左室射血分数正常心衰的诊治课件

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,内容概要,左室射血分数正常的心衰定义,流行病学,病理生理机制,诊断方法,治疗与预后,总结,内容概要,左室射血分数正常的心衰定义,流行病学,病理生理机制,诊断方法,治疗与预后,总结,左室射血分数正常的心衰定义,舒张功能不全性心衰,(DHF),正常收缩功能性心衰,(HF-PSF),正常射血分数心衰,(HF-NEF),左室射血分数正常的心衰（,HFNEF,）：,是指心脏射血分数,(EF),正常或接近正常,(0.50 or 0.45),但有临床症状和,/,或体征表现的心力衰竭。,内容概要,左室射血分数正常的心衰定义,流行病学,病理生理机制,诊断方法,治疗与预后,总结,66-103,75-86,70-84,75,50,40,25,55-95,78,76,75,60,68,65,年龄段,平均年龄,美国,(CHS),芬兰,(Helsinki),英国,(Poole),丹麦,.(,Copen,.),西班牙,(Asturias),葡萄牙,(EPICA),荷兰,(,Rotter,.),瑞典,(Vasteras),左心室收缩功能降低的比例,HFNEF,的比例,55,51,68,46,71,59,39,71,Petrie M,McMurray J.,Lancet,.2001;358:423-434.,Hogg K,et al,.,J Am,Coll,Card,.2004;43:317-327.,CHF,患病率,(%),0,1,2,3,4,5,6,7,8,9,10,流行病学,Owan,TE,et al,.,N Engl J Med,.2006;355:251-259.,心衰人群,心衰住院人群,流行病学：,HFNEF,发生率有增高趋势,流行病学,HFNEF,发病率逐渐升高，约占所有心 衰患者的,50,左右,患者多为老年、女性和肥胖者,生活质量差、合并症多、再入院率高,死亡率与收缩性心衰的死亡率相同,内容概要,左室射血分数正常的心衰定义,流行病学,病理生理机制,诊断方法,治疗与预后,总结,病理生理机制,心室主动松弛能力（,relaxation,）：影响因素有,Ca2+-ATP,酶表达减少或活性降低，肌浆网磷酸受纳蛋白活性增高，心肌缺血、低氧血症导致的能量代谢障碍等；,心室壁顺应性降低（,compliance,）：心肌纤维化、细胞支架蛋白的改变、以及心肌局部病变和某些全身性疾病。,年龄老化：年龄老化降低心脏和大血管弹性，结果导致收缩压升高和心肌僵硬度增加。,发病机制,目前研究表明的其他重要机制：,二尖瓣环缩短速度减慢,左心室变形,心室血管偶联,变时性机能不全,左心房扩大,容量负荷过度,肺动脉高压样,正常,收缩性心衰,HFNEF,Aurigemma,Zile,Gaasch,Circulation 2005,内容概要,左室射血分数正常的心衰定义,流行病学,病理生理机制,诊断方法,治疗与预后,总结,HFNEF,的诊断（,2005,年,ACC/AHA),有心衰的典型症状和体征,UCG,显示,LVEF,正常，且无心瓣膜异常,排除其它所有类似表现的患者（限制性心肌病、心包缩窄、严重高血压、心肌缺血、高输出量心衰、肺动脉高压、心房粘液瘤等）,HFNEF,的诊断（,2007,年,ESC),有慢性心衰的症状或体征。,正常或轻微异常的左室射血功能。,有左室舒张功能不全即左室充盈压增高的证据。,诊 断,在,2007,年,ESC,的指南中，第一次将组织多普勒（,TDI,）及利钠肽的指标纳入诊断标准，如：,左室舒张末容积指数（,LVEDVI,）、左室舒张末压（,LVEDP,）、,早期经二尖瓣血流与早期二尖瓣环运动速度（,E/E,）、,NT-proBNP,等。,正常或轻微异常的左室射血功能,LVEF50%,LVEDVI15,或,E/E 8+NT-,proBNP,220pg/ml,3,LVEDP16mmHg,PCWP12mmHg,HF,的症状或体征,LVEF 50%,且 左心室舒张末期容积指数,(,LVED VI,),12,mmHg,或,左心室舒张末压,16,mmHg,组织多普勒,NT,proBNP,220,pg,/ml,BNP 200,pg,/ml,E/E 15,15 E/E 8,超声血流多普勒,:,.E/A,DT,.,肺静脉血流,.,左房扩大,.,左心室肥厚,.,房颤,NT,proBNP,220,pg,/ml,or,BNP 200,pg,/ml,HFNEF,组织,多普勒,E/E 8,2007ESC,诊断流程,内容概要,左室射血分数正常的心衰定义,流行病学,病理生理机制,诊断方法,治疗与预后,总结,治疗与预后,HFNEF,治疗缺乏有力的循证依据，治疗尚无明确方案，相关药物治疗研究均未显示患者有更多生存获益。,治疗目标：,减轻充血、控制高血压、预防和治疗心肌缺血、控制心动过速、维持心房收缩功能、组织心肌纤维化、促进左室肥厚逆转以及改善左室松弛功能。,生活质量差、合并症多、再入院率高，,死亡率与收缩性心衰的死亡率相同。,PEP-CHF:,培哚普利治疗老年人心力衰竭,入选标准,:,年龄,70,岁,最近,6,个月内因心衰住院,临床诊断,HF,利尿剂治疗,舒张功能不全,的证据,随机,:,培哚普利,2mg,安慰剂,n=426,n=424,平均随访,2.2,年,主要研究终点,:,全因死亡或心力衰竭住院,Cleland JG.,Eur,Heart J,.2006;27:2338-2345.,HF hospitalization,Cleland,et al,.,Eur,Heart J,.2006;27:2338-2345.,Death and,HF hospitalization,3,70,69,Placebo,3,PEP-CHF:Effect of perindopril in HF-PEF patients,Pt.at risk,Perindopril,Placebo,0,1,2,424,426,374,356,184,186,Perindopril,1 yr=,HR 0.69,95%,CI 0.47-1.01,P=0.055,Overall:,HR 0.92,95%CI 0.70-1.21,P=0.545,Time(y),Proportion having an event(%),40,30,20,10,0,0,1,2,Perindopril,Time(y),424,426,374,356,184,186,70,69,0,1,2,3,Perindopril,Placebo,1 yr=,HR 0.63,95%,CI 0.41-0.97,P=0.033,Overall:,HR 0.859,95%CI 0.614-1.202,P=0.375,Time(y),40,30,20,10,0,Proportion having an event(%),Time(y),CHARM-Preserved,目的,验证,ARB,坎地沙坦能否使,左心室收缩功能正常的,慢性心力衰竭,患者受益,设计,多国多中心、随机、双盲、,安慰剂,对照试验,患者,年龄,18,岁的症状性心力衰竭患者,3023,例,(NYHA,分级,II,IV),左心室射血分数,40%,随访和主要终点,主要终点,:,心血管死亡,或因心力衰竭住院,.,平均随访,36.6,月,治疗,安慰剂,或,坎地沙坦,剂量逐渐增加到,32 mg,每天一次,Yusuf S,et al,.,Lancet,2003;362:777-781.,CHARM,研究,Number at Risk,Candesartan,Placebo,单独使用,ARB,组,1013,1015,831,798,434,427,122,126,929,887,1013,1015,831,798,434,427,122,126,929,887,50,40,0,0,2,3,3.5,Time(Years),30,20,10,1,50,40,0,0,2,3,3.5,Time(Years),30,20,10,1,Placebo,Candesartan,Proportion with CV Death or,or Hospitalization for CHF,23%RR,p=0.0004,ACEI+ARB,组,1276,1272,1063,1013,948,906,457,422,1176,1136,1276,1272,1063,1013,948,906,457,422,1176,1136,50,40,0,Time(Years),30,20,10,2,3,3.5,1,0,2,3,3.5,1,Placebo,Candesartan,Proportion with CV Death or,or Hospitalization for CHF,15%RR,p=0.01,左室舒张,功能不全组,1514,1509,1377,1359,833,824,182,195,1458,1441,1514,1509,1377,1359,833,824,182,195,1458,1441,0,2,3,3.5,Time(Years),1,0,2,3,3.5,Time(Years),1,Placebo,Candesartan,Proportion with CV Death or,or Hospitalization for CHF,11%RR,p=0.12,50,40,0,30,20,10,50,40,0,30,20,10,CHARM-Preserved Primary outcome,:,CV,death,or CHF,hospitalisation,0,1,2,3,years,3.5,0,10,20,30,Placebo,Candesartan,5,15,25,HR 0.89(95%CI 0.77-1.03),p=0.118Adjusted HR 0.86,p=0.051,%,366(24.3%),333(22.0%),Yusuf S,et al,.,Lancet.,2003;362:777781.,Number at risk,Candesartan 1514,1458,1377,833 182,Placebo,1509,1441,1359,824,195,CV death,CHF hosp.,333 366,-CV death170170,-CHF hosp.241276,CV death,HF hosp,365399 MI,CV death,HF hosp,388429 MI,stroke,CV death,HF hosp,460497,MI,stroke,revasc,candesartan better,Hazard ratio,placebo better,0.8,1,.0,1.2,p-value,0.918,0.072,0.118,0.126,0.078,0.123,Covariate,adjustedp-value,0.635,0.047,0.051,0.051,0.037,0.13,Candesartan,Placebo,0.89,0.99,0.85,0.90,0.88,0.91,CHARM-Preserved Primary and secondary outcomes,Yusuf S,et al,.,Lancet,2003;362:777-781.,2007,年中国指南,控制血压,130/80mmHg,；,控制房颤心室率（,I,、,C,）、转复并维持窦率（,IIb,、,C,）；,利尿剂（,I,、,C,）；,血运重建治疗（,IIa,、,C,）；,逆转左室肥厚，改善舒张功能：,ACEI,、,ARB,、,受体阻滞剂等（,IIb,、,C,）,;,无房颤者不推荐地高辛应用（,IIb,、,C,）；,如同时有收缩性心衰，治疗以此为主。,2009,年,ACC/AHA,心衰指南,I,类指征,（,1,）依据高血压指南控制,HFNEF,患者