【正文】 enal insufficiency ? Metabolic acidosis ALDOSTERONE INHIBITORS CONTRAINDICATIONS Heart Failure _ZhangQing 223。325:293 ACEI SURVIVAL n = 2589 CHF NYHA IIIII EF 35 Heart Failure _ZhangQing Mortality % 4 SAVE N Engl J Med 1992。316:1429 ACEI SURVIVAL 4 3 2 1 0 Heart Failure _ZhangQing 50 40 30 20 10 0 Months 0 6 12 p = 24 18 30 36 42 48 Enalapril n=2111 Placebo n=2117 SOLVD (Prevention) N Engl J Med 1992。314:1547 NITRATES SURVIVAL 0 6 12 18 24 30 36 42 Heart Failure _ZhangQing NITRATES TOLERANCE Can be avoided or minimized Intermittent administration Use the lowest possible dose Heart Failure _ZhangQing NITRATES CONTRAINDICATIONS Previous hypersensitivity Hypotension ( 80 mmHg) AMI with low ventricular filling pressure 1st trimester of pregnancy WITH CAUTION: ? Constrictive pericarditis ? Intracranial hypertension ? Hypertrophic cardiomyopathy Heart Failure _ZhangQing NITRATES CLINICAL USES Pulmonary congestion Orthopnea and paroxysmal nocturnal dyspnea CHF with myocardial ischemia In acute CHF and pulmonary edema: NTG . or . Heart Failure _ZhangQing VASOCONSTRICTION VASODILATATION Kininogen Kallikrein Inactive Fragments Angiotensinogen Angiotensin I RENIN Kininase II Inhibitor ALDOSTERONE SYMPATHETIC VASOPRESSIN PROSTAGLANDINS tPA ANGIOTENSIN II BRADYKININ ACEi. Mechanism of Action . Heart Failure _ZhangQing ACEI HEMODYNAMIC EFFECTS Arteriovenous Vasodilatation PAD, PCWP and LVEDP SVR and BP CO and exercise tolerance No change in HR / contractility Renal, coronary and cerebral flow Heart Failure _ZhangQing 75 95 No Additional Treatment Necessary (%) Quinapril Heart Failure Trial JACC 1993。 ++ + 177。 ++ 223。 5 223。 ++ 2 5 223。 177。ADRENERGIC STIMULANTS CLASSIFICATION B1 Stimulants Increase contractility Dobutamine Doxaminol Xamoterol Butopamine Prenalterol Tazolol B2 Stimulants Produce arterial vasodilatation and reduce SVR Pirbuterol Carbuterol Rimiterol Fenoterol Tretoquinol Salbutamol Terbutaline Salmefamol Soterenol Quinterenol Mixed Dopamine Heart Failure _ZhangQing DOPAMINE AND DOBUTAMINE EFFECTS Receptors Contractility Heart Rate Arterial Press. Renal perfusion Arrhythmia DA (181。336:525 Months p = Heart Failure _ZhangQing DIGOXIN LONG TERM EFFECTS Survival similar to placebo Fewer hospital admissions More serious arrhythmias More myocardial infarctions Heart Failure _ZhangQing DIGOXIN CLINICAL USES AF with rapid ventricular response CHF refractory to other drugs Other indications? Can be bined with other drugs Heart Failure _ZhangQing DIGOXIN CONTRAINDICATIONS ABSOLUTE: Digoxin toxicity RELATIVE Advanced AV block without pacemaker Bradycardia or sick sinus without PM PVC’s and TV Marked hypokalemia WPW with atrial fibrillation Heart Failure _ZhangQing DIGOXIN TOXICITY CARDIAC MANIFESTATIONS ARRHYTHMIAS : Ventricular (PVCs, TV, VF) Supraventricular (PACs, SVT) BLOCKS: SA and AV blocks CHF EXACERBATION Heart Failure _ZhangQing DIGOXIN TOXICITY EXTRACARDIAC MANIFESTATIONS GASTROINTESTINAL: Nausea, vomiting, diarrhea NERVOUS: Depression, disorientation, paresthesias VISUAL: Blurred vision, scotomas and yellowgreen vision Heart Failure _ZhangQing CARDIAC GLYCOSIDES SYMPATHOMIMETICS Catecholamines 223。 Blockers Digoxin Heart Failure _ZhangQing Common Symptoms of Heart Failure ? Dyspnea on exertion ? Paroxysmal nocturnal dyspnea ? Orthopnea ? Fatigue ? Lower extremity edema ? Cough, usually worse at night ? Nausea, vomiting, anorexia, RUQ pain, ascites ? Nocturia ? Sleep disorders ? Increased abdominal girth Heart Failure _ZhangQing Common Physical Findings of Heart Failure ? Elevated jugular venous pressure ? Hepatojugular reflux ? Displaced apical impulse ? S3 gallop ? Pulmonary rales ? Hepatomegaly ? Peripheral edema ? Ascites Heart Failure _ZhangQing Clinical manifestation ? Left heart failure:SOB,cough,rales,gallop ? Right heart failure:gastrointestinal congestion,anorexia,nausea,a sense of fullness after meals,hepatojugular reflux,swelling of feet or ankles ? Low cardiac output:fatigue and weakness,oliguria ? Biventricular heart failure:both clinical manifestation of left and right heart failure,one of which maybe predominant. Heart Failure _ZhangQing Functional Classification ? A classification of patients with heart disease based on the relation between symptoms and the amount of effort required to provoke them has been developed by the New York Heart Association. Heart Failure _ZhangQing ? Class 1No limitation Ordinary physical activity does not cause undue fatigue,dyspnea,or palpitation ? Class 2Slight limitation of physical activity Such patients are fortable at physical activity results in fatigue,palpitation,dyspnea,or angina Heart Failure _ZhangQing ? Class 3Marked limitation of physical activity Although patients are fortable at rest,less than ordinary activity will lead to symptoms. ? Class 4Inability to carry on any physical activity Symptoms of congestive failure are present even at any physical activity,increased disfort is experienced. Heart Failure _ZhangQing Heart Failure _ZhangQing Complication ? Pulmonary embolism, ? Congestive hepatomegaly, ? Ascites, ? Hepatic sclerosis, ? Imbalance of electrolytes Heart Failure _ZhangQing Laboratory Finding ? Venous pressure:elevated ? Chest roentgenogram:cardiothoracic ratio,pulmonary edema— Kerley’s lines,perivascular and