInactiveFragment

sAngiotensinogenAngiotensinIRENINKininaseIIInhibitorALDOSTERONESYMPATHETICVASOPRESSINPROSTAGLANDINStPAANGIOTENSINIIBRADYKININACE-i.MechanismofActionA

.C.E.ACE-I:ClinicalEffects•Improvesymptoms•Reduceremodelling/progression•Reducehospitalization•ImprovesurvivalMortalityReductionwithACE-iStudyA

CE-iClinicalSettingCONSENSUSEnalaprilCHFSOLVDtreatmentEnalaprilCHFAIRERamiprilCHFVHeft-IIEnalaprilCHFTRACETrandolaprilCHF/LVDSAVECaptopr

ilLVDSMILEZofenoprilHighriskHOPERamiprilHighriskACE-i.Dose(mg)InitialMaximumCaptopril6.25/8h50/8hEnalapril2.5/12

h10to20/12hFosinopril5to10/day40/dayLisinopril2.5to5.0/day20to40/dayQuinapril10/12h40/12hRamipril1.25to2.5/day10/dayAHA/ACCHFguidelines2001ACE

-I.Contraindications•Intolerance(angioedema,anuricrenalfail.)•Bilateralrenalarterystenosis•Pregnancy•Renalinsufficiency(cr

eatinine>3mg/dl)•Hyperkalemia(>5,5mmol/l)•Severehypotensionß-AdrenergicBlockersMechanismofaction•Densityofß1receptors•Inhibitcardiotoxicity

ofcatecholamines•Neurohormonalactivation•HR•Antiischemic•Antihypertensive•Antiarrhythmic•Antioxidant,

Antiproliferativeß-AdrenergicBlockersClinicalEffects•Improvesymptoms(onlylongterm)•Reduceremodelling/progression•Reducehospit

alization•Reducesuddendeath•ImprovesurvivalUSCarvedilolHFNEJM1996;334:1349-55Carvedilol(n=696)Placebo(n=398)Riskreduction=65%p<0.00105010015

02002503003504001.00.90.80.70.6ß-AdrenergicBlockers0.70.80.91.0Survival%DaysI-IIHF•Symptomaticheartfailure•Asymptomaticventric

ulardysfunction-LVEF<35-40%•AfterAMIAHA/ACCHFguidelines2001ESCHFguidelines2001ß-AdrenergicBlockers:I

ndications•Patientstable•Nophysicalevidenceoffluidretention•Noneedfori.v.inotropicdrugs•StartACE-I/diureticfirst•N

ocontraindications•Inhospitalornotß-AdrenergicBlockersWhentostartInitialTargetBisoprolol1.25/24h10/24hCarvedilol3.125/1

2h25/12hMetoprololtartrate6.25/12h75/12hMetoprololsuccinnate12,5-25/24h200/24h•StartLow,IncreaseSlowly•Increasethedoseevery2-4weeksß-Adren

ergicBlockersDose(mg)•Hypotension•Fluidretention/worseningheartfailure•Fatigue•Bradycardia/heartblockß-AdrenergicBlockersAdverseEffects•Reviewt

reatment(+/-diuretics,otherdrugs)•Reducedose•Considercardiacpacing•DiscontinuebetablockeronlyinseverecasesDigi

talis:MechanismofActionBlocksNa+/K+ATPase=>Ca++•Inotropiceffect•Natriuresis•Neurohormonalcontrol-PlasmaNoradrenaline-Peripheraln

ervoussystemactivity-RAASactivity-Vagaltone-NormalizesarterialbaroreceptorsNEJM1988;318:358Digitalis.Clinic

alEffects•Improvesymptoms•Modestreductioninhospitalization•Doesnotimprovesurvival•Digoxintoxicity•AdvancedA-Vblockwi

thoutpacemaker•BradycardiaorsicksinuswithoutPM•PVC’sandVT•Markedhypokalemia•W-P-WwithatrialfibrillationDigoxin.Contraindication

sRENINAngiotensinogenAngiotensinIANGIOTENSINIIACEOtherpathwaysVasoconstrictionProliferativeActionVasodilatationAntiproliferativeActionAT1AT2AT1R

eceptorBlockersRECEPTORSAngiotensinIIReceptorBlockers(ARB)•Candesartan,Eprosartan,IrbesartanLosartan,Telmisartan,Valsartan•Efficacynotsuperiorto

ACE-I•Likelynotindicatedwithbetablockers•IndicatedinpatientsintoleranttoACE-IAngiotensinIIReceptorBlockers(ARB)AHA/ACCHFguidelines20

01ESCHFguidelines2001Months1.00.90.80.7ValsartanPlaceboP=0.8Survival0369122118152427AngiotensinIIReceptorBlockers(

ARB)Val-HeFTAHA2000Nitrates:ClinicalUse•CHFwithmyocardialischemia•Orthopneaandparoxysmalnocturnaldyspnea•InacuteCHFandpulmonaryedema:NTGsl/iv•Nitrate

s+HydralazineinintolerancetoACE-I(hypotension,renalinsufficiency)0,540,480122448600.750.500.2500.470.360.250

.130.090.310.180.4236Monthsp=0.08V-HeFTIINEnglJMed1991;325:303EnalaprilHZ+ISDNn=804p=0.016ProbabilityofdeathNitra

te+Hydralazine•Inotropes,longterm/intermittent•Antiarrhythmics(exceptamiodarone)•Calciumantagonists(exceptamlodipine)•N

on-steroidalantiinflammatorydrugs(NSAIDS)•Tricyclicantidepressants•Corticosteroids•LithiumDrugstoAvoid(mayincreasesymptoms

,mortality)ESCHFguidelines2001RefractoryEnd-StageHF•Reviewetiology,treatment&aggrav.factors•Controlfluidretention•Resis

tancetodiuretics•Ultrafiltration?•ivinotropics/vasodilatorsduringdecompensation•Considerresynchronization•Considermechanicalassistdevices•Consider

hearttransplantationHeartTransplant.Indications•Refractorycardiogenicshock•DocumenteddependenceonIVinotropicsupporttomaintainadequateorganperfusion•P

eakVO2<10ml/kg/min•Severesymptomsofischemianotamenabletorevascularization•Recurrentsymptomaticventriculararrhythmiasrefractor

ytoalltherapeuticmodalitiesContraindications:age,severecomorbidityNewHeartFailureTrials1.Candesartan(ARB):CHARMProgramme2.Carvedilolvs.Metoprolol:

COMET3.BiventricularPacemaker+/-Internalcardiacdefibrillator(ICD):COMPANION4.ICDonlyinnonischemicHF:DEFINITECHARMStu

dy:DesignPurpose:Todeterminetheefficacyofcandasartan(ARB)invariousscenariosinHF:–AddedtoACEinhibitor–Inst

eadofACEinhibitor–InpatientswithHFbutpreservedEFPfeffer,etal:Lancet2003CHARMStudy:AllgroupsPfeffer,etal:Lancet2003Purpose:To

answerthequestion:•WhichBeta-BlockerisbetterinpatientswithdepressedEFandCHF:MetoprololorCarvedilol?COMET:Carvedilolvs.MetoprololPoole-Wilso

n,etal:Lancet2003Poole-Wilson,etal:Lancet2003COMET:Carvedilolvs.MetoprololCardiac-Resynchronization+/-ICDinHeartFailure:COMPANIONTrial•Patientswithh

eartfailureandwidenedQRScomplex>120mscanbenefitfromresynchronizationtherapy•Threeleads:oneinRVapex,oneinRAando

neincoronarysinus(LVpacing)•Purpose:tohelprestoreinterventricularsynchrony,andimprovehemodynamics•InternalCardia

cDebrillators(ICD)topreventarrhythmicsuddencardiacdeath•1520patients:meanage67years;meanEF22%;meanQRS160ms;ischemiccause~55%ofpatientsBri

stow,etal:NEnglJMed2004ICDTherapyinNonischemicCardiomyopathy:DEFINITETrial•MADITIItrialshowedthatpatien

tswithEF<35%afterMIhavelowermortalitywithprophylacticICDtherapy•458patientswithnonischemicDCMrandomizedandPVCsorNSVTtooptimum

medicaltherapy+/-internalcardiacdefibrillator•Meanage:58years;meanQRS115ms;meanEF21%Kadish,etal:NEnglJMed2004CHFTreatmentSummary1.Maketh

erightdiagnosis:Echoisessential2.Dietandexerciseareimportant3.Diureticforsymptoms4.ACEinhibitorforsymptomsandsurvival5.Beta-blockerfo

rsymptomsandsurvival(Carvedilollikelybetter)CHFTreatmentSummary6.Spironolactone(oreplerenone)forClassIIIorI

Vheartfailure7.Candesartanisagoodadjunctivemedication8.Devices:CardiacresynchronizationtherapyandICDhelpreducemorbidityandmortalit

yinqualifyingHFpatients

小橙橙
小橙橙
文档分享,欢迎浏览!
  • 文档 25747
  • 被下载 7
  • 被收藏 0
相关资源
广告代码123
若发现您的权益受到侵害,请立即联系客服,我们会尽快为您处理。侵权客服QQ:395972555 (支持时间:9:00-21:00) 公众号
Powered by 太赞文库
×
确认删除?