ESC心力衰竭指南解读-李永乐优质PPT.pptx

ESC心力衰竭指南解读-李永乐优质PPT.pptx

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天津医科大学总医院李永乐2016ESC心力衰竭指南解读www.escardio.org/guidelinesAvailableat.http:

@#@/www.escardio.org/Guidelines-&@#@-Education/Clinical-Practice-Guidelines/Acute-and-Chronic-Heart-Failurewww.escardio.org/guidelines3Intheyear2016,byapplyingallevidence-baseddiscoveries,heartfailureisbecomingapreventableandtreatabledisease.www.escardio.org/guidelinesu2012ESCHFGuidelines:

@#@ExcellentstartingpointuSpacelimitations:

@#@reduce“textbookknowledge”uFurtherimproveclinicalapplicibilityuNewdefinitionandclassificationHFrEF/HFmrEF/HFpEFuNewdiagnosticalgorythmsforacuteandchronicHFuNewtherapeuticalgorythmsforacuteandchronicHFuExpandchaptersonco-morbiditiesandmultidisciplinarycareuUpdatedrecommendationsbasedonnewevidence5Whatisnew?

@#@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www.escardio.org/guidelinesDefinitionHFisaclinicalsyndromecharacterizedbytypicalsymptoms（e.g.breathlessness,ankleswellingandfatigue）thatmaybeaccompaniedbysigns（e.g.elevatedjugularvenouspressure,pulmonarycracklesandperipheraloedema）causedbyastructuraland/orfunctionalcardiacabnormality,resultinginareducedcardiacoutputand/orelevatedintracardiacpressuresatrestorduringstressHFrEFHFmrEFHFpEFSymptoms（+/-signs）symptoms（+/-signs）symptoms（+/-signs）LVEF40%LVEF40-49%LVEF50%1.Elevated（NT-pro）BNP2.Relevantstructuralheartdisease（LVHorLAE）+/-diastolicdysfunction1.Elevated（NT-pro）BNP2.Relevantstructuralheartdisease（LVHorLAE）+/-diastolicdysfunctionwww.escardio.org/guidelinesNewClassificationofHeartFailurewww.escardio.org/guidelinesPATIENTWITHSUSPECTEDHF（non-acuteonset）ASSESSMENTOFHFPROBABILITY1.Clinicalhistory:

@#@HistoryofCAD（MI,revascularization）HistoryofarterialhypertensionExpositiontocardiotoxicdrug/radiationUseofdiureticsOrthopnoea/paroxysmalnocturnaldyspnoea2.Physicalexamination:

@#@RalesBilateralankleoedemaHeartmurmurJugularvenousdilatationLaterallydisplaced/broadenedapicalbeat3.ECG:

@#@Anyabnormality9PATIENTWITHSUSPECTEDHF（non-acuteonset）ASSESSMENTOFHFPROBABILITY1.Clinicalhistory;@#@2.Physicalexamination;@#@3.ECGallabsent1presentHFunlikely:

@#@considerotherdiagnosisIfHFconfirmed（basedonallavailabledata）:

@#@determineaetiologyandstartappropriatetreatmentwww.escardio.org/guidelinesNATRIURETICPEPTIDESNT-proBNP125pg/mLBNP35pg/mLyesECHOCARDIOGRAPHYnonormalAssessmentofnatriureticpeptidesnotroutinelydoneinclinicalpracticeDiseasedmyocardium-Ischemicheartdisease-ToxicDamage-Immunemediated-Inflammtorydamage-Infiltration-Metabolicderangements-GeneticAbnormalitiesAbnormalloadingconditions-Hypertension-Valvulardefects-StructuralMyocardialdefects-Pericardialandendomyocardialabnormalities-HighOutputstates-VolumeoverloadArrhythmias-Tachyarrhythmia-Bradyarrhythmia病因的识别非常重要During/afterdiagnosis:

@#@alwaysconsideraetiologywww.escardio.org/guidelines-AnginaCachexiaandsarcopeniaCancerCentralnervoussystemDiabetesErectiledysfunctionGoutandarthritisHypo-hyperkalemiaHyperlipidemiaHypertensionIrondeficiencyandanemiaKidneydysfucntionLungdiseaseObesitySleepdisorderedbreathingValvularheartdisease心衰患者运动和多学科管理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ICDCRTHFmrERandHFpEF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www.escardio.org/guidelines1.TopreventordelayonsetofHFandprolonglife:

@#@treatmentofarterialhypertension,useofstatinsinpatientswithorathighriskofCAD,useofACE-Iinpatientswithasymptomaticleftventriculardysfunctionbeta-blockersinthosewithasymptomaticLVdysfunctionandahistoryofmyocardialinfarctionarerecommended.ESCHeartFailureGuidelines:

@#@Take-homesummarywww.escardio.org/guidelines2.Implementlife-savingpharmacotherapyinpatientswithsymptomaticHFrEF,containingacombinationofanACE-I（orARBifACE-Inottolerated）,a-blockerandaMRA.Ifapatientstillremainssymptomaticsacubitril/valsartanisrecommendedtoreplaceACE-I.Usediureticsinordertoimprovesymptomsandexercisecapacityinpatientswithsignsand/orsymptomsofcongestion.ESCHeartFailureGuidelines:

@#@Take-homesummarywww.escardio.org/guidelinesTherapeuticalgorithmforapatientwithsymptomaticHFrEFwww.escardio.org/guidelines3.EnsureanICDimplantationinpatientswhoeitherhaverecoveredfromaVAcausinghaemodynamicinstabilityorinthosewithsymptomaticHF,LVEF35%（despiteatleast3monthsofOMT）,inordertoreducetheriskofsuddendeathandall-causemortality.ICDimplantationisnotrecommendedwithin40daysofMIasatthistimedoesnotimproveprognosis.ESCHeartFailureGuidelines:

@#@Take-homesummarywww.escardio.org/guidelines4.ImplantacardiacresynchronizationtherapyinsymptomaticpatientswithHF,LVEF35%（despiteatleast3monthsofOMT）,insinusrhythmwithaQRSduration130msecandLBBBQRSmorphology,inordertoimprovesymptomsandreducemorbidityandmortality.CRTiscontra-indicatedinpatientswithaQRSduration130msec.ESCHeartFailureGuidelines:

@#@Take-homesummarymod.Cle