充血性心衰的治疗课件..pptVIP

;The Problem (USA) ? 5,000,000 patients ? 6,500,000 hospital days / year ? 300,000 deaths / year ? 6% - 10% of people 65 years ? 5.4% of health care budget (38 billion) ? Incidence x 2 in last ten years;Definition of heart failure;Suspected Heart Failure because of SYMPTOMS and/or SIGNS;Heart disease No symptoms;ACE-i ? blockers;Aggravating Factors;Initial / Ongoing Evaluation;80; ; ;Diuretics ? Essential to control symptoms secondary to fluid retention ? Prevent progression from HTN to HF;Diuretics. Indications 1. Symptomatic HF, with fluid retention Edema Dyspnea Lung Rales Jugular distension Hepatomegaly Pulmonary edema (Xray); ;ACE-I: Clinical Effects;Mortality Reduction with ACE-i;;ACE-I. Contraindications Intolerance (angioedema, anuric renal fail.) Bilateral renal artery stenosis Pregnancy Renal insufficiency (creatinine 3 mg/dl) Hyperkalemia ( 5,5 mmol/l) Severe hypotension;?-Adrenergic Blockers Mechanism of action; ;US Carvedilol HF NEJM 1996; 334: 1349-55; Symptomatic heart failure Asymptomatic ventricular dysfunction - LVEF 35 - 40 % After AMI;Patient stable No physical evidence of fluid retention No need for i.v. inotropic drugs Start ACE-I / diuretic first No contraindications In hospital or not; Initial Target Bisoprolol 1.25 / 24h 10 / 24h Carvedilol 3.125 / 12h 25 / 12h Metoprolol tartrate 6.25 / 12h 75 / 12h Metoprolol succinnate 12,5-25 / 24h 200 / 24h;Hypotension Fluid retention / worsening heart failure Fatigue Bradycardia / heart block;Digitalis: Mechanism of Action Blocks Na+ / K+ ATPase = Ca+ + ? Inotropic effect ? Natriuresis ? Neurohormonal control;Digitalis. Clinical Effects; Digoxin toxicity Advanced A-V block without pacemaker Bradycardia or sick sinus without PM PVC’s and VT Marked hypokalemia W-P-W with atrial fibrillation; ;Candesartan, Eprosartan, Irbesartan Losartan, Telmisartan, Valsartan Efficacy not superior to ACE-I Likely not indicated with beta blockers Indicated in patients intolerant to A