2016ESC心力衰竭指南解读-李永乐

Abnormal loading conditions
- Hypertension
Arrhythmias
- Tachyarrhythmia
- Valvular defects - Bradyarrhythmia - Structural Myocardial defects During/after - Pericardial and diagnosis: always consider aetiology endomyocardial abnormalities - High Output states - Volume overload
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病因的识别非常重要
Diseased myocardium
- Ischemic heart disease
Toxic Damage Immune mediated Inflammtory damage Infiltration Metabolic derangements Genetic Abnormalities
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心衰患者运动和多学科管理
第二部分
• 预防和延缓心衰并延长生命的处理 • 使用降低死亡率的药物
• HFrEF的治疗流程
• ICD • CRT • HFmrER and HFpEF治疗建议 • 急性心竭的初始管理
• 急性心衰早期根据临床情况的处理流程
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Angina Cachexia and sarcopenia Cancer Central nervous system Diabetes Erectile dysfunction Gout and arthritis Hypo- hyperkalemia Hyperlipidemia Hypertension Iron deficiency and anemia Kidney dysfucntion Lung disease Obesity Sleep disordered breathing Valvular heart disease
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In the year 2016,… by applying all evidence-based discoveries, heart failure is becoming a preventable and treatable disease.
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3. Ensure an ICD implantation in patients who either have recovered from a VA causing haemodynamic instability or in those with symptomatic HF, LVEF ≤35% (despite at least 3 months of OMT), in order to reduce the risk of sudden death and all-cause mortality. ICD implantation is not recommended within 40 days of MI as at this time does not improve prognosis.
What is new?
2012 ESC HF Guidelines: Excellent starting point Space limitations: reduce “textbook knowledge” Further improve clinical applicibility New definition and classification HFrEF/HFmrEF/HFpEF New diagnostic algorythms for acute and chronic HF New therapeutic algorythms for acute and chronic HF Expand chapters on co-morbidities and multidisciplinary care Updated recommendations based on new evidence
yes ECHOCARDIOGRAPHY
HF unlikely: consider other diagnosis
normal
If HF confirmed (based on all available data): determine aetiology and start appropriate treatment
HFpEF
symptoms (+/-signs) LVEF≥50%
1.Elevated (NT-pro) BNP 2.Relevantstructural heart disease(LVH or LAE)+/-diastolic dysfunction
www.escardio.org/guidelines
www.escardio.org/guidelines
ESC Heart Failure Guidelines: Take-home summary
4. Implant a cardiac resynchronization therapy in symptomatic patients with HF, LVEF ≤35% (despite at least 3 months of OMT), in sinus rhythm with a QRS duration ≥130 msec and LBBB QRS morphology, in order to improve symptoms and reduce morbidity and mortality. CRT is contra-indicated in patients with a QRS duration < 130 msec.
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New Classification of Heart Failure
HFrEF
Symptoms (+/-signs) LVEF<40%
HFmrEF
symptoms (+/-signs) LVEF40-49%
1.Elevated (NT-pro) BNP 2.Relevant structural heart disease(LVH or LAE)+/-diastolic dysfunction
www.escardio.org/guidelines
Therapeutic algorithm for a patient with symptomatic HFrEF
www.escardio.org/guidelines
ESC Heart Failure Guidelines: Take-home summary
www.escardio.org/guidelines
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第一部分
• 定义和分类 • 诊断流程：
– 首先评估心衰概率 – 然后检查 (NT-pro)BNP 和超声心动图 – 诊断过程中和之后一直要考虑病因
• 合并症、运动和多学理科管理的重要性
Definition
• HF is a clinical syndrome characterized by typical symptoms (e.g. breathlessness, ankle swelling and fatigue) that may be accompanied by signs (e.g. elevated jugular venous pressure, pulmonary crackles and peripheral oedema) caused by a structural and/or functional cardiac abnormality, resulting in a reduced cardiac output and/or elevated intracardiac pressures at rest or during stress
www.escardio.org/guidelines
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PATIENT WITH SUSPECTED HF (non-acute onset)
ASSESSMENT OF HF PROBABILITY
1. Clinical history; 2. Physical examination; 3. ECG
www.escardio.org/guidelines
ESC Heart Failure Guidelines: Take-home summary
2. Implement life-saving pharmacotherapy in patients with symptomatic HFrEF, containing a combination of an ACE-I (or ARB if ACE-I not tolerated), a β-blocker and a MRA. If a patient still remains symptomatic sacubitril/valsartan is recommended to replace ACE-I. Use diuretics in order to improve symptoms and exercise capacity in patients with signs and/or symptoms of congestion.
ESC Heart Failure Guidelines: Take-home summary
1. To prevent or delay onset of HF and prolong life: • treatment of arterial hypertension, • use of statins in patients with or at high risk of CAD, • use of ACE-I in patients with asymptomatic left ventricular dysfunction • beta-blockers in those with asymptomatic LV dysfunction and a history of myocardial infarction are recommended.
Assessment of natriuretic peptides not routinely done in clinical practice
≥1 present
all absent
no
NATRIURETIC PEPTIDES •NT-proBNP ≥125 pg/mL •BNP ≥35 pg/mL
PATIENT WITH SUSPECTED HF (non-acute onset) ASSESSMENT OF HF PROBABILITY
1. Clinical history: History of CAD (MI, revascularization) History of arterial hypertension Exposition to cardiotoxic drug/radiation Use of diuretics Orthopnoea / paroxysmal nocturnal dyspnoea 2. Physical examination: Rales Bilateral ankle oedema Heart murmur Jugular venous dilatation Laterally displaced/broadened apical beat 3. ECG: Any abnormality
2016ESC心力衰竭指南解读
天津医科大学总医院
李永乐
Available at..
http://www.escardio.org/Guidelines-&-Education/Clinical-PracticeGuidelines/Acute-and-Chronic-Heart-Failure
www.escardio.org/guidelines