舒张性心力衰竭

Clinical Aspects of Diastolic Heart FailureShin-ichi Momomura,MDCardiovascular CenterToranomon HospitalTokyo,JapanIncidence of Heart Failure Framingham Heart StudyJ Am Coll Cardiol 1993;22:6A13AMaleFemaleDistribution of Left Ventricular Ejection Fraction:EuroHeart Failure SurveyEuropean Heart Journal(2003)24,442463What is Diastolic Heart Failure?Diastolic(Heart)Failure Heart failure due to diastolic dysfunction Heart Failure with Preserved or NormalSystolic Function Cf)Systolic Heart FailureCauses of Diastolic DysfunctionLeft ventricular hypertrophy(common)Aortic stenosis Chronic hypertension Hypertrophic cardiomyopathy(with/wothout outflow tract obstruction)Acute episodic myocardial ischemica(common)Pericardial disease(rare)Tamponade Constriction Constrictive-effusive disease due to prior radiation therapyRestrictive cardiomyopathy(rare)Amyloid disease Idiopathic restrictive cardiomyopathyMechanism of DHFLV diastolicdysfunctionCONeurohormnal activityExersional dyspneastroke volumeSodium/water retensionLV filling pressureedemaPulmonary edemaPulmonary congestioncAcute elevation of BPEpidemiology of DHFPrevalence of DHFDiagnosticCriteriaEvaluation of LV functionPrevalenceGhaliFHSFS24%(UCG)28%TaffetFHSEF45%(RNV)43%TakaradaFHSFS30%(UCG)24%VasanFHSEF50%(UCG)51%Distribution of the severity of left ventricular systolicdysfunction by qualitative assessmentWomenMenEuropean Heart Journal(2003)24,442463EF50%EF50%7859584451354432362916151.00.80.60.40.001234560.2ExpectedEF50%EF50%SurvivalYearsSenni M.et al.：Circulation,98,2282,1998.P=0.279Smith GL.JACC 2003;41:1510-8Characteristics:DemographicPreserved EF(n=200)Depressed EF(n=213)p ValueAge73+1170+110.004Male gender74(37%)139(65%)0.001White race158(79%)159(75%)0.30Smith GL.JACC 2003;41:1510-8Characteristics:Cardiac HistoryPreserved EF(n=200)Depressed EF(n=213)p ValueEF60+828+100.0001HF128(64%)169(79%)0.001Previous.hospitalization for HF60(30%)94(45%)0.002Years of HF2.4+5.43.3+5.50.002Hypertension160(80%)139(65%)0.001Arrhythmia77(39%)112(53%)0.004Pacemaker placement20(10%)40(19%)0.01Smith GL.JACC 2003;41:1510-8Characteristics:Cardiac HistoryPreserved EF(n=200)Depressed EF(n=213)p ValueChronic stable angina66(33%)91(43%)0.04Myocardial infarction78(39%)118(55%)0.001Cardiac catheterization75(38%)123(58%)0.001CABG39(20%)67(31%)0.006PCI19(10%)32(15%)0.09Coronary artery disease56(24%)176(76%)0.0001Aortic stenosis9(9%)14(9%)0.86Smith GL.JACC 2003;41:1510-8Characteristics:Non-cardiac HistoryPreserved EF(n=200)Depressed EF(n=213)p ValueRenal insufficiency72(36%)74(35%)0.79Respiratory disease61(31%)56(26%)0.34CVA/stroke30(15%)33(15%)0.89Diabetes95(48%)102(48%)0.94Smith GL.JACC 2003;41:1510-8DHF in JapanAll(n=172)Preserved Systolic Function(n=61)Intermediate Systolic Function(n=38)Depressed Systolic Function(n=73)Age(yrs)(mean+SD)68+1469+1669+967+14Men105(61%)30(49%)23(61%)52(71%)*Previous admission for CHF60(35%)15(25%)13(34%)31(44%)*Cause of CHF Ischemic75(44%)26(43%)16(42%)33(45%)Hypertensive45(26%)20(33%)11(29%)14(19%)Cardiomyopathic43(25%)7(12%)9(24%)27(37%)Tsutsui H et al.Am J Cardiol 2001;88:230-33*p0.05,p0.01 vs.preserved systolic function valuesDHF in JapanAll(n=172)Preserved Systolic Function(n=61)Intermediate Systolic Function(n=38)Depressed Systolic Function(n=73)Comorbidity Myocardial infarction61(36%)21(34%)10(26%)30(41%)Systemic hypertension89(52%)40(66%)19(50%)30(41%)Diabetes mellitus52(30%)18(30%)10(26%)30(41%)Chronic renal failure22(13%)7(11%)8(21%)7(10%)LV hypertrophy59(36%)31(51%)11(29%)17(23%)Atrial fibrillation54(31%)18(30%)10(26%)26(36%)Smoking46(27%)17(28%)10(26%)19(26%)Alcohol41(24%)16(26%)8(21%)17(23%)Tsutsui H et al.Am J Cardiol 2001;88:230-33 p0.01 vs.preserved systolic function valuesDHF in JapanAll(n=172)Preserved Systolic Function(n=61)Intermediate Systolic Function(n=38)Depressed Systolic Function(n=73)Digitalis82(48%)24(39%)16(43%)42(58%)*Diuretic120(70%)37(61%)25(66%)58(80%)*ACE inhibitor101(59%)26(43%)20(53%)55(75%)Beta-blocker40(23%)11(18%)13(34%)16(22%)Ca antagonist64(37%)31(51%)12(32%)21(29%)*Tsutsui H et al.Am J Cardiol 2001;88:230-33p0.05,p0.01 vs.preserved systolic function values;p40%CHARMAddedCHARMPreservedCHARMAlternativeCHARM:DesignCHARM：CharaceteristicsCHARMAlternativeAdded Preservedn2,0282,548 3,025Age676467Female(%)322140NYHA (%)482461NYHA (%)497338mean LVEF(%)302854Treatment ACEIs010018 Diuretics859075 Digitalis465828-blockers545556 Spironolactone251712Eur J Heart Failure 2001;3 Suppl 1:S17-18CHARM preserved:Primary Endpoint:Time to cardiovascular death or admission for heart failureLancet 2003;362:77781Proportion with cardiovascular death or hospital admission for CHF(%)CHARM preserved:Admission for HFTotal number ofadmissions for CHFNumber of patients who were admitted tohospital for CHFfrom Lancet 2003;362:77781ACC/AHA Guidelines4.3.2.Patients With HF and Normal LVEF Class I 1.Physicians should control systolic and diastolic hypertension in patients with HF and normal LVEF,in accordance with published guidelines.(Level of Evidence:A)2.Physicians should control ventricular rate in patients with HF and normal LVEF and atrial fibrillation.(Level of Evidence:C)3.Physicians should use diuretics to control pulmonary congestion and peripheral edema in patients with HF and normal LVEF.(Level of Evidence:C)Circulation.2005;112:1825-1852 ACC/AHA Guidelines4.3.2.Patients With HF and Normal LVEF(cont.)Class IIa Coronary revascularization is reasonable in patients with HF and normal LVEF and coronary artery disease in whom symptomatic or demonstrable myocardial ischemia is judged to be having an adverse effect on cardiacdiastolic function.(Level of Evidence:C)Class IIb 1.Restoration and maintenance of sinus rhythm in patients with atrial fibrillation and HF and normal LVEF might be useful to improve symptoms.(Level of Evidence:C)2.The use of beta-adrenergic blocking agents,ACEIs,ARBs,or calcium antagonists in patients with HF and normal LVEF and controlled hypertension might be effective to minimize symptoms of HF.(Level of Evidence:C)3.The usefulness of digitalis to minimize symptoms of HF in patients with HF and normal LVEF is not well established.(Level of Evidence:C)Circulation.2005;112:1825-1852