Heartfailure.ppt

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1、Diagnosis Case 1 60 y/o male with PMH of HTN and CHD LVEF% 40% and LV enlargement w/o any symptoms or signs Heart failure? Yes? Or No?Diagnosis HF is defined as a clinical syndrome that is characterized by specific symptoms (dyspnea and fatigue) in the medical history and signs (edema, rales) on the

2、 physical examination. There is no single diagnostic test for HF because it is largely a clinical diagnosis that is based on a careful history and physical examinationStage: from A to D Stage A and B :clearly not HF at risk for developing HF Stage C and D:HF Different stage, different treatmentStage

3、s vs NYHA functional class Objective and subjective Progressive ReverseAssessment: Are you sure? The same case 60 y/o male with PMH of HTN and CHD p/w dyspnea,fatigue,lower extremities edema PE detect rale on the bilateral lower lung Dx?Further evaluation Medical history Laboratory test imageHeart f

4、ailure assessment详细的病史和查体病因的询问用药（加药，减药）日常活动耐量容量状态,既往出入量,体重变化颈静脉CBC/BUN/Cr/electrolytes/UA/FBG/TSH/lipid profile/liver functionECG/CXR/echocardiographyBNPDrugs: are you sure Case 2 60 y/o male w/ PMH of OMI LVEF 40% w/o symptoms and signs Shall I use ACEI or B-blocker? Shall I use digoxin? Shall I us

5、e diuretics?Therapy: ACEIStage A:prevent HF in patients at high risk for developing HF who have a history of atherosclerotic vascular disease, diabetes mellitus, or hypertension with associated cardiovascular risk factors(IIa A)Stage B:be used in all patients with a recent or remote history of MI re

6、gardless of EF or presence of HF(I A)/used in patients with a reduced EF and no symptoms of HF, even if they have not experienced MI(I A)Stage C: recommended for all patients with current or prior symptoms of HF and reduced LVEF, unless contraindicated (I A)Therapy: B-blockerStage A: No roleStage B:

7、 be used in all patients with a recent or remote history of MI regardless of EF or presence of HF(I A)/in all patients without a history of MI who have a reduced LVEF with no HF symptoms(I C)Stage C: recommended for all stable patients with current or prior symptoms of HF and reduced LVEF, unless co

8、ntraindicated(I A)Therapy: DigoxinStage A: No roleStage B: should not be used in patients with low EF,sinus rhythm, and no history of HF symptoms(III C)=No roleStage C: can be beneficial in patients with current or prior symptoms of HF and reduced LVEF to decrease hospitalizations for HF(IIa B)Thera

9、py:SpironolactoneStage A: NO roleStage B: NO role eitherStage C:is reasonable in selected patients with moderately severe to severe symptoms of HF and reduced LVEF(I B)BNP(NT-proBNP) 60 y/o male w/ PMH of OMI HTN LVEF 40% p/w dyspnea,lower extremities edema and can not lie flat Dx? Shall I order BNP

10、?About: BNP and NT-proBNP Diagnosis: in the acute setting to rule out or confirm the diagnosis(I A) emphasize: among patients presenting with ambiguous signs and symptoms can be helpful to exclude the diagnosis of heart failure among patients with signs and symptoms suspicious of heart failure in th

11、e non-acute setting(IIa C) Routine testing for patients with an obvious clinical diagnosis of heart failure is not recommended(III C)About: BNP and NT-proBNP Guiding management The value of serial measurements of BNP to guide therapy for patients with HF is not well established Routine blood BNP or

12、NT-proBNP testing is not warranted for making specific therapeutic decisions for patients with acute or chronic heart failureConclusion Diagnosis: Are you sure? Assessment The role of BNP: Are you sure? Pharmacological therapy: Are you sure?Further learning: beyond todays scope Management of acute o

13、nset heart failure Devices: ICD and CRT Role of CCB and ARB Etiology/classification Patients With HF and Normal LVEFBeyond scope Heart failure! Too much, too hard, too complicated! I am not sure! I feel frustrated!Q and A Any questions?References2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults.J Am Coll Cardiol, 2009; 53:1343-1382 ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult.Circulation 2005;112;e154-e235Clinical Utilization of Cardiac Biomarker Testing in Heart Failure.2007