Этиология, патофизиология, диагностика и лечение ХСН презентация

ХСН: Встречаемость и распространённость

распространённость
В мире - 22 млн1
США - 5 млн2
Встречаемость
В мире - 2 млн новых случаев ежегодно1
США – 500 000 новых случаев ежегодно2
ХСН – у 10 пац из 1 0000 старше 65 лет в США2

Hunt, SA, et al ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult, 2001

Опасность ХСН виды смерти

12%

24%

64%

ХСН

другие

ВСС

n = 103

NYHA II

26%

15%

59%

ХСН

Другие

ВСС

n = 103

NYHA III

56%

11%

33%

ХСН

Другие

ВСС

n = 27

NYHA IV

1 Lilly, L. Pathophysiology of Heart Disease. Second Edition p 200

Дисфункция левого желудочка

↑ сократимость

тахикардия

вазоконстрикция

Компенсаторные механизмы: Симпатическая нервная система

Снижение АДср

Задержка соли
и воды, жажда

Симп.
активация

вазоконстрикция

Компенсаторные механизмы: Ренин-Ангиотензин-Альдостерон (RAAS)

СВ

↑ УО

+

-

+

вены

↑ вен. возврат (↑ преднагрузка)

Отёки и застой
в лёгких

Компенсаторные механизмы

Желудочковое ремоделирование
Изменения сердечных размеров, формы, структуры и функции в результате хронического гемодинамического стресса

Эндотелиальные факторы

Возрастание серд. нагрузки
(преднагрузка и постнагрузка)

Порочный круг ХСН

1 Hunt, SA, et al ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult, 2001 p. 20.

Ресинхронизирующая терапия

NB: CRT лишь дополнение к медикаментам, а не замена их

1 Abraham, WT, et. Al. Cardiac Resynchronization in Chronic Heart Failure. N Engl J Med 2002;346:1845-53

Ресинхронизирующая терапия: Будем реалистами…

* This is not a complete list for many practitioners and is presented here only as a guideline.

Indications
-          The Medtronic InSync device is indicated for the reduction of the symptoms of moderate to severe heart failure (NYHA Functional Class III or IV) in those patients who remain symptomatic despite stable, optimal medical therapy, and have a left ventricular ejection fraction less than or equal to 35% and a QRS duration greater than or equal to 130ms. The InSync ICD system is, also, intended to provide ventricular antitachycardia pacing and ventricular defibrillation for automated treatment of life threatening ventricular arrhythmia.
-          The Medtronic Models 9790 and 2090 Programmers are portable, microprocessor-based instruments used to program Medtronic implantable devices.
-          The Attain Left heart leads have application as part of a Medtronic biventricular pacing system.
 
Contraindications
-          Asynchronous pacing is contraindicated in the presence (or likelihood) of competitive or intrinsic rhythms.
-          Unipolar pacing is contraindicated in patients with an implanted defibrillator or cardioverter-defibrillator (ICD) because it may cause unwanted delivery or inhibition of defibrillator or ICD therapy.
∙          The InSync ICD is contraindicated in patients whose ventricular tachyarrhythmias may have transient or reversible causes, or for patients with incessant VT or VF.
∙          The Attain Models 2187, 2188, and 4193 leads are contraindicated for patients with coronary venous vasculature that is inadequate for lead placement, as indicated by venogram.
-          Do not use steroid eluting leads in patients for whom a single dose of 1.0 mg dexamethasone sodium phosphate may be contraindicated.
 
Warnings and Precautions
-          Patients should avoid sources of magnetic resonance imaging, diathermy, high sources of radiation, electrosurgical cautery, external defibrillation, lithotripsy, and radiofrequency ablation. These may result in underdetection of VT/VF, inappropriate therapy delivery, and/or electrical reset of the device.
-          Certain programming and device operations may not provide cardiac resynchronization.
-          The InSync Elective Replacement Indicator (ERI) results in the device switching to VVI pacing at 65 ppm. For this reason, the device should be replaced prior to ERI being set.
-          An implantable defibrillator may be implanted concomitantly with an InSync system, provided implant protocols are followed.
-          Leads, stylets and guide wires should be handled with great care, their use may cause trauma to the heart. When using a Model 4193 lead, only use compatible stylets (stylets with downsized knobs and are 3 cm shorter than the lead length).
-          Chronic repositioning or removal of leads may be difficult because of fibrotic tissue development.
-          Previously implanted pulse generators, implantable cardioverter-defibrillators, and leads should generally be explanted.
-          Back-up pacing should be readily available during implant. Use of leads may cause heart block.
 
See the appropriate technical manuals for detailed information regarding instructions for use, indications, contraindications, warnings and precautions, and potential adverse events.
 
Caution: Federal law (USA) restricts these devices to sale by or on the order of a physician.