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 Endocarditis O
2、besity Hypertension Physical activity Dietary excess Pregnancy Arrhythmias(AF)Infections Thromboembolism Hyper/hypothyroidismInitial/Ongoing Evaluation Treatment ObjectivesSurvivalMorbidityExercise capacityQuality of lifeNeurohormonal changes Progression of CHFSymptoms Pharmacologic TherapyDiuretics
3、ACE inhibitorsBeta Blockers Digitalis Spironolactone(Eplerenone)Angiotensin II Blockers(Candesartan)HMG-CoA Reductase Inhibitors(“Statins”)VASOCONSTRICTIONVASODILATATION KininogenKallikreinInactive FragmentsAngiotensinogenAngiotensin IRENINKininase IIInhibitorALDOSTERONESYMPATHETICVASOPRESSINPROSTAG
4、LANDINStPAANGIOTENSIN 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 insufficiency(creatinine 3 mg/dl)H
5、yperkalemia(5,5 mmol/l)Severe hypotension-Adrenergic BlockersMechanism of action Density of 1 receptors Inhibit cardiotoxicity of catecholamines Neurohormonal activation HRAntiischemicAntihypertensiveAntiarrhythmicAntioxidant,Antiproliferative-Adrenergic BlockersClinical Effects Improve symptoms(onl
6、y 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 in RA and one in coronary sinus(LV p
7、acing)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 patientsBristow,et al:N Engl J Med 2004ICD Therapy in Nonisc
8、hemic 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 cardiac defibrillator Mean age:58 years;mean QRS 115 ms;me
9、an 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.Candesartan is a good adjunctive medication8.Devices:Cardiac resynchronization therapy and ICD help reduce morbidity and mortality in qualifying HF patients
