舒張性心力衰竭

1、Clinical Aspects of Diastolic Heart Failure,Shin-ichi Momomura, MDCardiovascular CenterToranomon HospitalTokyo, Japan,Incidence of Heart Failure Framingham Heart Study,,J Am Coll Cardiol 1993;22:6A–13A,Male,Female,Di

2、stribution of Left Ventricular Ejection Fraction: EuroHeart Failure Survey,European Heart Journal (2003) 24, 442–463,What is Diastolic Heart Failure?,Diastolic (Heart) FailureHeart failure due to diastolic dysfunction

3、Heart Failure with Preserved or Normal　Systolic FunctionCf) Systolic Heart Failure,≒,,Causes of Diastolic Dysfunction,Left ventricular hypertrophy (common)Aortic stenosisChronic hypertensionHypertrophic cardiomyopat

4、hy (with/wothout outflow tract obstruction)Acute episodic myocardial ischemica (common)Pericardial disease (rare)TamponadeConstrictionConstrictive-effusive disease due to prior radiation therapyRestrictive cardiomy

5、opathy (rare)Amyloid diseaseIdiopathic restrictive cardiomyopathy,Mechanism of DHF,,,,,,,,,LV diastolicdysfunction,↓CO,Neurohormnal activity,Exersional dyspnea,↓stroke volume,,Sodium/water retension,↑LV filling pressur

6、e,edema,,Pulmonary edema,Pulmonary congestionc,Acute elevation of BP,Epidemiology of DHF,Prevalence of DHF,Distribution of the severity of left ventricular systolicdysfunction by qualitative assessment,,Women,Men,Europe

7、an Heart Journal (2003) 24, 442–463,Prognosis of DHF and SHF (1),EF＜50%EF≧50%,7859,5844,5135,4432,3629,1615,,,,,,,,,,,,,,1.0,0.8,0.6,0.4,0.0,0,1,2,3,4,5,6,,,,,0.2,ExpectedEF＜50%EF≧50%,,,,Survival,Years,Senni M.

8、et al.：Circulation,98,2282,1998.,P=0.279,Prognosis of DHF and SHF (2),,Smith GL. JACC 2003;41:1510-8,Characteristics: Demographic,Smith GL. JACC 2003;41:1510-8,Characteristics: Cardiac History,Smith GL. JACC 2003;41:1510

9、-8,Characteristics: Cardiac History,Smith GL. JACC 2003;41:1510-8,Characteristics: Non-cardiac History,Smith GL. JACC 2003;41:1510-8,DHF in Japan,Tsutsui H et al. Am J Cardiol 2001;88:230-33,* p<0.05, ? p<0.01 vs.

10、preserved systolic function values,DHF in Japan,Tsutsui H et al. Am J Cardiol 2001;88:230-33,? p<0.01 vs. preserved systolic function values,DHF in Japan,Tsutsui H et al. Am J Cardiol 2001;88:230-33,p<0.05, ? p<

11、0.01 vs. preserved systolic function values; ? p<0.05 vs. intermediate systolic function values,DHF in Japan：Mortality and Readmission,Tsutsui H et al. Am J Cardiol 2001;88:230-33,Chronic Heart Failure Analysis Regis

12、tryin Tohoku District (CHART),Circ J 2003; 67: 431 –436,Diagnosis of DHF,Sign and symptoms of heart failureNon-cardiac disease are excludedNormal or preserved LV contractionDocumented diastolic dysfunction Elevated

13、plasma BNP,Definite DHF,Probable DHF,Possible DHF,Circulation. 2000;101:2118-2121,Diagnostic Criteria of DHF,Evaluation of LV diastolic function,Indexes of isovolumic relaxationPeak negative dP/dt, Time constant (Tau)I

14、RTIndexes of passive distensibilityStiffness constant of diastolic PV relationEnd-diastolic P/V ratioIndexes of LV fillingPeak filling rate, Deceleration time, E, E/A,Indexes of LV isovolumic relaxation,,,,,Peak neg

15、ative dP/dt,,P(t)=(P0-PB)×e-τ/t + PB,LV pressure (mmHg),LV dP/dt,time,Doppler Criteria for Classification of Diastolic Function Participants,Redfield: JAMA, Volume 289(2).January 8, 2003.194–202,BNP levels in patien

16、ts with normal function and with diastolic dyfunction,Lubien: Circulation 2002; 105:595-601,BNP values and three diastolic patterns,Lubien: Circulation 2002; 105:595-601,Treatment,Randomized Clinical Trials on the Treatm

17、ent of Chronic Heart Failure,SHFCONSENSUSSOLVDVHeFT IIELITRE IIVal-HeFTCHARM alternativeCHARM addedUS CarvedilolMERIT-HFCBIS IICOPERNICUSCOMETRALESDIG,DHFCHARM preserved?i-preserve (on-going)Hong Kong Di

18、astolic Heart Failure study (on-going)PEP-CHF (on-going),Each Study：Cardiovascular death or admission for heart failureOverall：All cause death,Primary Endpoint,,Symptomatic Heart FailureCandesartan or Placebo,n=2028E

19、F ≦ 40%ACE intolerant,n=2548EF ≦40%ACE tolerant,n=3025EF>40%,25th European Society of Cardiology Annual Congress (2003),CHARMAdded,CHARMPreserved,CHARMAlternative,CHARM: Design,CHARM：Characeteristics,Eur J Hear

20、t Failure 2001; 3 Suppl 1: S17-18,,P=0.118,Hazard Ratio 0.89,25,20,15,10,5,0,0,1,2,3,3.5,30,,,Placebo366 (24.3%),Candesafrtan333 (22.0%),Time (years),(%),CHARM preserved:,Primary Endpoint: Time to cardiovascular death

21、 or admission for heart failure,Lancet 2003; 362: 777–81,Proportion with cardiovascular death or hospital admission for CHF (%),,,700,600,300,200,0,p=0.014,,,(%),25,20,15,10,5,0,Placebo,Candesartan,p<0.017,500,100,400

22、,Placebo,Candesartan,CHARM preserved: Admission for HF,Total number ofadmissions for CHF,Number of patients who were admitted tohospital for CHF,from Lancet 2003; 362: 777–81,ACC/AHA Guidelines4.3.2. Patients With HF

23、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

24、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

25、LVEF. (Level of Evidence: C),Circulation. 2005;112:1825-1852,ACC/AHA Guidelines4.3.2. Patients With HF and Normal LVEF (cont.),Class IIaCoronary revascularization is reasonable in patients with HF and normal LVEF and c

26、oronary 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 IIb1. Restoration and maintenance of sin

27、us 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 pati

28、ents 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