充血性心力衰竭PPT课件
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1.0 Carvedilol (n=696)
MERIT-HF2
20
Placebo (n=2001)
0.9
Placebo (n=398) 65%
0.8
P<.001
15
34%
P=.0062 (adjusted)
10
Metoprolol CR/XL
5
(n=1990)
0.7 0.0
0
1.0
100 200 300 400 Days
180 (n=2289)
(n=624)
25 25
153 134
20
19
120
15 15
63
10
60
44
5
3
Number of Events Number of Events
0 8 Weeks
Placebo
Krum H et al. JAMA. 2003;289:712–718.
0 Carvedilol
8 P<.0001
COPERNICUS: Early Clinical
Outcomes
Death or Hospitalization
Deaths
for Any Reason
All Patients Higher-Risk Patients
30
(n=2289)
(n=624)
All Patients Higher-Risk Patients
Beta-blocker Therapy in Heart Failure
Potential Beneficial Effects
Protection from Catecholamine
Toxicity
Renin Angiotensin
System
Reversal of Remodeling
Up-regulation of b-adrenergic
asymptomatic and symptomatic stages • HF morbidity and mortality can be reduced
by stage specific treatments
Hunt, et al. J Am Coll Cardiol. 2001; 38:2101-2113.
ACC/AHA Proposed Stages of HF
STAGE A High risk for developing HF STAGE B Asymptomatic LV dysfunction STAGE C Past or current symptoms of HF STAGE D End-stage HF
Placebo
70
(n=1133)
Risk
Reduction
60
35%
P=.00013
50 0 4 8 12 16 20 24 28 Months
Packer M et al. N Engl J Med. 2001;344:1651–1658.
COPERNICUS: Number of Hospitalizations
Total M ortality
CHF R eadm ission
QOL
Group I 6.4
$5728 5.9 12.9
24.6
27.1
6.4
Group II 6.1
$7428* 4.3 11.2
18.4*
23.9
7.1*
Group III 8.4* $9027 5.6 10.9
21.1
22.8*
8 Weeks
Does Subspecialty Care Affect CHF Outcome
• SUPPORT
1298 Hospitalized Patients
743 (57%) Cardiolgist (C)
555 (43%) Primary Care (P)
C
P
Age
63
71
Male
71%
Group I more NH, more comorbidity
more females, less B-Blocker use
Upstate New York Results
CHF Etiology Documented
LVEF Documented
Dietary Counseling
Case Management ACE – I used
$ 9 4 0 ,1 1 3
$ 2 1 6 ,2 2 6
HF Management Meta Analysis
Mortality HF Hospitalization Al Cause Hospitalization Multidisciplinary Management Team .75 [.59-.96] .74 [.63-.87] .81 [.71-.92] Enhancing Patient Self Management 1.14 [.67-1.94] .66 [.52-.83] .73 [.57-.93] Telephone Monitoring to PCP .91 [.67-1.29] .75 [.57-.99] .98 [.80-1.20]
Multidisciplinary HF Clinic
.66 [.42-.1.05] .76 [.58-.99] .76 [.58-.1.01]
Multidisciplinay Nonclinical Setting .81 [.65-.1.01] .72 [.59 -.87] .81 [.72-.91]
For any reason
900
For cardiovascular
reason
600
450
For heart failure
20%
29%
33%
600
400
300
Placebo
Carvedilol
300
200
150
0 P=.0012
0 P=.0002
Packer M et al. Circulation. 2002;106:2194–2199.
52%
EF known 69%
47%
EF < 20% 52%
39%
SUPPORT Results
Cardiologists vs. Primary Care:
RHC
2.9 times more likely
Coronary angio 3.9 times more likely
Hospital costs 43% higher
Lancet. 1999;353:9–13. 4Packer M et al. N Engl J Med. 2001;344:1651–1658.
COPERNICUS: All-Cause
Mortality
All patients
100
% Survival
90
Carvedilol
(n=1156)
80
Congestive Heart Failure Collaborative, October 14, 2004
Preventing Readmissions
Kenneth A. LaBresh, MD, FAHA, FACC V.P., Medical Affairs and Quality Improvement, MassPRO
• Elements of the Program
– Multidisiplinary team – Inpatient and outpatient treatment protocols – Patient and family education – Follow up telephone calls – Outpatient infusion center
Morbidity and Mortality
Adrenergic Pathway in Heart Failure Progression
CNS sympathetic outflow
Vascular sympathetic activity
Cardiac sympathetic activity
6.6
Philbin E, CHEST 116:2, 346 - 354
Hospital Based CHF Clinic
• Retrospective analysis before (n = 407) and after (n = 357) implementation of a CHF program in 1994
Renal sympathetic activity
b1 b2 1
1
b1 1
Myocyte hypertrophy Myocyte injury
Increased arrhythmias
Vasoconstriction
Activation of RAS
Sodium retention
Disease progression
B- Blocker
Group I 66 51 68 15 58 13
Group II 83* 86* 84* 26* 73* 25*
Group III 81* 90* 83* 29* 65* 18*
Results (cont.)
Hospital LOS
Charges
M ortality
C u m u lative CHF Mortality
Receptors
Ancillary Factors
Major Placebo Controlled Trials of
b-Blockade in Heart Failure
Cumulative Mortality (%)
Probability of Event-free Survival
US Carvedilol Trials1
Impact of Subspeciality Care
Upstate New York 10 hospitals
Three patient groups
I Noncardiologist
n = 977
II Cardiologist Attending n = 419
III Cardiology Consult n = 1058
Hunt, et al. J Am Coll Cardiol. 2001; 38:2101-2113.
Neurohormonal Activation in
Heart Failure
Angiotensin II
Norepinephrine
Hypertrophy, apoptosis, ischemia, arrhythmias, remodeling, fibrosis
Outcomes
C on trol G rou p (n = 407)
9 0 d ay read m issio n
18%
rate
C o sts p er A d m issio n
$6719
P rogram G roup (n = 347) 13% *
$5601*
H o sp ital “ L o ss”
ACE-I
64% IN BOTH groups
Short term mortality similar
4.6 year follow up mortality 20% lower for cardiologists (rr 0.80 (0.66 - 0.96))
Aurebach ad, AIM 2000;132:191-200
Clinical Associate Professor, Brown University
ACC/AHA Guidelines for Evaluation and Management of Chronic Heart Failure 2001
• HF can be prevented • HF has established risk factors • HF is a progressive condition with
80 35%
70 P=.00013
60
Placebo (n=1133)
0.0
0
0
200
400
600
800
0 100 200 300 400 500 600
Days
Days
1Packer M et al. N Engl J Med. 1996;334:1349–1355. 2MERIT-HF Study Group. Lancet. 1999;253:2001–2007. 3CIBIS-II Investigators.
CIBIS-II3
Bisoprolol (n=1327)
0 0
100 90
100 200 300 400 500 600 Days
COPERNICUS4
Carvedilol (n=1156)
Survival (%Байду номын сангаасof Patients)
Survival
0.8 34%
P<.0001
0.6
Placebo (n=1320)
MERIT-HF2
20
Placebo (n=2001)
0.9
Placebo (n=398) 65%
0.8
P<.001
15
34%
P=.0062 (adjusted)
10
Metoprolol CR/XL
5
(n=1990)
0.7 0.0
0
1.0
100 200 300 400 Days
180 (n=2289)
(n=624)
25 25
153 134
20
19
120
15 15
63
10
60
44
5
3
Number of Events Number of Events
0 8 Weeks
Placebo
Krum H et al. JAMA. 2003;289:712–718.
0 Carvedilol
8 P<.0001
COPERNICUS: Early Clinical
Outcomes
Death or Hospitalization
Deaths
for Any Reason
All Patients Higher-Risk Patients
30
(n=2289)
(n=624)
All Patients Higher-Risk Patients
Beta-blocker Therapy in Heart Failure
Potential Beneficial Effects
Protection from Catecholamine
Toxicity
Renin Angiotensin
System
Reversal of Remodeling
Up-regulation of b-adrenergic
asymptomatic and symptomatic stages • HF morbidity and mortality can be reduced
by stage specific treatments
Hunt, et al. J Am Coll Cardiol. 2001; 38:2101-2113.
ACC/AHA Proposed Stages of HF
STAGE A High risk for developing HF STAGE B Asymptomatic LV dysfunction STAGE C Past or current symptoms of HF STAGE D End-stage HF
Placebo
70
(n=1133)
Risk
Reduction
60
35%
P=.00013
50 0 4 8 12 16 20 24 28 Months
Packer M et al. N Engl J Med. 2001;344:1651–1658.
COPERNICUS: Number of Hospitalizations
Total M ortality
CHF R eadm ission
QOL
Group I 6.4
$5728 5.9 12.9
24.6
27.1
6.4
Group II 6.1
$7428* 4.3 11.2
18.4*
23.9
7.1*
Group III 8.4* $9027 5.6 10.9
21.1
22.8*
8 Weeks
Does Subspecialty Care Affect CHF Outcome
• SUPPORT
1298 Hospitalized Patients
743 (57%) Cardiolgist (C)
555 (43%) Primary Care (P)
C
P
Age
63
71
Male
71%
Group I more NH, more comorbidity
more females, less B-Blocker use
Upstate New York Results
CHF Etiology Documented
LVEF Documented
Dietary Counseling
Case Management ACE – I used
$ 9 4 0 ,1 1 3
$ 2 1 6 ,2 2 6
HF Management Meta Analysis
Mortality HF Hospitalization Al Cause Hospitalization Multidisciplinary Management Team .75 [.59-.96] .74 [.63-.87] .81 [.71-.92] Enhancing Patient Self Management 1.14 [.67-1.94] .66 [.52-.83] .73 [.57-.93] Telephone Monitoring to PCP .91 [.67-1.29] .75 [.57-.99] .98 [.80-1.20]
Multidisciplinary HF Clinic
.66 [.42-.1.05] .76 [.58-.99] .76 [.58-.1.01]
Multidisciplinay Nonclinical Setting .81 [.65-.1.01] .72 [.59 -.87] .81 [.72-.91]
For any reason
900
For cardiovascular
reason
600
450
For heart failure
20%
29%
33%
600
400
300
Placebo
Carvedilol
300
200
150
0 P=.0012
0 P=.0002
Packer M et al. Circulation. 2002;106:2194–2199.
52%
EF known 69%
47%
EF < 20% 52%
39%
SUPPORT Results
Cardiologists vs. Primary Care:
RHC
2.9 times more likely
Coronary angio 3.9 times more likely
Hospital costs 43% higher
Lancet. 1999;353:9–13. 4Packer M et al. N Engl J Med. 2001;344:1651–1658.
COPERNICUS: All-Cause
Mortality
All patients
100
% Survival
90
Carvedilol
(n=1156)
80
Congestive Heart Failure Collaborative, October 14, 2004
Preventing Readmissions
Kenneth A. LaBresh, MD, FAHA, FACC V.P., Medical Affairs and Quality Improvement, MassPRO
• Elements of the Program
– Multidisiplinary team – Inpatient and outpatient treatment protocols – Patient and family education – Follow up telephone calls – Outpatient infusion center
Morbidity and Mortality
Adrenergic Pathway in Heart Failure Progression
CNS sympathetic outflow
Vascular sympathetic activity
Cardiac sympathetic activity
6.6
Philbin E, CHEST 116:2, 346 - 354
Hospital Based CHF Clinic
• Retrospective analysis before (n = 407) and after (n = 357) implementation of a CHF program in 1994
Renal sympathetic activity
b1 b2 1
1
b1 1
Myocyte hypertrophy Myocyte injury
Increased arrhythmias
Vasoconstriction
Activation of RAS
Sodium retention
Disease progression
B- Blocker
Group I 66 51 68 15 58 13
Group II 83* 86* 84* 26* 73* 25*
Group III 81* 90* 83* 29* 65* 18*
Results (cont.)
Hospital LOS
Charges
M ortality
C u m u lative CHF Mortality
Receptors
Ancillary Factors
Major Placebo Controlled Trials of
b-Blockade in Heart Failure
Cumulative Mortality (%)
Probability of Event-free Survival
US Carvedilol Trials1
Impact of Subspeciality Care
Upstate New York 10 hospitals
Three patient groups
I Noncardiologist
n = 977
II Cardiologist Attending n = 419
III Cardiology Consult n = 1058
Hunt, et al. J Am Coll Cardiol. 2001; 38:2101-2113.
Neurohormonal Activation in
Heart Failure
Angiotensin II
Norepinephrine
Hypertrophy, apoptosis, ischemia, arrhythmias, remodeling, fibrosis
Outcomes
C on trol G rou p (n = 407)
9 0 d ay read m issio n
18%
rate
C o sts p er A d m issio n
$6719
P rogram G roup (n = 347) 13% *
$5601*
H o sp ital “ L o ss”
ACE-I
64% IN BOTH groups
Short term mortality similar
4.6 year follow up mortality 20% lower for cardiologists (rr 0.80 (0.66 - 0.96))
Aurebach ad, AIM 2000;132:191-200
Clinical Associate Professor, Brown University
ACC/AHA Guidelines for Evaluation and Management of Chronic Heart Failure 2001
• HF can be prevented • HF has established risk factors • HF is a progressive condition with
80 35%
70 P=.00013
60
Placebo (n=1133)
0.0
0
0
200
400
600
800
0 100 200 300 400 500 600
Days
Days
1Packer M et al. N Engl J Med. 1996;334:1349–1355. 2MERIT-HF Study Group. Lancet. 1999;253:2001–2007. 3CIBIS-II Investigators.
CIBIS-II3
Bisoprolol (n=1327)
0 0
100 90
100 200 300 400 500 600 Days
COPERNICUS4
Carvedilol (n=1156)
Survival (%Байду номын сангаасof Patients)
Survival
0.8 34%
P<.0001
0.6
Placebo (n=1320)