Guideline directed medical therapy for “Chronic Heart Failure“

Editor's Notes

• #5: 心臟衰竭是一種高死亡率的疾病 住院死亡率約3.8% 出院後一個月死往率約10% 一年後死亡率約20% 五年後死亡率約40% 這樣的致死率，甚至比某些癌症還來的高
• #9: Therapeutic algorithm for a patient with symptomatic heart failure with reduced ejection fraction. Green indicates a class I recommendation; yellow indicates a class IIa recommendation. ACEI ¼ angiotensin-converting enzyme inhibitor; ARB ¼ angiotensin receptor blocker; ARNI ¼ angiotensin receptor neprilysin inhibitor; BNP ¼ B-type natriuretic peptide; CRT ¼ cardiac resynchronization therapy; HF ¼ heart failure; HFrEF ¼ heart failure with reduced ejection fraction; H-ISDN ¼ hydralazine and isosorbide dinitrate; HR ¼ heart rate; ICD ¼ implantable cardioverter defibrillator; LBBB ¼ left bundle branch block; LVAD ¼ left ventricular assist device; LVEF ¼ left ventricular ejection fraction; MR ¼ mineralocorticoid receptor; NT-proBNP ¼ N-terminal pro-B type natriuretic peptide; NYHA ¼ New York Heart Association; OMT ¼ optimal medical therapy; VF ¼ ventricular fibrillation; VT ¼ ventricular tachycardia. aSymptomatic ¼ NYHA Class II-IV. bHFrEF ¼ LVEF ,40%. cIf ACE inhibitor not tolerated/contra-indicated, use ARB. dIf MR antagonist not tolerated/contra-indicated, use ARB. eWith a hospital admission for HF within the last 6 months or with elevated natriuretic peptides (BNP . 250 pg/ml or NTproBNP . 500 pg/ml in men and 750 pg/ml in women). fWith an elevated plasma natriuretic peptide level (BNP ≥ 150 pg/mL or plasma NT-proBNP ≥ 600 pg/mL, or if HF hospitalization within recent 12 months plasma BNP ≥ 100 pg/mL or plasma NT-proBNP ≥ 400 pg/mL). gIn doses equivalent to enalapril 10 mg b.i.d. hWith a hospital admission for HF within the previous year. iCRT is recommended if QRS ≥ 130 msec and LBBB (in sinus rhythm). jCRT should/may be considered if QRS ≥ 130 msec with non-LBBB (in a sinus rhythm) or for patients in AF provided a strategy to ensure bi-ventricular capture in place (individualized decision). For further details, see Sections 7 and 8 and corresponding web pages. ESC Guidelines Page 21 of 85 NOT FOR PUBLIC RELEASE 2285 2290 2295 2300 2305 2310 2315 2320 2325 2330 2335 2340 2345 2350 2355 2360 2365 2370 2375 2380 2385
• #15: Evolution of pharmacologic approaches in HF:Neprilysin inhibition as a new therapeutic strategy A decline in left ventricular systolic function leads to activation of three major compensatory neurohormonal systems in an attempt to increase cardiac output (CO):1 Sympathetic nervous system (SNS) Renin-angiotensin-aldosterone system (RAAS) Natriuretic peptide (NP) system SNS and RAAS suppression Long-term over-activation of the SNS and RAAS in HF are thought to be harmful and blockade of these pathways has been the focus of current HF therapies. The SNS can be inhibited using β-blockers and the RAAS using RAAS inhibitors such as angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor antagonists (ARBs), and mineralocorticoid receptor antagonists (MRAs).2 Natriuretic peptide system enhancement In contrast to the RAAS and SNS, the natriuretic peptide system is a potentially beneficial counter-regulatory system in HF.2 Augmentation of this system is a new therapeutic strategy being considered for HF. This can be achieved by blocking the enzyme neprilysin which is responsible for the breakdown of NPs. Neprilysin inhibition may enhance the effects of natriuretic and other vasoactive peptides, which include vasodilation, diuresis and natriuresis, reduced sympathetic tone, reduced aldosterone, and antifibrotic and hypertrophic effects.2–4 Abbreviations ACEI=angiotensin-converting enzyme inhibitor; ARB=angiotensin receptor blocker; CO=cardiac output; HF=heart failure; MRA=mineralocorticoid receptor antagonist; NP=natriuretic peptide; RAAS=renin-angiotensin-aldosterone system; SNS=sympathetic nervous system References Kemp & Conte. Cardiovascular Pathology 2012;365–71 McMurray et al. Eur J Heart Fail 2013;15:1062–73 Levin et al. N Engl J Med 1998;339:321–8 Nathisuwan & Talbert. Pharmacotherapy 2002;22:27–42
• #29: ACEI ¼ angiotensin-converting enzyme inhibitor; CAD ¼ coronary artery disease; HF ¼ heart failure; ICD ¼ implantable cardioverter-defibrillator; LV ¼ left ventricular; LVEF ¼ left ventricular ejection fraction; OMT ¼ optimal medical therapy aClass of recommendation. bLevel of evidence.