Insuficiencia cardíaca Definición Rafael Porcile · PDF fileInsuficiencia...
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Insuficiencia cardíaca Definición Rafael Porcile [email protected] D E P A R T A M E N T O D E C A R D I O L O G I A C A T E D R A D E F I S I O L O G Í A Universidad Abierta Interamericana
Transcript of Insuficiencia cardíaca Definición Rafael Porcile · PDF fileInsuficiencia...
Insuficiencia cardíaca
Definición
Rafael [email protected]
D E P A R T A M E N T O D E C A R D I O L O G I A
C A T E D R A D E F I S I O L O G Í A
Universidad Abierta Interamericana
“The situation when the heart is
incapable of maintaining a cardiac
output adequate to accommodate
metabolic requirements and the
venous return."E. Braunwald
2013 ACCF/AHA Guideline for the
Management of Heart Failure
Developed in Collaboration With the American Academy of Family Physicians, American College of Chest Physicians, Heart Rhythm Society, and International Society for Heart and Lung Transplantation
Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation
© American College of Cardiology Foundation and American Heart Association, Inc.
Definition of Heart FailureClassification Ejection
Fraction
Description
I. Heart Failure with
Reduced Ejection Fraction
(HFrEF)
≤40% Also referred to as systolic HF. Randomized clinical trials have
mainly enrolled patients with HFrEF and it is only in these patients
that efficacious therapies have been demonstrated to date.
II. Heart Failure with
Preserved Ejection
Fraction (HFpEF)
≥50% Also referred to as diastolic HF. Several different criteria have been
used to further define HFpEF. The diagnosis of HFpEF is
challenging because it is largely one of excluding other potential
noncardiac causes of symptoms suggestive of HF. To date,
efficacious therapies have not been identified.
a. HFpEF, Borderline 41% to 49% These patients fall into a borderline or intermediate group. Their
characteristics, treatment patterns, and outcomes appear similar to
those of patient with HFpEF.
b. HFpEF, Improved >40% It has been recognized that a subset of patients with HFpEF
previously had HFrEF. These patients with improvement or recovery
in EF may be clinically distinct from those with persistently
preserved or reduced EF. Further research is needed to better
characterize these patients.
2016 ESC Guidelines for the
diagnosis and treatment of acute
and chronic heart failure
DOI: http://dx.doi.org/10.1093/eurheartj/ehw1282129-
2200 First published online: 20 May 2016
HF is a clinical syndrome characterized
by typical symptoms (e.g. breathlessness,
ankle swelling and fatigue) that may be
accompanied by signs (e.g. elevated
jugular venous pressure, pulmonary
crackles and peripheral oedema) caused
by a structural and/or functional cardiac
abnormality, resulting in a reduced
cardiac output and/or elevated
intracardiac pressures at rest or during
stress.
Insuficiencia cardíaca
EPIDEMIOLOGÍARafael Porcile
D E P A R T A M E N T O D E C A R D I O L O G I A
C A T E D R A D E F I S I O L O G Í A
Universidad Abierta Interamericana
Prevalencia
• Informa que proporción de la
población padece insuficiencia
cardíaca
• Generalmente son estudios de tipo
Cross section que pueden subestimar la
realidad
La prevalencia de la IC está en aumento
Altas hospitalarias por IC por sexo (EE. UU.: 1979–2006)*
Años
Varones
Mujeres
700
600
500
400
300
200
100
0
Alta
s e
n m
iles
79 80 85 90 95
00 05
*Las altas hospitalarias incluyen personas dadas de alta vivas, muertas y con estado desconocido
IC: insuficiencia cardíaca; EE. UU.: Estados Unidos de América
Lloyd-Jones et al. Circulation 2010;121:e46–e215
Incidencia
• Número de casos nuevos de insuficiencia
cardíaca en un determinado período ,
generalmente se toma un año
• 0.14% mujer por año
• 0.23% en hombre por año
• Llega al 3% en pacientes entre 85-94 añ[email protected]
Re hospitalización
• 2% de las causas de admisión en
hospitales generales
• Primera causa de internación en
pacientes mayores de 65 años
• 40 % de los pacientes re
hospitalizados han muerto 12 meses
después [email protected]
Mortalidad de la insuficiencia
cardíaca no tratada
Mortalidad
50 % a los 5 años de aparecidos
los síntomas
90% a los 10 años de aparecidos
los síntomas
1,3 años promedio de
menor sobrevida respecto
de cáncer de mama,
próstata y vejiga [email protected]
Insuficiencia cardíaca
• Sin deterioro de la funcíon sistólica
• Con deterioro de la función sistólica
– Dilatada
– Con diámetros conservados
Recommendations for Invasive Evaluation
Recommendation COR LOE
Monitoring with a pulmonary artery catheter should be performed in patients
with respiratory distress or impaired systemic perfusion when clinical
assessment is inadequate
I C
Invasive hemodynamic monitoring can be useful for carefully selected
patients with acute HF with persistent symptoms and/or when hemodynamics
are uncertain
IIa C
When coronary ischemia may be contributing to HF, coronary arteriography
is reasonable IIa C
Endomyocardial biopsy can be useful in patients with HF when a specific
diagnosis is suspected that would influence therapyIIa C
Routine use of invasive hemodynamic monitoring is not recommended in
normotensive patients with acute HF
III: No
Benefit
B
Endomyocardial biopsy should not be performed in the routine evaluation of
HFIII: Harm C
Definición de ICFEr e ICFEp
ICFEp: insuficiencia cardíaca con fracción de eyección preservada; ICFEr: insuficiencia cardíaca con fracción de eyección reducida; FEVI: fracción de eyección ventricular
izquierda
Steinberg et al. Circulation 2012;126:65–75
0% 20% 40% 60% 80% 100%
ICFEp definida
(FEVI ≥50%)
ICFEr definida
(FEVI <40%)
Incierta
(40% ≤FEVI <50%)
Proporción de pacientes
14 %50 % 36 %
La ICFEp y la ICFEr se asocian con niveles de mortalidad
similarmente altos
La tasa de sobrevida de los pacientes con diagnóstico de alta de IC en los EE. UU. fue ligeramente más alta entre los pacientes con ICFEp que entre aquellos con ICFEr entre
1987–20011Las tasas de mortalidad fueron, respectivamente, del 29% y 32% a 1 año y del 65% y 68% a 5 años
En Argentina las etiologías predominantes de IC son la isquémica (40,5%) y la hipertensiva (23,7%). Las causas de descompensación más frecuentes son infecciones,
suspensión del tratamiento y transgresión alimentaria. La mediana de permanencia durante una internacion por IC aguda es de 7 (5-11) días. La mortalidad hospitalaria es del
8%. A los 90 días, la reinternación es del 24,5% y la mortalidad posalta del 12,8%.
So
bre
vid
a
1,0
0,8
0,6
0,4
0,2
00 1 2 3 4 5
Año
ICFEr (FEVI <50%)
ICFEp (FEVI ≥50%)
p=0,03
• La ICFEp se asocia con una morbimortalidad significativa, pese a tener una tasa de sobrevida ligeramente más alta en comparación con la ICFEr2,3
1. Owan et al. N Engl J Med 2006;355:251–9; 2. Blanche et al. Swiss Med Wkly 2010;140:66–72;
3. Meta-analysis Global Group in Chronic Heart Failure (MAGGIC). Eur Heart J 2012;33:1750–7
IC: insuficiencia cardíaca; ICFEp: insuficiencia cardíaca con fracción de eyección preservada; ICFEr: insuficiencia cardíaca con fracción de eyección reducida; FEVI: fracción de eyección
ventricular izquierda; EE. UU.: Estados Unidos de América
Phenomapping for Novel Classification of Heart
Failure With Preserved Ejection
FractionCLINICAL PERSPECTIVE
Sanjiv J. Shah, Daniel H. Katz, Senthil Selvaraj, Michael A. Burke,
Clyde W. Yancy, Mihai Gheorghiade, Robert O. Bonow, Chiang-
Ching Huang and Rahul C. Deo
http://dx.doi.org/10.1161/CIRCULATIONAHA.114.010637
Published: January 20, 2015Phenomapping results in novel classification of HFpEF.
Statistical learning
algorithms, applied to dense phenotypic data, may allow for
improved classification of
heterogeneous clinical syndromes, with the ultimate goal of
defining therapeutically homogeneous
patient subclasses. [email protected]
Survival free of cardiovascular (CV) hospitalization or death stratified by phenogroup.
Sanjiv J. Shah et al. Circulation. 2015;131:269-279
Copyright © American Heart Association, Inc. All rights reserved.
Tres sub grupos
1) Menore de 65 años , bnp bajo, hipertrofia
ventricular leve
2) Obesidad , congestion con w y resisetncia
vasculares pulmonares elevadas
3) Mayores de 65 , bnp elevado, insuficiencia renal
Survival free of cardiovascular (CV) hospitalization or death stratified by phenogroup.
Sanjiv J. Shah et al. Circulation. 2015;131:269-279
Copyright © American Heart Association, Inc. All rights reserved.
Insuficiencia cardíaca
DIAGNOSTICORafael Porcile
D E P A R T A M E N T O D E C A R D I O L O G I A
C A T E D R A D E F I S I O L O G Í A
Universidad Abierta Interamericana
• CRITERIOS MAYORES
• Disnea paroxistica nocturna,rales, edema agudo de pulmon
• Ingurgitacion yugular
• Presion venosa central mayor a 16
• Tiempo circulatorio mayor a 25 segundos
• Reflejo hepatoyugular
• CRITERIOS MENORES
• Edema pretibial,hepatomegalia taquicardia de mas de 120
• Capacidad vital disminuida en 33 %
• Derrame pleural
• Dos mayores o dos menores y un mayor
No perder el objetivo clinico
Clinical profiles of patients with heart failure based on the presence/absence of congestion
and/or hypoperfusion.
Piotr Ponikowski et al. Eur Heart J 2016;37:2129-2200
The article has been co-published with permission in European Heart Journaland European
Journal of Heart Failure.All rights reserved in respect of European Heart Journal. © European
Society of Cardiology 2016. All rights reserved. For permissions please email:
2016 ESC Guidelines for the
diagnosis and treatment of acute
and chronic heart failure
DOI: http://dx.doi.org/10.1093/eurheartj/ehw1282129-
2200 First published online: 20 May 2016
Miocard hipertrófica obstructiva
rafael [email protected]@vaneduc.edu.ar
El consumo de oxígeno
en reposo de un
individuo normal es
alrededor de 250 ml/min
y en ejercicio intenso
puede aumentar más de
10 veces.
rafael [email protected]@vaneduc.edu.ar
La disnea es
sumplemente el
desequilibrio entre el
consumo y el transporte
rafael [email protected]@vaneduc.edu.ar
EVALUACION DEL TRANSPORTE DE
OXIGENO
DO2= CaO2 x VM x 10
VN= 520-720 ml/min/m2
Cont. de O2 = (0,003 x pO2) +
(1,39 x [Hb] x SO2) ml/dl
Disuelto Unido a la Hb
rafael [email protected]@vaneduc.edu.ar
rafael [email protected]
rafael [email protected]
PEQUEÑAS
O
MODERADAS
CAIDAS
DE LA
PRESION
ARTERIAL
DE OXIGENO
AFECTAN
MINIMAMENTE
LA
SATURACIÓN
rafael [email protected]
rafael [email protected]
rafael [email protected]
rafael [email protected]
2016 ESC Guidelines for the
diagnosis and treatment of acute
and chronic heart failure
DOI: http://dx.doi.org/10.1093/eurheartj/ehw1282129-
2200 First published online: 20 May 2016
Vol minuto respiratorio:
frecuencia respiratoria
x volumen corriente
Pco2 y ph
Etapas de la
enfermedad
2013 ACCF/AHA Guideline for the
Management of Heart Failure
Developed in Collaboration With the American Academy of Family Physicians, American College of Chest Physicians, Heart Rhythm Society, and International Society for Heart and Lung Transplantation
Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation
© American College of Cardiology Foundation and American Heart Association, Inc.
Stages, Phenotypes and Treatment of HF
STAGE AAt high risk for HF but
without structural heart
disease or symptoms of HF
STAGE BStructural heart disease
but without signs or
symptoms of HF
THERAPY
Goals
· Control symptoms
· Improve HRQOL
· Prevent hospitalization
· Prevent mortality
Strategies
· Identification of comorbidities
Treatment
· Diuresis to relieve symptoms
of congestion
· Follow guideline driven
indications for comorbidities,
e.g., HTN, AF, CAD, DM
· Revascularization or valvular
surgery as appropriate
STAGE CStructural heart disease
with prior or current
symptoms of HF
THERAPYGoals· Control symptoms· Patient education· Prevent hospitalization· Prevent mortality
Drugs for routine use· Diuretics for fluid retention· ACEI or ARB· Beta blockers· Aldosterone antagonists
Drugs for use in selected patients· Hydralazine/isosorbide dinitrate· ACEI and ARB· Digoxin
In selected patients· CRT· ICD· Revascularization or valvular
surgery as appropriate
STAGE DRefractory HF
THERAPY
Goals
· Prevent HF symptoms
· Prevent further cardiac
remodeling
Drugs
· ACEI or ARB as
appropriate
· Beta blockers as
appropriate
In selected patients
· ICD
· Revascularization or
valvular surgery as
appropriate
e.g., Patients with:
· Known structural heart disease and
· HF signs and symptoms
HFpEF HFrEF
THERAPY
Goals
· Heart healthy lifestyle
· Prevent vascular,
coronary disease
· Prevent LV structural
abnormalities
Drugs
· ACEI or ARB in
appropriate patients for
vascular disease or DM
· Statins as appropriate
THERAPYGoals· Control symptoms· Improve HRQOL· Reduce hospital
readmissions· Establish patient’s end-
of-life goals
Options· Advanced care
measures· Heart transplant· Chronic inotropes· Temporary or permanent
MCS· Experimental surgery or
drugs· Palliative care and
hospice· ICD deactivation
Refractory symptoms of HF at rest, despite GDMT
At Risk for Heart Failure Heart Failure
e.g., Patients with:
· Marked HF symptoms at
rest
· Recurrent hospitalizations
despite GDMT
e.g., Patients with:
· Previous MI
· LV remodeling including
LVH and low EF
· Asymptomatic valvular
disease
e.g., Patients with:
· HTN
· Atherosclerotic disease
· DM
· Obesity
· Metabolic syndrome
or
Patients
· Using cardiotoxins
· With family history of
cardiomyopathy
Development of
symptoms of HFStructural heart
disease
Recommendations for Biomarkers in HFBiomarker, Application Setting COR LOE
Natriuretic peptides
Diagnosis or exclusion of HFAmbulatory,
AcuteI A
Prognosis of HFAmbulatory,
AcuteI A
Achieve GDMT Ambulatory IIa B
Guidance of acutely decompensated
HF therapyAcute IIb C
Biomarkers of myocardial injury
Additive risk stratificationAcute,
AmbulatoryI A
Biomarkers of myocardial fibrosis
Additive risk stratification
Ambulatory IIb B
AcuteIIb A
Recommendations for Noninvasive ImagingRecommendation COR LOE
Patients with suspected, acute, or new-onset HF should undergo a chest x-
rayI C
A 2-dimensional echocardiogram with Doppler should be performed for
initial evaluation of HFI C
Repeat measurement of EF is useful in patients with HF who have had a
significant change in clinical status or received treatment that might affect
cardiac function, or for consideration of device therapy
I C
Noninvasive imaging to detect myocardial ischemia and viability is
reasonable in HF and CADIIa C
Viability assessment is reasonable before revascularization in HF patients
with CADIIa B
Radionuclide ventriculography or MRI can be useful to assess LVEF and
volume IIa C
MRI is reasonable when assessing myocardial infiltration or scar IIa B
Routine repeat measurement of LV function assessment should not be
performed
III: No
BenefitB
Recommendations for Invasive Evaluation
Recommendation COR LOE
Monitoring with a pulmonary artery catheter should be performed in patients
with respiratory distress or impaired systemic perfusion when clinical
assessment is inadequate
I C
Invasive hemodynamic monitoring can be useful for carefully selected
patients with acute HF with persistent symptoms and/or when hemodynamics
are uncertain
IIa C
When coronary ischemia may be contributing to HF, coronary arteriography
is reasonable IIa C
Endomyocardial biopsy can be useful in patients with HF when a specific
diagnosis is suspected that would influence therapyIIa C
Routine use of invasive hemodynamic monitoring is not recommended in
normotensive patients with acute HF
III: No
Benefit
B
Endomyocardial biopsy should not be performed in the routine evaluation of
HFIII: Harm C
2016 ESC Guidelines for the
diagnosis and treatment of acute
and chronic heart failure
DOI: http://dx.doi.org/10.1093/eurheartj/ehw1282129-
2200 First published online: 20 May 2016
Diagnostico de
insuficiencia
cardíaca fon fey
conservada
Siempre cae el
volumen sistólico
aunque la fey sea
normal o alta
Como diagnosticar insuf card con fey conservada
Dispositivos
implantadles para en
monitoreo y
diagnostico de la
insuficiencia
cardíaca
Continuous Hemodynamic Monitoring in Patients With Mild to Moderate Heart Failure: Results of
the Reducing Decompensation Events Utilizing Intracardiac Pressures in Patients With Chronic
Heart Failure (REDUCEhf) Trial
Congestive Heart Failure
Volume 17, Issue 5, pages 248-254, 10 AUG 2011 DOI: 10.1111/j.1751-7133.2011.00247.x
http://onlinelibrary.wiley.com/doi/10.1111/j.1751-7133.2011.00247.x/full#f1
Continuous Hemodynamic
Monitoring in Patients With
Mild to Moderate Heart
Failure: Results of the
Reducing Decompensation
Events Utilizing Intracardiac
Pressures in Patients With
Chronic Heart Failure
(REDUCEhf) TrialCongestive Heart Failure
Volume 17, Issue 5, pages 248–254, September/October 2011
Continuous Hemodynamic Monitoring in Patients With Mild to Moderate Heart Failure: Results of
the Reducing Decompensation Events Utilizing Intracardiac Pressures in Patients With Chronic
Heart Failure (REDUCEhf) Trial
Congestive Heart Failure
Volume 17, Issue 5, pages 248-254, 10 AUG 2011 DOI: 10.1111/j.1751-7133.2011.00247.x
http://onlinelibrary.wiley.com/doi/10.1111/j.1751-7133.2011.00247.x/full#f2
Continuous Hemodynamic Monitoring in Patients With Mild to Moderate Heart Failure: Results of
the Reducing Decompensation Events Utilizing Intracardiac Pressures in Patients With Chronic
Heart Failure (REDUCEhf) Trial
Congestive Heart Failure
Volume 17, Issue 5, pages 248-254, 10 AUG 2011 DOI: 10.1111/j.1751-7133.2011.00247.x
http://onlinelibrary.wiley.com/doi/10.1111/j.1751-7133.2011.00247.x/full#f3
Continuous Hemodynamic Monitoring in Patients With Mild to Moderate Heart Failure: Results of
the Reducing Decompensation Events Utilizing Intracardiac Pressures in Patients With Chronic
Heart Failure (REDUCEhf) Trial
Congestive Heart Failure
Volume 17, Issue 5, pages 248-254, 10 AUG 2011 DOI: 10.1111/j.1751-7133.2011.00247.x
http://onlinelibrary.wiley.com/doi/10.1111/j.1751-7133.2011.00247.x/full#f4
Efficacy was inconclusively tested
because of the early termination of the
trial, but the experience helps define
the patient population most likely to
benefit from IHM-based HF
management
•2015
OPTILINK HF STUDY DESIGN
Access arm:
Telemedicine guided,
No audible alert for fluid retention
Control arm:
Standard clinical assessment,
No alert for fluid retention
Risk stratified:
NYHA II vs. III,
Ischemic vs. Non-Ischemic,
Atrial Fibrillation,
Primary vs. Secondary Prevention (VT/VF
before Implant)
Implant
Enrollment
1:1
Access arm Control arm
Follow up6 Months
every 6 Months
day 3 – 21
after implant
Follow up6 Months
every 6 Months
R
0
0.2
0.4
0.6
0.8
1
0 6 12 18 24 30 36 42
OPTILINK HF: PRIMARY ENDPOINT: ALL-CAUSE DEATH OR CV HOSPITALISATION
239Control 227
Intervention
Su
rviv
alP
rob
abil
ity
Months since Randomisation
Number at risk
Control 497 361 302 175 84 64 45 29
Intervention 505 361 310 183 94 80 58 35
Hazard ratio = 0.867 (0.72, 1.044)
Stratified log-rank p-value = 0.132
