Download قصور القلب - تدبير ومعالجة

‫قصور القلب‬
‫تدبير و معالجة‬
‫الدكتور زياد نوفل‬
‫اختصاصي أمراض قلب و أوعية‬
‫مشفى دمشق‬
Management of Chronic HF
•
•
•
•
•
•
Establish diagnosis (BNP, echo)
Determine etiology
Define syndrome (e.g. systolic vs. diastolic)
Correct precipitating factors (NSAIDS, COX2, etc.)
Evaluate and correct ischemia
Initiate chronic therapy
•
•
•
•
Nonpharmacologic (e.g. exercise, tx. of sleep apnea, etc)
Pharmacologic (ACE - I, b - Blockers, ARB, diuretics, digoxin, etc.)
Electrical
Surgical
• Assess response to therapy
‫عالج قصور القلب‬
‫األهداف‪:‬‬
‫‪ (1‬تحسين البقيا‬
‫‪ (2‬تحسين نوعية وطبيعة الحياة‪.‬‬
‫‪ (3‬تخفيف احتمالية تطور قصور القلب‬
‫‪ (4‬كسر التغيرات الهرمونية العصبية مثل األنجيوستين ‪II‬‬
‫الذي تؤدي الى احتباس السوائل وارتفاغ الضغط وبالتالي‬
‫احداث ضخامة في جدار البطين األيسر وزيادة قصور‬
‫القلب‪.‬‬
‫‪ (5‬تخفيف درجات قصور القلب باصالح اضطراب النظم مثال‬
Heart Failure Clinical Stages
NORMAL
Asymptomatic
LV Dysfunction
No symptoms
Normal exercise
Normal LV fxn
No symptoms
Normal exercise
Abnormal LV fxn
Compensated
No symptoms
Exercise
Abnormal LV fxn
Decompensated
Symptoms
Exercise
Abnormal LV fxn
Refractory
Symptoms not
controlled
with treatment
New Classification of Heart Failure
Stage
Patient Description
A
High risk for developing heart Hypertension •
CAD •
failure (HF)
B
Asymptomatic HF
C
Symptomatic HF
D
Refractory
end-stage HF
Hunt SA et al. J Am Coll Cardiol. 2005; 46: e1-e86.
Diabetes mellitus •
Family history of cardiomyopathy •
Previous MI •
LV systolic dysfunction •
Asymptomatic valvular disease •
Known structural heart disease •
Shortness of breath and fatigue •
Reduced exercise tolerance •
Marked symptoms at rest despite maximal •
medical therapy (eg, those who are recurrently
hospitalized or cannot be safely discharged from
the hospital without specialized interventions)
‫‪A‬‬
‫‪STAGE‬‬
‫‪‬تشمل المرضى الذين لديهم عوامل خطورة لتطور‬
‫قصور القلب (المسنين‪,‬السكري‪,‬ارتفاع الضغط‬
‫الشرياني‪,‬ارتفاع الكوليسترول‪,‬التدخين‪,)......‬دون‬
‫اضطراب في بنية العضلة القلبية‪.‬‬
‫‪‬جميع هؤالء المرضى يجب أن يخضعوا للعالج لمنع‬
‫التطور للمرحلة التالية‬
‫‪STAGE B‬‬
‫‪‬هم المرضى الذين تطور لديهم خلل في بنية‬
‫العضلة القلبة لكنهم ما زالوا ال يعانون من أي‬
‫أعراض أو عالمات لقصور القلب‪.‬‬
‫‪STAGE C‬‬
‫‪‬هم المرضى الذين تطور لديهم أعراض‬
‫قصور القلب باالضافة لوجود الخلل في بنية‬
‫العضلة القلبية‪.‬‬
‫‪STAGE D‬‬
‫‪‬هي مرحلة متطورة من قصور القلب‬
‫‪%50‬من هؤالء المرضى يموتون‬
‫خالل ‪6‬أشهر وهم يقابلون المرحلة ‪IV‬‬
‫من تصنيف ‪.NYHA‬‬
Treatment of Stages A to D
Nonpharmacological
Interventions
Stage C: Nonpharmacological
Interventions
I IIa IIb III
Patients with HF should receive specific education to
facilitate HF self-care.
I IIa IIb III
Exercise training (or regular physical activity) is
recommended as safe and effective for patients with HF who
are able to participate to improve functional status.
I IIa IIb III
Sodium restriction is reasonable for patients with
symptomatic HF to reduce congestive symptoms.
Stage C: Nonpharmacological
Interventions (cont.)
I IIa IIb III
I IIa IIb III
Continuous positive airway pressure (CPAP) can be beneficial
to increase LVEF and improve functional status in patients
with HF and sleep apnea.
Cardiac rehabilitation can be useful in clinically stable
patients with HF to improve functional capacity, exercise
duration, HRQOL, and mortality.
Treatment of Stages A to D
Pharmacological Treatment for
Stage C HFrEF
Stage B (cont.)
I IIa IIb III
I IIa IIb III
In patients with structural cardiac abnormalities, including LV
hypertrophy, in the absence of a history of MI or ACS, blood
pressure should be controlled in accordance with clinical practice
guidelines for hypertension to prevent symptomatic HF.
ACE inhibitors should be used in all patients with a reduced EF to
prevent symptomatic HF, even if they do not have a history of MI.
I IIa IIb III
Beta blockers should be used in all patients with a reduced EF to
prevent symptomatic HF, even if they do not have a history of MI.
Renin-angiotensin-aldosterone
axis in heart failure
Pharmacological Treatment for
Stage C HFrEF (cont.)
I IIa IIb III
Diuretics are recommended in patients with HFrEF who have
evidence of fluid retention, unless contraindicated, to improve
symptoms.
I IIa IIb III
ACE inhibitors are recommended in patients with HFrEF and
current or prior symptoms, unless contraindicated, to reduce
morbidity and mortality.
I IIa IIb III
ARBs are recommended in patients with HFrEF with current or
prior symptoms who are ACE inhibitor-intolerant, unless
contraindicated, to reduce morbidity and mortality.
Pharmacological Treatment for
Stage C HFrEF (cont.)
I IIa IIb III
I IIa IIb III
ARBs are reasonable to reduce morbidity and mortality as
alternatives to ACE inhibitors as first-line therapy for patients
with HFrEF, especially for patients already taking ARBs for
other indications, unless contraindicated.
Addition of an ARB may be considered in persistently
symptomatic patients with HFrEF who are already being
treated with an ACE inhibitor and a beta blocker in whom an
aldosterone antagonist is not indicated or tolerated.
Pharmacological Treatment for
Stage C HFrEF (cont.)
I IIa IIb III
Routine combined use of an ACE inhibitor, ARB, and aldosterone
antagonist is potentially harmful for patients with HFrEF.
Harm
I IIa IIb III
Use of 1 of the 3 beta blockers proven to reduce mortality (i.e.,
bisoprolol, carvedilol, and sustained-release metoprolol
succinate) is recommended for all patients with current or prior
symptoms of HFrEF, unless contraindicated, to reduce morbidity
and mortality.
Pharmacological Therapy for Management
of Stage C HFrEF
Recommendations
Diuretics
Diuretics are recommended in patients with HFrEF with fluid
retention
ACE Inhibitors
ACE inhibitors are recommended for all patients with HFrEF
ARBs
ARBs are recommended in patients with HFrEF who are ACE
inhibitor intolerant
ARBs are reasonable as alternatives to ACE inhibitor as first
line therapy in HFrEF
The addition of an ARB may be considered in persistently
symptomatic patients with HFrEF on GDMT
Routine combined use of an ACE inhibitor, ARB, and
aldosterone antagonist is potentially harmful
COR
LOE
I
C
I
A
I
A
IIa
A
IIb
A
III: Harm
C
Drugs Commonly Used for HFrEF
(Stage C HF)
Drug
ACE Inhibitors
Captopril
Enalapril
Fosinopril
Lisinopril
Perindopril
Quinapril
Ramipril
Trandolapril
ARBs
Candesartan
Losartan
Valsartan
Aldosterone Antagonists
Spironolactone
Eplerenone
Initial Daily Dose(s)
Maximum Doses(s)
Mean Doses Achieved in
Clinical Trials
6.25 mg 3 times
2.5 mg twice
5 to 10 mg once
2.5 to 5 mg once
2 mg once
5 mg twice
1.25 to 2.5 mg once
1 mg once
50 mg 3 times
10 to 20 mg twice
40 mg once
20 to 40 mg once
8 to 16 mg once
20 mg twice
10 mg once
4 mg once
122.7 mg/d (421)
16.6 mg/d (412)
--------32.5 to 35.0 mg/d (444)
---------------------------------
4 to 8 mg once
25 to 50 mg once
20 to 40 mg twice
32 mg once
50 to 150 mg once
160 mg twice
24 mg/d (419)
129 mg/d (420)
254 mg/d (109)
12.5 to 25 mg once
25 mg once
25 mg once or twice
50 mg once
26 mg/d (424)
42.6 mg/d (445)
Pharmacological Treatment for
Stage C HFrEF (cont.)
I IIa IIb III
Aldosterone receptor antagonists [or mineralocorticoid receptor
antagonists (MRA)] are recommended in patients with NYHA class II-IV
and who have LVEF of 35% or less, unless contraindicated, to reduce
morbidity and mortality. Patients with NYHA class II should have a
history of prior cardiovascular hospitalization or elevated plasma
natriuretic peptide levels to be considered for aldosterone receptor
antagonists. Creatinine should be 2.5 mg/dL or less in men or 2.0
mg/dL or less in women (or estimated glomerular filtration rate >30
mL/min/1.73m2) and potassium should be less than 5.0 mEq/L.
Careful monitoring of potassium, renal function, and diuretic dosing
should be performed at initiation and closely followed thereafter to
minimize risk of hyperkalemia and renal insufficiency.
Pharmacological Treatment for
Stage C HFrEF (cont.)
I IIa IIb III
I IIa IIb III
Harm
Aldosterone receptor antagonists are recommended to reduce
morbidity and mortality following an acute MI in patients who have
LVEF of 40% or less who develop symptoms of HF or who have a
history of diabetes mellitus, unless contraindicated.
Inappropriate use of aldosterone receptor antagonists is potentially
harmful because of life-threatening hyperkalemia or renal
insufficiency when serum creatinine greater than 2.5 mg/dL in men
or greater than 2.0 mg/dL in women (or estimated glomerular
filtration rate <30 mL/min/1.73m2), and/or potassium above 5.0
mEq/L.
Pharmacological Treatment for
Stage C HFrEF (cont.)
I IIa IIb III
I IIa IIb III
Digoxin can be beneficial in patients with HFrEF, unless
contraindicated, to decrease hospitalizations for HF.
Patients with chronic HF with permanent/persistent/
paroxysmal AF and an additional risk factor for cardioembolic
stroke (history of hypertension, diabetes mellitus, previous
stroke or transient ischemic attack, or ≥75 years of age) should
receive chronic anticoagulant therapy (in the absence of
contraindications to anticoagulation).
Pharmacological Treatment for
Stage C HFrEF (cont.)
I IIa IIb III
The selection of an anticoagulant agent (warfarin, dabigatran,
apixaban, or rivaroxaban) for permanent/persistent/paroxysmal
AF should be individualized on the basis of risk factors, cost,
tolerability, patient preference, potential for drug interactions,
and other clinical characteristics, including time in the
international normalized rate therapeutic ration if the patient
has been taking warfarin.
I IIa IIb III
Chronic anticoagulation is reasonable for patients with chronic
HF who have permanent/persistent/paroxysmal AF but are
without an additional risk factor for cardioembolic stroke (in
the absence of contraindications to anticoagulation).
Pharmacological Treatment for
Stage C HFrEF (cont.)
I IIa IIb III
No Benefit
I IIa IIb III
No Benefit
I IIa IIb III
Anticoagulation is not recommended in patients with chronic
HFrEF without AF, a prior thromboembolic event, or a
cardioembolic source.
Statins are not beneficial as adjunctive therapy when
prescribed solely for the diagnosis of HF in the absence of other
indications for their use.
Omega-3 polyunsaturated fatty acid (PUFA) supplementation is
reasonable to use as adjunctive therapy in patients with NYHA
class II-IV symptoms and HFrEF or HFpEF, unless
contraindicated, to reduce mortality and cardiovascular
hospitalizations.
Pharmacological Treatment for
Stage C HFrEF (cont.)
I IIa IIb III
Harm
Long-term use of infused positive inotropic drugs is potentially
harmful for patients with HFrEF, except as palliation for patients
with end-stage disease who cannot be stabilized with standard
medical treatment (see recommendations for stage D).
I IIa IIb III
Calcium channel blocking drugs are not recommended as
routine treatment for patients with HFrEF.
No Benefit
Pharmacological Treatment for
Stage C HFrEF (cont.)
I IIa IIb III
I IIa IIb III
The combination of hydralazine and isosorbide dinitrate is
recommended to reduce morbidity and mortality for patients selfdescribed as African Americans with NYHA class III–IV HFrEF
receiving optimal therapy with ACE inhibitors and beta blockers,
unless contraindicated.
A combination of hydralazine and isosorbide dinitrate can be useful
to reduce morbidity or mortality in patients with current or prior
symptomatic HFrEF who cannot be given an ACE inhibitor or ARB
because of drug intolerance, hypotension, or renal insufficiency,
unless contraindicated.
Pharmacological Treatment for
Stage C HFrEF (cont.)
I IIa IIb III
No Benefit
I IIa IIb III
No Benefit
I IIa IIb III
Harm
Nutritional supplements as treatment for HF are not
recommended in patients with current or prior symptoms of
HFrEF.
Hormonal therapies other than to correct deficiencies are not
recommended for patients with current or prior symptoms of
HFrEF.
Drugs known to adversely affect the clinical status of patients
with current or prior symptoms of HFrEF are potentially harmful
and should be avoided or withdrawn whenever possible (e.g.,
most antiarrhythmic drugs, most calcium channel blocking
drugs (except amlodipine), NSAIDs, or TZDs).
Pharmacological Therapy for Management
of Stage C HFrEF (cont.)
Recommendations
Beta Blockers
Use of 1 of the 3 beta blockers proven to reduce mortality is
recommended for all stable patients
Aldosterone Antagonists
Aldosterone receptor antagonists are recommended in
patients with NYHA class II-IV HF who have LVEF ≤35%
Aldosterone receptor antagonists are recommended in
patients following an acute MI who have LVEF ≤40% with
symptoms of HF or DM
Inappropriate use of aldosterone receptor antagonists may be
harmful
Hydralazine and Isosorbide Dinitrate
COR
LOE
I
A
I
A
I
B
III:
Harm
B
The combination of hydralazine and isosorbide dinitrate is
recommended for African-Americans, with NYHA class III– I
IV HFrEF on GDMT
A combination of hydralazine and isosorbide dinitrate can be
useful in patients with HFrEF who cannot be given ACE
IIa
inhibitors or ARBs
A
B
Pharmacologic Therapy for Management
of Stage C HFrEF (cont.)
Recommendations
Digoxin
Digoxin can be beneficial in patients with HFrEF
Anticoagulation
Patients with chronic HF with permanent/persistent/paroxysmal AF and an
additional risk factor for cardioembolic stroke should receive chronic
anticoagulant therapy*
The selection of an anticoagulant agent should be individualized
Chronic anticoagulation is reasonable for patients with chronic HF who have
permanent/persistent/paroxysmal AF but without an additional risk factor for
cardioembolic stroke*
Anticoagulation is not recommended in patients with chronic HFrEF without
AF, prior thromboembolic event, or a cardioembolic source
Statins
Statins are not beneficial as adjunctive therapy when prescribed solely for HF
Omega-3 Fatty Acids
Omega-3 PUFA supplementation is reasonable to use as adjunctive therapy in
HFrEF or HFpEF patients
COR
LOE
IIa
B
I
A
I
C
IIa
B
III: No
Benefit
B
III: No
Benefit
A
IIa
B
Pharmacological Therapy for Management
of Stage C HFrEF (cont.)
Recommendations
Other Drugs
Nutritional supplements as treatment for HF are not recommended
in HFrEF
Hormonal therapies other than to replete deficiencies are not
recommended in HFrEF
Drugs known to adversely affect the clinical status of patients with
HFrEF are potentially harmful and should be avoided or
withdrawn
Long-term use of an infusion of a positive inotropic drug is not
recommended and may be harmful except as palliation
Calcium Channel Blockers
Calcium channel blocking drugs are not recommended as routine
in HFrEF
COR
III: No
Benefit
III: No
Benefit
LOE
B
C
III: Harm
B
III: Harm
C
III: No
Benefit
A
Drugs Commonly Used for HFrEF
(Stage C HF) (cont.)
Drug
Initial Daily Dose(s)
Beta Blockers
Bisoprolol
1.25 mg once
Carvedilol
3.125 mg twice
Carvedilol CR
10 mg once
Metoprolol succinate
extended release
12.5 to 25 mg once
(metoprolol CR/XL)
Hydralazine & Isosorbide Dinitrate
37.5 mg hydralazine/
Fixed dose combination
20 mg isosorbide
(423)
dinitrate 3 times daily
Hydralazine and
Hydralazine: 25 to 50
isosorbide dinitrate (448) mg, 3 or 4 times daily
and isorsorbide
dinitrate:
20 to 30 mg
3 or 4 times daily
Maximum Doses(s)
Mean Doses Achieved in
Clinical Trials
10 mg once
50 mg twice
80 mg once
8.6 mg/d (118)
37 mg/d (446)
---------
200 mg once
159 mg/d (447)
75 mg hydralazine/
~175 mg hydralazine/90 mg
40 mg isosorbide
isosorbide dinitrate daily
dinitrate 3 times daily
Hydralazine: 300 mg
daily in divided doses
and isosorbide dinitrate
--------120 mg daily in
divided doses
Medical Therapy for Stage C HFrEF:
Magnitude of Benefit Demonstrated in RCTs
GDMT
ACE inhibitor or
ARB
Beta blocker
Aldosterone
antagonist
RR Reduction
in Mortality
RR Reduction
in HF
(Standardized to 36 mo) Hospitalizations
NNT for Mortality
Reduction
17%
26
31%
34%
9
41%
30%
6
35%
Hydralazine/nitrate 43%
7
33%
Treatment of Stages A to D
Treatment for Stage C HFpEF
I IIa IIb III
Pharmacological Treatment for
Stage C HFpEF
Systolic and diastolic blood pressure should be controlled in
patients with HFpEF in accordance with published clinical
practice guidelines to prevent morbidity.
I IIa IIb III
Diuretics should be used for relief of symptoms due to volume
overload in patients with HFpEF.
I IIa IIb III
Coronary revascularization is reasonable in patients with CAD in
whom symptoms (angina) or demonstrable myocardial
ischemia is judged to be having an adverse effect on
symptomatic HFpEF despite GDMT.
Pharmacological Treatment for
Stage C HFpEF (cont.)
I IIa IIb III
I IIa IIb III
Management of AF according to published clinical practice
guidelines in patients with HFpEF is reasonable to improve
symptomatic HF.
The use of beta-blocking agents, ACE inhibitors, and ARBs in
patients with hypertension is reasonable to control blood
pressure in patients with HFpEF.
Pharmacological Treatment for
Stage C HFpEF (cont.)
I IIa IIb III
I IIa IIb III
No Benefit
The use of ARBs might be considered to decrease
hospitalizations for patients with HFpEF.
Routine use of nutritional supplements is not recommended for
patients with HFpEF.
Treatment of HFpEF
Recommendations
COR
Systolic and diastolic blood pressure should be controlled
I
according to published clinical practice guidelines
Diuretics should be used for relief of symptoms due to
volume overload
Coronary revascularization for patients with CAD in
whom angina or demonstrable myocardial ischemia is
present despite GDMT
Management of AF according to published clinical
practice guidelines for HFpEF to improve symptomatic
HF
Use of beta-blocking agents, ACE inhibitors, and ARBs
for hypertension in HFpEF
I
IIa
LOE
B
C
C
IIa
C
IIa
C
ARBs might be considered to decrease hospitalizations in
IIb
HFpEF
Nutritional supplementation is not recommended in
III: No
HFpEF
Benefit
B
C
Treatment of Stages A to D
Device Treatment for Stage C
HFrEF
Device Therapy for Stage C HFrEF
I IIa IIb III
ICD therapy is recommended for primary prevention of SCD to reduce
total mortality in selected patients with nonischemic DCM or ischemic
heart disease at least 40 days post-MI with LVEF of 35% or less, and
NYHA class II or III symptoms on chronic GDMT, who have reasonable
expectation of meaningful survival for more than 1 year.
I IIa IIb III
NYHA Class III/IV
I IIa IIb III
NYHA Class II
CRT is indicated for patients who have LVEF of 35% or less, sinus
rhythm, left bundle-branch block (LBBB) with a QRS duration of 150 ms
or greater, and NYHA class II, III, or ambulatory IV symptoms on GDMT.
Device Therapy for Stage C HFrEF
(cont.)
I IIa IIb III
ICD therapy is recommended for primary prevention of SCD to
reduce total mortality in selected patients at least 40 days postMI with LVEF less than or equal to 30%, and NYHA class I
symptoms while receiving GDMT, who have reasonable
expectation of meaningful survival for more than 1 year.
I IIa IIb III
CRT can be useful for patients who have LVEF of 35% or less,
sinus rhythm, a non-LBBB pattern with a QRS duration of 150
ms or greater, and NYHA class III/ambulatory class IV symptoms
on GDMT.
Device Therapy for Stage C HFrEF
(cont.)
I IIa IIb III
CRT can be useful for patients who have LVEF of 35% or less,
sinus rhythm, LBBB with a QRS duration of 120 to 149 ms, and
NYHA class II, III, or ambulatory IV symptoms on GDMT.
I IIa IIb III
CRT can be useful in patients with AF and LVEF of 35% or less on
GDMT if a) the patient requires ventricular pacing or otherwise
meets CRT criteria and b) atrioventricular nodal ablation or
pharmacological rate control will allow near 100% ventricular
pacing with CRT.
Device Therapy for Stage C HFrEF
(cont.)
I IIa IIb III
CRT can be useful for patients on GDMT who have LVEF of 35%
or less, and are undergoing placement of a new or replacement
device placement with anticipated requirement for significant
(>40%) ventricular pacing.
I IIa IIb III
The usefulness of implantation of an ICD is of uncertain benefit
to prolong meaningful survival in patients with a high risk of
nonsudden death as predicted by frequent hospitalizations,
advanced frailty, or comorbidities such as systemic malignancy
or severe renal dysfunction.
Device Therapy for Stage C HFrEF
(cont.)
I IIa IIb III
I IIa IIb III
CRT may be considered for patients who have LVEF of 35% or
less , sinus rhythm, a non-LBBB pattern with a QRS duration of
150 ms or greater, and NYHA class II symptoms on GDMT.
CRT may be considered for patients who have LVEF of 30% or
less, ischemic etiology of HF, sinus rhythm, LBBB with a QRS
duration of 150 ms or greater, and NYHA class I symptoms on
GDMT.
‫إعادة التناغم بين انقباض البطينات‬
‫‪Cardiac Resynchronization‬‬
‫‪Therapy‬‬
‫‪with biventricular pacing‬‬
‫أثبتت الدراسات امكانية التحسن‬
‫السريري وانقاص االستشفاء‬
‫وتحسين معدّل الوفيات لدى‬
‫مرضى استرخاء القلب ‪ ,‬وهو‬
‫بالطبع يحتاج الى تقنية خاصة ‪,‬‬
‫ويطبق فقط عند وجود عرض‬
‫في مركب ‪. QRS‬‬
‫‪CRT‬‬
CRT: Who Should Get It?
• Patients with heart failure due to severe LV
systolic dysfunction (EF < 35%) with class III
and IV symptoms, in spite of adequate and
maximum medical therapy.
• QRS duration of 120 ms.
• Responders?
‫‪ACE-Is‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪(1‬‬
‫‪(2‬‬
‫‪(3‬‬
‫‪(4‬‬
‫‪(5‬‬
‫‪‬‬
‫‪(1‬‬
‫‪(2‬‬
‫‪(3‬‬
‫‪(4‬‬
‫موسعات وعائية متوازنة شريانية وريدية ( تخفض الحمل البعدي – الحمل القلبي )‪.‬‬
‫يفضل استخدامها بجرعات صغيرة خاصة عند استعمال المبيالت لتالفي هبوط الضغط الشرياني ‪,‬‬
‫و يمكن زيادة الجرعة تدريجيا ‪ .‬تزيد من البقيا وتطيل الحياة‪.‬‬
‫التأثيرات الجانبية‪:‬‬
‫انخفاض الضغط الدموي‬
‫ارتفاع البوتاسيوم‬
‫تدهور وظائف الكلية‬
‫سعال تحسسي بنسبة ‪ %20-5‬وهنا نستبدلها بحاصرات مستقبالت األنجيوستين‬
‫طفح واندفاعات جلدية‬
‫مضادات االستطباب‪:‬‬
‫الحمل‬
‫تضيق الشريان الكلوي ثنائي الجانب‬
‫قصور كلوي حيث أن الكرياتينين>‪3‬‬
‫ارتفاع البوتسيوم >‪5,5‬‬
ACE Inhibitors
Most pts. tolerate ACE - I.
ACE - I improve symptoms immediately (days).
Pts. should not be “too dry” (no orthostatic ↓ BP).
If ↓ BP, check for orthostatic changes. If none, ACE - I OK.
Low BP and CRF are not CI for ACE - I.
If BUN/ Cr are raising, adjust the diuretic dose.
Low BP, low Na, renal dysfunction: low dose, short acting
ACE - I, titrate to target dose or the highest dose tolerated.
• Low vs. high dose ACE - I: difference in outcomes.
•
•
•
•
•
•
•
Hunt SA et al. J Am Coll Cardiol. 2005; 46: e1-e86.
Angiotensin Receptor Blockers
• Combination ARB + ACE - I + Beta - Blockers is safe.
• No mortality benefit when ARB is added to ACE - I.
• ARB are useful in pts. who are ACE intolerant.
• ARB could be added to ACE - I for symptomatic
improvement.
• Triple RAAS blockade (ACE - I, ARB, aldosterone
blockers) should not be used (Hyper K).
Diuretics
Loop diuretics in pts. with CrCl < 30
Torsemide ↓ hospitalizations compared to furosemide
Have to be given bid to avoid rebound Na reabsorbtion
May use thiazides if CrCl > 30
Use combination (e.g. furosemide + thiazide), iv bolus
or iv drips
• Metolazone in refractory HF or in pts. with renal failure.
Should not be used daily.
• Add spironolactone if Cr < 2.5 and K < 5.
•
•
•
•
•
Hunt SA et al. J Am Coll Cardiol. 2005; 46: e1-e86.
‫‪-1‬مدرات البول ‪Diuretics‬‬
‫• عالج أساسي ويساعد في منع تطور ارتفاع التوتر الشرياني الى قصور‬
‫القلب‪.‬‬
‫• ‪ -1‬المدرات التيازيدية‪:‬‬
‫‪ ‬تستخدم هذه األدوية فمويا في قصور القلب الخفيف و متوسط الشدة ‪ ,‬تكون‬
‫فعالة في معالجة قصور القلب طالما كان الترشيح الكبيبي أكثر من ‪ % 50‬من‬
‫السوي ‪.‬‬
‫‪ ‬من هذه المدرات( الكلورتيازيد ‪ ,‬و الهيدروكلورتيازيد ‪ ,‬و الكلورتاليدون )‪.‬‬
‫‪ ‬أهم التأثيرات الجانبية لهذه المجموعة ‪:‬‬
‫‪ - (1‬نقص البوتاسيوم ‪ ,‬نقص مغنيزيوم الدم ‪.‬‬
‫‪ - (2‬ارتفاع حمض اليوريك ( حمض البول ) في الدم ‪.‬‬
‫‪ - (3‬تأثير رافع لسكر الدم مع اضطراب اختبار تحمل السكر ‪.‬‬
‫‪ - (4‬قد تحدث اندفاعات جلدية ‪ ,‬نقص الصفيحات و نقص المحببات ‪.‬‬
‫‪ - (5‬آالم معدية ‪ ,‬قياء إسهال ‪ ,‬آالم عضلية ‪ ,‬نقص الشهية ‪.‬‬
‫‪ -2‬مدرات العروة‬
‫‪ ‬تملك هذه األدوية نفس آلية التأثير ‪ ,‬رغم اختالف تركيبها الكيماوي ‪ .‬و‬
‫هي مبيالت قوية تثبط عودة امتصاص الصوديوم و البوتاسيوم و الكلور‬
‫في الجزء الصاعد الثخين لعروة هنلة و ذلك بإحصار الجهاز الناقل في‬
‫الغشاء الصفيحي ‪.‬‬
‫‪ ‬أهم التأثيرات الجانبية ‪:‬‬
‫‪ - (1‬نقص عابر أو دائم بالسمع ‪.‬‬
‫‪ - (2‬طفح جلدي و نقص بالمحببات عند استخدام حمض اإليتاكرنيك‬
‫‪. Ethacrynic Acid‬‬
‫‪ - (3‬نقص البوتاسيوم ‪.‬‬
‫‪ - (4‬اضطراب اختبار تحمل السكر ‪.‬‬
‫‪ - (5‬ارتفاع حمض اليوريك في الدم ‪.‬‬
‫السيطرة على احتباس السوائل الزائد‬
‫‪‬تهدف المعالجة إلى إنقاص مخزون الصوديوم الكلي بالجسم ‪ ,‬و‬
‫يمكن الوصول إلى توازن سلبي للصوديوم بإقالل المدخول‬
‫التغذوي من الصوديوم و زيادة الطرح البولي باستخدام المبيالت‬
‫‪.‬‬
‫‪‬في الحاالت الشديدة من قصور القلب يمكن التخلص من السوائل‬
‫بسوائل أخرى مثل البزل الجنبوي ‪ ,‬بزل الحبن ‪ ,‬و نادرا ما نلجأ‬
‫للديال الدموي أو الصفاقي ‪.‬‬
‫‪‬في قصور القلب الشديد يجب إنقاص الوارد من الصوديوم حتى‬
‫‪1‬غ‪ /‬اليوم مع حذف بعض األطعمة مثل ( الحليب ‪ ,‬الجبنة ‪,‬‬
‫الخبز ‪ ,‬الخضراوات المعلبة ‪ ,‬و بعض أنواع الخضراوات‬
‫الطازجة مثل السبانخ ) ‪.‬‬
‫‪ -3‬مضادات األلدسترون ‪Aldastrone‬‬
‫‪antagonists‬‬
‫‪‬السبيرنوالكتون ‪ 17 –Spirinolactone‬يشبه األلدوسترون من‬
‫ناحية التركيب و يؤثر على النصف القاصي من النبيب المعوج و‬
‫الجزء القشري لالنبوب الجامع بالتثبيط التنافسي مع األلدوسترون‬
‫‪ ,‬فيحصر التبادل بين الصوديوم من جهة ‪ ,‬و البوتاسيوم و‬
‫الهيدروجين من جهة أخرى ‪ ,‬فيزيد بذلك طرح الصوديوم و يقلل‬
‫طرح البوتاسيوم ‪.‬‬
‫‪‬يصبح السبيرونوالكتون أكثر فعالية عند مشاركته مع مبيالت‬
‫المجموعة األولى أو الثانية ‪ ,‬و عند إجراء هذه المشاركة فإن‬
‫التأثير الطارح للصوديوم لهاتين المجموعتين سوف لن يترافق‬
‫بتغير مستوى البوتاسيوم المصوري ‪.‬‬
‫‪‬أهم التأثيرات الجانبية ‪ :‬غثيان ‪ ,‬ألم شرسوفي ‪ ,‬تخليط ذهني ‪,‬‬
‫دوار ‪ ,‬تثدي و اندفاعات جلدية‬
‫‪-3‬حاصرات بيتا ‪B- BLOCKERS‬‬
‫‪ ‬تحسن األعراض وتطيل البقيا وتقلل من الوفيات ألنها تخفف من اضطرابات‬
‫النظم ونقص التروية وارتفاع التوتر الدموي الشرياني‪.‬‬
‫‪ ‬التأثيرات الجانبية‪:‬‬
‫‪ (1‬انخفاض الضغط‬
‫‪ (2‬بطء القلب أو حصار القلب‬
‫‪ (3‬تدهور األعراض نتيجة نقص القلوصي واحتباس السوائل عند بداية‬
‫استخدامها ثم يحدث تحسن بعد أسبو أو أسبوعين‪.‬‬
‫‪ ‬مضادات االستطباب‪:‬‬
‫‪ (1‬الربو وهو مضاد اتطباب مطلق‬
‫‪ (2‬حصار أذيني بطيني اال في حال تركيب ناظم خطا‬
‫‪ (3‬السكري وهو مضاد استطباب نسبي‬
‫‪ (4‬انخفاض الضغط أو بطء القلب‬
‫‪ ‬هناك أربعة أدوية تستخدم للعالج‪ :‬كارفيدولول‪,‬البيسوبرولول‪,‬الميتوبرولول‬
‫سكسينات‪,‬النيبفولول‪.‬‬
Beta - Blockers
• Only bisoprolol, carvedilol and metoprolol succinate.
• Start at low doses, increase every 2 weeks to target dose or the
highest tolerated dose.
• Intermediate vs. high dose: no difference in outcomes.
• Do not start in pts. dependent of inotropic support.
• Can start before hospital discharge in pts. not fluid overloaded.
• Do not stop BB in hospitalized pts. who are on chronic BB
therapy (may worsen HF).
• BB will take 3-6 months to improve symptoms.
• Low BP and severe HF are not CI for BB.
Hunt SA et al. J Am Coll Cardiol. 2005; 46: e1-e86.
Relative contraindications in patients
with HF
•
•
•
•
•
•
•
•
Relative contraindications in patients with HF include:
Heart rate <60 bpm
Symptomatic hypotension
Greater than minimal evidence of fluid retention
Signs of peripheral hypoperfusion
PR interval >0.24 sec
Second- or third-degree atrioventricular block
History of asthma or reactive airways
Peripheral artery disease with resting limb ischemia
Time Course of Changes in LV EF
Ejection Fraction
0.40
Standard Therapy
Metoprolol
p < 0.0001
0.35
p = 0.013 for metoprolol vs. standard
therapy
0.30
p < 0.05
0.25
0.20
Baseline
Day 1
1 Mo
3 Mo
Hall SA et al. J Am Coll Cardiol. 1995; 25: 1154-1160.
Baseline
Day 1
1 Mo
3 Mo
Dose-related increase in LVEF with
carvedilol in nonischemic cardiomyopathy
Beta - Blockers
Question
• Drugs proved to reduce mortality in chronic
congestive heart failure include all of the
following EXCEPT
(A) Captopril
(B) Carvedilol
(C) Digoxin
(D) Enalapril
(E) Spironolactone
‫‪-4‬الديجوكسين‬
‫‪ ‬يحسن األعراض لكنه ال يطيل البقيا‪.‬‬
‫‪ ‬يستطب في حال عدم االستجابة للمدرات ومثبطات ‪ACE-I‬‬
‫‪ ‬وحاصرات بيتا أو حدوث رجفان أذيني عالي االستجابة‪.‬‬
‫‪ ‬مضادات االستطباب‪:‬‬
‫‪ (1‬ظهور سمية لديجوكسين‬
‫‪ (2‬بطء قلب‬
‫‪ (3‬هبوط بوتاسيوم شديد‬
‫‪ (4‬حصار قلب دون وجود ناظم خطا‬
‫‪ (5‬خوارج انقباض بطينية أو تسارع بطيني‬
‫‪ (6‬وولف باركنسون وايت ‪WPW‬مع تليف أذيني‬
New Methods
Implantable ventricular assist devices
Biventricular pacing (only in patient with LBBB &
CHF)
Artificial Heart
ICD for Primary Prevention
• Patients with heart failure due to severe LV
systolic dysfunction (EF < 30%) with class II
and III symptoms, with survival > 12 months.
• At least 40 days post MI, > 3 months for NICM.
‫‪Automatic, implantable cardioverter‬‬‫‪defbrillators AICD‬‬
‫يستطب زرع ‪ICD&RCT‬‬
‫• للمرضى العرضين من استرخاء القلب‬
‫)‪> QRS , %35< EF, NYHAIII&IV‬‬
‫‪120‬ميلي ثا )‪.‬‬
‫• يفيد في إطالة معدل البقيا لدى مرضى‬
‫استرخاء القلب وحدث لديهم توقف قلب‬
‫أو تسرع بطيني مستمر‪ ,‬مع تناقص‪. EF‬‬
‫• مريض احتشاء عضلة قلبية (بعد اليوم‬
‫‪ , ) 40‬ولديه استرخاء قلب ‪< EF‬‬
‫‪ , %30‬معند على المعالجة الدوائية ‪:‬‬
‫‪ACEi + ARBs + B-Blocker +‬‬
‫‪ , spironolactone‬يفيد في‬
‫الوقاية من الموت المفاجئ‬
‫المعالجة الجينية & زراعة الخاليا‬
‫‪Cell Transplantation‬‬
‫معالجة االقفار القلبي المعند على المعالجة الدوائية‬
‫مستخدمين تقنيات الخاليا الجزعية‬
‫‪Stem Cell Techniques‬‬
‫• حقن خلية جذعيه مستخلصه من نقي العظم في الشريان االكليلي‬
‫المسبب لالحتشاء‬
‫نُشرت عام ‪ 2001‬أول حالة حقن الخاليا الجذعية لمريض‬
‫عمره ‪ 46‬في نفس الوقت الذي اجري له توسيع اكليلي‪.‬‬
‫معالجة االقفار القلبي المعند على المعالجة الدوائية‬
‫مستخدمين تقنيات توليد األوعية الدموية‬
‫‪Myocardial Angiogenesis‬‬
‫• يتم ذلك بحقن العامل المولد لألوعية ‪ ,‬مباشرة ضمن الشريان األكليلي‪.‬‬
‫)‪• VEGF(vascular endothelial growth factor‬‬
‫• أواستخدام مورثة العامل المولد لألوعية ‪, angiogenic gene therapy‬‬
‫بشكل بالسميد ‪ , Plasmid‬أو فيروس ‪ Adenovirus‬المعدل وراثيا َ بحيث‬
‫يحمل جينة البروتينات المولدة لالوعية ‪ ,‬حيث حقنت مباشرة ضمن العضلة‬
‫القلبية من خالل فتحة صغيرة في جدار الصدر‬
‫• في كال النوعين من المعالجة تشكلت اوعية جديدة ‪ ,‬وتحسن اداء القلب ‪,‬‬
‫وتناقص الخناق‬
‫• مشاركة الزراعة النسجية مع المعالجة الجينية‬
‫‪Cell Transplantation& Gene Therapy‬‬
‫حيث قام ‪ Suzuki‬و معاونيه بادخال جين ‪VEGV156‬‬
‫وهو جين بشري مولد لالوعية ‪ ,‬الى داخل الخاليا‬
‫الجذعية العضلية ‪.‬‬
Intraaortic Balloon Pump
Cardiac Transplant
It has become more widely used since the advances
in immunosuppressive treatment
Survival rate
1 year 80% - 90%
5 years 70%
‫‪Dr, Christian Pernard‬‬
‫د‪.‬كريستيان‬
‫برنارد ( جنوب‬
‫أفريقيا ) أول‬
‫زراعة قلب‬
‫‪1967‬‬
THE END