recommandation consensuelle du traitement du patient avec dysfonction ventriculaire gauche...
TRANSCRIPT
Recommandation consensuelle du traitement du patient avec dysfonction ventriculaire
gauche asymptomatique.
Dr Serge Lepage cardiologue
CHUS
Dysfonction VG
Cardiomyopathie F R Post mi
Pré-angioplastie primaire
Post-angioplastie primaire
L ’insuffisance cardiaque (2)
Classification
Classes NYHA2
(New York Heart Association)
III : Symptômes pendant des activités moins qu’ordinaires
IV : Symptômes au repos
A : Avant
B : Émergence de l ’insuffisance cardiaque
Étapes de la maladie et (périodes critiques d ’organisation des services3)
I : Aucun symptôme
II : Symptômes pendant des activités ordinaires
C : Relative autonomie
D: Perte sévère d ’autonomie
E: Fin de vie
Pronostic de l’IC
Smith WM. Am J Cardiol 1985;55:3A-8A.NYHA = New York Heart Association
1 2 3 4 5 6
Période après inclusion (années)
Pas d’IC (n = 1728)Classe I NYHA (n = 36)Classe II NYHA (n = 79)Classe III NYHA (n = 62)Classe IV NYHA (n = 59)
Su
rvie
1,0
0,8
0,6
0,4
0,2
0
Diagnostic cliniqueCritères de Framingham1
Majeur
• DNP ou orthopnée
• DVC
• Râles
• Cardiomégalie
• Œdème pulmonaire aigu
• Bruits de galop
• PVC > 16 cm H2O
• Temps de circulation 25 sec.
• Reflux hépatojugulaire
Mineur
• Œdème bilatéral des chevilles
• Toux nocturne
• Dyspnée à l’effort ordinaire
• Hépatomégalie
• Épanchement pleural
• Baisse de la capacité vitale du ⅓ p/r aux valeurs maximales notées
• Tachycardie (≥ 120 battements/min.)
Majeur ou mineur
• Perte pondérale ≥ 4,5 kg en 5 jours en réponse au traitementPVC = pression veineuse centrale
PVJ = pression veineuse jugulaireDVC = distention des veines du couDNP = dyspnée nocture paroxystique
1. McKee PA, et al. N Engl J Med 1971;285:1441-1446.
2 symptômes majeurs OU 1 majeur + 2 mineurs = diagnostic
Screening studies using LVEF
• The prevalence in echocardiographic screening studies varies in part with the LVEF used to define LV systolic dysfunction and with age. The normal reference limit for LVEF by echocardiography is ≥55 percent [8]. The following observations illustrate the reported prevalence of asymptomatic LV systolic dysfunction in relation to LVEF; the mean age in these studies was 50 to 70 years [9]:
• LVEF ≤54 percent — 12.5 percent [10]
• LVEF ≤50 percent — 3.3 to 4.7 percent [11,12]
• LVEF ≤40 percent — 0.9 to 2.1 percent [10-13]
• LVEF ≤30 percent — 1.4 percent; almost all of these patients with severe LV dysfunction had evidence of coronary heart disease and/or hypertension [14 ]
First National Health and Nutrition Examination Survey (NHANES I)
• 13,643 men and women who were followed for 19 years found that the risk factors for HF and their population attributable risk (PAR) were as follows
• Coronary heart disease — relative risk 8.1; overall PAR 62 percent, 68 percent in men and 56 percent in women
• Cigarette smoking — relative risk 1.6, PAR 17 percent
• Hypertension — relative risk 1.4, PAR 10 percent
• Overweight — relative risk 1.3, PAR 8 percentDiabetes — relative risk 1.9, PAR 3 percent
• Valvular heart disease — relative risk 1.5, PAR 2 percent; however, valve disease is an increasingly common cause of HF at older ages, with calcific aortic stenosis being the most common disorder requiring surgery
Symptomatic and asymptomatic left-ventricular systolic dysfunction in an urban population.
• BACKGROUND: In most previous epidemiological studies on the prevalence of chronic heart failure (CHF) the disorder has been defined on clinical criteria. In a cross-sectional survey of 2000 men and women aged 25-74, randomly sampled from one geographical area, we assessed left-ventricular systolic function by echocardiography.
• METHODS: 1640 (83%) of those invited took part. They completed a questionnaire on current medication, history, and symptoms of breathlessness. Blood pressure was measured and electrocardiography (ECG) and echocardiography were done. Left-ventricular ejection fraction was measurable in 1467 (89.5%) participants by the biplane Simpson's rate method.
• FINDINGS: The mean left-ventricular ejection fraction was 47.3%. The prevalence of definite left-ventricular systolic dysfunction (defined as a left-ventricular ejection fraction<or = 30%) was 2.9% overall (43 participants); it increased with age and was higher in men than in women (4.0 vs 2.0%). The left-ventricular systolic dysfunction was symptomatic in 1.5% of participants and asymptomatic in 1.4%, 83% of participants with left-ventricular systolic dysfunction had evidence of ischaemic heart disease (IHD) from history or ECG criteria compared with 21% of those without this abnormality (p<0.001). Hypertension was also more common in those with left-ventricular systolic dysfunction (72 vs 38%, p<0.001), but there was no difference between those with and without left-ventricular systolic dysfunction in the rate of hypertension without IHD.
• INTERPRETATION: Left-ventricular systolic dysfunction was at least twice as common as symptomatic heart failure defined by clinical criteria. The main risk factors are IHD and hypertension in the presence of IHD; screening of such high-risk groups for left-ventricular systolic dysfunction should be considered.
Lancet. 1997;350(9081):829.
McDonagh TA, Morrison CE, Lawrence A, Ford I, Tunstall-Pedoe H, McMurray JJ, Dargie HJ
Echocardiography has been used to diagnose LV dysfunction in community-based studies and clinical trials. However, echocardiography is
expensive and serial testing would be required if the initial test is negative. Furthermore, the yield is very low in patients with no risk factors (1 of
444 [0.2 percent] in one report) [15]. Thus, routine screening with echocardiography is not
recommended [7].
Copyright ©2010 American College of Cardiology Foundation. Restrictions may apply.
Atherton, J. J. J Am Coll Cardiol Img 2010;3:421-428
Kaplan-Meier Curves for Survival of Participants From the Framingham Study
Diagnostic d’IC
Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.
Principes de la pharmacothérapie
• Les médicaments dont les effets ont été prouvés lors d’essais cliniques à grande échelle sont recommandés, car ils ont des doses cibles efficaces reconnues
(Classe I, Niveau A)
• Il faut utiliser les doses issues d’essais cliniques à grande échelle ou une dose inférieure correspondant à la dose maximale tolérée (voir tableau de la diapositive suivante)
(Classe I, Niveau A)
Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.
* L’essai Healing and Early Afterload Reduced Therapy (HEART) a montré que la dose efficace pour atténuer le remodelage du ventricule gauche était de 10 mg od.
† Non disponible au Canada.
Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.
Quelle dose de médicament doit-on utiliser?
SOLVD(Studies of Left Ventricular Dysfunction)
• Enalapril vs placebo in 6,794 patients• Ejection fraction < 35%
– End points include : Delaying the progression of heart failure– Improving signs and symptoms– Reducing mortality
• Treatment arm - 2,568 symptomatic class II-III patients most on digitalis and diuretics
• Prevention arm - 4,226 asymptomatic class I-II patients, most on no concomitant therapy
N Engl J Med 1991:325:293-302
SOLVD Prevention Trial All Cause Mortality
0
5
10
15
20
25
0 6 12 18 24 30 36 42 48
Months
Mor
talit
y fro
m A
ll C
ause
s (%
) PlaceboEnalapril
Risk Reduction 8%Risk Reduction 8%
P=0.30P=0.30
N Engl J Med 1992;327:685-91
SOLVD Prevention TrialDeath or Development of CHF
05
101520253035404550
0 6 12 18 24 30 36 42 48Months of Follow-up
% E
vents
Placebo
Enalapril
Risk Reduction 29%Risk Reduction 29%
p<0.001p<0.001
N Engl J Med 1992;327:685-91
SOLVD Prevention TrialFirst Hospitalization for CHF
0
2
46
8
10
1214
16
18
0 6 12 18 24 30 36 42 48
Months of Follow-up
% E
vent
s
Placebo
Enalapril
Risk Reduction 36%Risk Reduction 36%
p<0.001p<0.001
N Engl J Med 1992;327:685-91
SOLVD Prevention Trial
13,2
8,3
27,8
22,3
0
5
10
15
20
25
30
35
Median length of time to first CHFhospitalization
Median length of time to develop CHF
months
placeboenalapril
N Engl J Med 1992;327:685-91
SOLVD Prevention- Enalapril Asymptomatic HF Patients w/ LVD (EF < 35%)
(NYHA Class I-II)
0
50
100
150
200
250
300
Placebo (n=2,177)
Enalapril (n=2,111)
32% Fewer FirstHospitalizations
p<0.001
Number of First Hospitalizations for Heart FailureNumber of First Hospitalizations for Heart Failure
The SOLVD Investigators, N Engl J Med, 1992.
273273 184184
SOLVD Prevention TrialMorbidity and Combined Outcomes
Endpoint Placebo %
Enalapril %
RR P value
Development of CHF 30.2 20.7 37% <0.001
Development of CHF and anti-CHF Rx
22.5 13.9 43% <0.001
First Hospitalization for CHF
12.9 8.7 36% <0.001
Multiple Hospitalization for CHF
4.8 2.7 44% <0.001
Death or Development of CHF
38.6 29.8 29% <0.001
Death or Hospitalization for CHF
24.5 20.6 20% <0.001
Par où commencer?
• Une pharmacothérapie combinée fondée sur des preuves scientifiques est recommandée pour la majorité des patients souffrant d’IC
(Classe I, Niveau A)
• Tous les patients souffrant d’IC avec une FEVG < 40 % doivent être traités avec un IECA et un bêta-bloquant, sauf dans le cas d’une contre-indication particulière
(Classe I, Niveau A)
Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.
Quand doit-on utiliser des inhibiteurs de l’ECA?
Tous les patients souffrant d’IC avec une FEVG < 40 % doivent être traités avec un IECA et un bêta-bloquant, sauf dans le cas d’une contre-indication particulière (Classe I, Niveau A)
CONSENSUS Trial. N Engl J Med 1987;316:1429-35. SOLVD Investigators. N Engl J Med 1991;325:293-302. Flather MD et al. Lancet 2000;355:1575-81.
Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.
Ces études constituent le fondement de l’utilisation des IECA chez les insuffisants cardiaques avec une FEVG < 40 % ou chez les patients post-IM présentant une FEVG réduite ou une IC.
Quand doit-on utiliser des inhibiteurs de l’ECA?
Les inhibiteurs de l’ECA préviennent la survenue de l’IC chez les patients à risque
Arnold JMO et al. Circulation 2003;107:1284-90. SOLVD Investigators. N Engl J Med 1992;327:685-91.
Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.
Hall AS et al. Lancet 1997;349:1493-7.Swedberg K et al. Eur Heart J 1999;20:136-9.
Jong P et al. Lancet 2003;361:1843-8.HOPE/HOPE-TOO Study Investigators. Circulation 2005;112:1339-46.
Des études additionnelles soulignent les avantages prolongés des inhibiteurs
des ECA
Traitement Ramipril Énalapril Énalapril Ramipril
Suivi 5-10 ans 10 ans 12 ans 7,2 ans
Caractéristique IC clinique, IC de classe IV IC, dysfonctionnement Risque CV élevépost-IM (NYHA) du VG sans dysfonctionnement
du VG, sans IC
Résultats RRR de mortalité Survie générale Survie prolongée Réduction du nombrede 36 % prolongée de 9,4 mois d’événements CV majeurs de 50 %
et de nouveaux cas de diabète
Résumé Importante réduction de Effets bénéfiques Meilleure survie Avantages CV etmortalité à long terme maintenus pendant à long terme métaboliques à longavec le traitement IECA au moins 4 ans terme chez les patients post-IM ne souffrant ni d’insuffisance
cardiaque ni d’un dysfonctionnement du VG
Jong P et al. Lancet 2003;361:1843-8.Hall AS et al. Lancet 1997;349:1493-7.
Les avantages à long terme des inhibiteurs d’ECA sur la mortalité
Les avantages à long terme des inhibiteurs d’ECA sur la mortalité
HOPE/HOPE-TOO Study Investigators. Circulation2005;112:1339-46. Swedberg K et al. Eur Heart J 1999;20:136-9.
Quand utiliser les bêta-bloquants?
• Chez tous les patients souffrant d’IC avec une FEVG ≤ 40 % (utiliser des bêta-
bloquants ayant fait l’objet de preuves scientifiques) (Classe I, Niveau A)
• Chez tous les patients stabilisés présentant des symptômes de classe IV NYHA
(Classe I, Niveau C)
MERIT-HF Study Group. Lancet 1999;353:2001-7.CIBIS II Investigators Lancet 1999;353:9-13.Packer M et al. Circulation 2002;106:2194-9.
Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.
Stratégies de traitement de l’IC
IECA/(ARA)
Ajustement des BB
Spironolactone
Digoxine/Dérivés nitrés
Aucun selajouté
2 gm Na
Suivi cliniquede l’IC
Programme de style de vie
personnalisé
CRT (LBBB), CPAP
Asymptomatique Légère/Mod. Grave Réfractaire
Risque de mort subit — AICD
Treatment Approach for the Patient with Heart Failure
Stage A
At high risk, no structural disease
Stage B
Structural heart disease,
asymptomatic
Stage D
Refractory HF requiring
specialized interventions
Therapy
• Treat Hypertension
• Treat lipid disorders
• Encourage regular exercise
• Discourage alcohol intake
• ACE inhibition
Therapy
• All measures under stage A
• ACE inhibitors in appropriate patients
• Beta-blockers in appropriate patients
Therapy
• All measures under stage A
Drugs:
• Diuretics
• ACE inhibitors
• Beta-blockers
• Digitalis
• Dietary salt restriction
Therapy
• All measures under stages A,B, and C
• Mechanical assist devices
• Heart transplantation
• Continuous (not intermittent) IV inotropic infusions for palliation
• Hospice care
Stage C
Structural heart disease with prior/current
symptoms of HF
Hunt, SA et al. ACC/AHA Guidelines CHF, 2001.
Treatment Approach for the Patient with Heart FailureStage A
At high risk, no structural disease
Stage B
Structural heart disease,
asymptomatic
Therapy
• Treat Hypertension
• Treat lipid disorders
• Encourage regular exercise
• Discourage alcohol intake
• ACE inhibition
Therapy
• All measures under stage A
• ACE inhibitors in appropriate patients
• Beta-blockers in appropriate patients
Hunt, SA et al. ACC/AHA Guidelines CHF, 2001.
Treatment Overview
Jessup and Brozena. Heart Failure; N Engl Med. 2003;348:2007-2018.
Mortality Trials in Systolic Heart Failure: 1986-2004
ACE inhibitors
CONSENSUS-IIV-HeFT-IISOLVD-TSOLVD-PSAVEAIRETRACEATLAS
-Blockers
MDCU.S. CarvedilolANZ CarvedilolMERIT-HFCIBIS-IIBESTCOPERNICUSCAPRICORN
Aldosterone antagonists
RALESEPHESUS
ARBs
ELITE-IIVal-HeFTOPTIMAALCHARMVALIANT
Inotropic agents
PROMISEVESTDIGOPTIME-II
Vasodilators
V-HeFTFIRSTPRAISE-I/-II
ACE/NEP Inhibitors
OVERTURE
Cytokine antagonists
RENAISSANCERECOVER
Endothelin antagonists
ENABLE-2
PositiveBorderline/NeutralNegative
Sympatholytic agents
MOXCON
Slide courtesy of G. Francis
Traitement de l’insuffisance cardiaque
Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.
ACE inhibition, angiotensin receptor blockade and aldosterone antagonism
• Recommendations Consensus conference recommendations on heart failure 2006
• ACE inhibitors should be used in all patients as soon as safely possible after acute myocardial infarction, and should be continued indefinitely if LVEF is less than 40% or if AHF complicated the myocardial infarction
(class I, level A).
Can J Cardiol Vol 22 No 1 January 2006
• ACE inhibitors should be used in all asymptomatic patients with an LVEF less than 35% (class I, level A).
• ACE inhibitors should be used in all patients with symptoms of heart failure and an LVEF less than 40% (class I, level A).
ACE inhibition, angiotensin receptor blockade and aldosterone antagonism
Consensus conference recommendations on heart failure 2006
Beta-adrenoceptor blockade
Recommendations
All heart failure patients with an LVEF equal to or less than 40% should receive a beta-blocker
proven to be beneficial in large-scale clinical trials (class I, level A).
Consensus conference recommendations on heart failure 2006
Practical tips• Patients in NYHA class I or II can be safely initiated andtitrated with a beta-blocker by nonspecialist physicians.
New York Heart Association functional classificationClass DefinitionI No symptoms
Potential to Prevent HF Hospitalizations
17%Other
19%Failure to Seek
Care
16%Inappropriate Rx
Rx Noncompliance 24%
Diet Noncompliance24%