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Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Keep guideline in mind,walking your own way!,Michael Fu,MD,PhD,FESC,Professor,Senior Consultant Physician,Head,Heart Failure Center Medicine,Sahlgrenska University Hospital/Sahlgrenska,Gteborg,SWEDEN,How to optimize heart failure management?,Chronic Heart FailureMore common than we believe,!,2%,10%,CHF:A aged population,0,100,200,300,400,500,600,700,1960,1980,2000,2021,Millions,165,296,403,649,Chronic Heart Failure A disease state which seldom stops!,Risk factors:,diabetes,hypertension,Vascular,dysfunction,Vascular disease,Tissue injury,(MI,stroke),Pathological,remodeling,Target organ dysfunction(HF,renal),Sympatikus,Angiotensin II,aldosterone,-,The Cardiovascular Continuum,Adapted 2003 from Dzau V,Braunwald E.,Am Heart J,.1991;Gibbons 1999.,Heart failure,Death,Chronic Heart Failure More malignant than we believe!,CHF:More malignant than most cancer!,Stewart et al.Eur J Heart Failure 2001,3(3):315-,A,Risk factor,Ischemea,Hypertention,Diabetes,B,Heart dysfunction,C,Heart failure,D,Refractory HF,Standard Heart failure care,Extraordinary measure,Risk modification,X,X,Chronic Heart Failure,Worse than we believe in CHF treatment,diuretic,digoxin,diuretic,digoxin,diuretic,digoxin,ACE-I,diuretic,digoxin,ACE-I,diuretic,digoxin,ACE-I,blocker,diuretic,digoxin,ACE-I,blocker,ACEI (1991),blocker(1999),ARB (2003),ACE-I,blocker,ARB,Evidence-based heart failure medications,One year mortality(%),Worldwide Gteborg,blocker:50%82%,ACEI:64%75%,Age 80 years Worldwide Gteborg,blocker:15%80%,ACEI:35%73%,European heat survey,Heart failure registry in Gteborg,A Gap between Guideline and Clinical Practice,Can we do better?,To clarify objectives,of treatment of chronic heart failure,Prognosis,Morbidity,Prevention,Life quality,No 1,Putting guideline into clinical prctice!,No 2,Evidence based medicine makes difference!,Beta-blocker ACE inhibitor AT1 receptor blocker Aldosteron receptor antagonist Digitalis Diuretics Antikoagulation,Vasodilator,Antiarytmics,Inotropic agents,Calcium channel blocker,Statin,ASA,TNF-,antagonist,Endothelin antagonist,AVP antagonist,Relieve Slow Prevent,Symptom prpgression SCD,?,?,?,CHF,ACEI+BB,ESC,CHF,ACEI+BB,Persisting symptoms&sign,Yes,ARB or Aldosterone antagonist,ESC,CHF,ACEI+BB,Persisting symptoms&sign,Yes,ARB or Aldosterone antagonist,Persisting symptoms,Yes,QRS120 ms,Yes,CRT/CRT-D,ESC,CHF,ACEI+BB,Persisting symptoms&sign,Yes,NO,ARB or Aldosterone antagonist,Persisting symptoms,Yes,QRS120 ms,Yes,CRT/CRT-D,NO,LVEF35%,Yes,ICD,ESC,CHF in particular,Sudden death,Sudden Death,“The major challenge confronting,contemporary cardiology,Bernard Lown,Most common death in,Hypertension,Post-MI patients,Heart failure,Sudden Death,Primary Prevention,Diu,Meto,5,10(y),(n=3 234),Hypertension,50,Cumulative No,.,Sudden Death-Risk Reduction with Metoprolol,Secondary Prevention,Plac,Meto,(n=5 474),1,2,3(y),Post Myocardial infarction,Tertiary Prevention,Plac,Meto,CR/XL,6,12,18(m),(n=3 991),Heart Failure,12,Cumulative No,.,120,Olsson G et al,Am J Hypertens 1991,Olsson G et al,Eur Heart J 1992,MERIT-HF Study Group,Lancet 1999,Cumulative Per Cent,CHF in particular,Post-MI,Postinfarct-HF,Heart failure at admission,0,1,2,3,4,5,6,Months,0.0,0.1,0.2,0.3,No heart failure at admission,20.7,5.9,12.0,2.9,Heart failure during hospitalisation,25.3,%Mortality,Survival Post-MI:GRACE Registry,Steg et al Circulation 2004,Metoprolol CR in Post-MI HF,Janosi et al.,Am Heart J 2003,146(4):721-,CHF in particular,Doubel RAAS inhibitors,CHARM Programme,CHARM-Added,Baseline characteristics(1),Mean age(years)6464,Women(%)2121,NYHA class(%)II 2424III7373 IV 33,Mean LVEF(%)2828,ACE inhibitor(%)100100,Beta-blocker(%)5556,Spironolactone(%)1717,McMurray et al,Lancet 2003,CandesartanPlacebo,n=1276 n=1272,0,1,2,3,years,0,10,20,30,40,50,Placebo,Candesartan,%,Number at risk,Candesartan127611761063948457,Placebo127211361013906422,3.5,HR 0.85 (95%CI 0.75-0.96),p=0.011Adjusted HR 0.85,p=0.010,483(37.9%),538(42.3%),McMurray et al,Lancet 2003,CHARM-Added,Primary outcome,CV death or CHF hospitalisation,Effect of Candesartan:,On top of ACEI,BB and Spironolacton,Walking out from misperceptions!,No 3,Beta-blockers should be avoided in diabetic CHF patients,Beta-blockers should be avoided in COPD and CHF patients,Beta-blockers and ACE inhibitors should be avoided in elderly CHF patients,Low dose of beta blocker/ACEI is not meningful,False,False,False,False,False,All beta blockers or ARB have class effects,False,To be creative!,No 4,Hypotension,Bradycardy,Renal dysfunction,Hyperkalaemia,Low compliance,For example,Not easy,but not impossible!,Too much diuretics?,Hypotension,Other vasodilators?,Symptomatic?,Time to re-consider!,Negative chronotropic drug(digitalis,CCB with low vascular selectivity)?,Bradycardy?,Symptomatic?,Time to re-consider !,Daytime?Evening?,At rest?Exercise?,Pacemaker?,What shall we do when guideline does,NOT,exist?,No guideline in most
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