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Icc diastolica, insuficiencia cardíaca, 2016, enfoque general

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Text of Icc diastolica, insuficiencia cardíaca, 2016, enfoque general

ICC: disfuncin Diastolica.

Facultad de MedicinaEscuela de MedicinaDpto. de Medicina Interna2016 Andres Romeo Wyss Mayo 2016Insuficiencia cardiaca con fraccin de eyeccin conservada.

Relacin volumen presin

Cliger C, et al. AJGC. 2006;15:5057

Scheme for diagnosis of heart failure with preserved ejection fraction.

Michel Komajda, and Carolyn S.P. Lam Eur Heart J 2014;35:1022-1032Published on behalf of the European Society of Cardiology. All rights reserved. The Author 2014. For permissions please email: [email protected]

Scheme for diagnosis of heart failure with preserved ejection fraction. In general, all proposed diagnostic criteria to date share three features in common: (1) symptoms and signs of heart failure; (2) evidence of preserved left ventricular (LV) ejection fraction; and (3) evidence of LV diastolic dysfunction, which may include structural, Doppler echocardiographic, biomarker, rhythm, or invasive haemodynamic criteria.

Historia natural.

Ouzounian M. Nature Clin Pract Cardiovasc Med. 2008; 5(7): 375-86

Schematic of the integrative physiology of heart failure with a preserved ejection fraction (HFpEF) showing various extracardiac mechanisms and how they are involved.

Kavita Sharma, and David A. Kass Circ Res. 2014;115:79-96Copyright American Heart Association, Inc. All rights reserved.

Schematic of the integrative physiology of heart failure with a preserved ejection fraction (HFpEF) showing various extracardiac mechanisms and how they are involved. From top left, counterclockwise: lung involvement including primary lung disease leading to pulmonary arterial hypertension, secondary pulmonary venous hypertension (PVH), impaired lung muscle mechanics, and eventual increased pulsatile right ventricular (RV) load; abdominal compartment mechanisms including splanchnic circulation (preload), bowel congestion leading to endotoxin translocation and systemic inflammation; skeletal muscle mechanisms including impaired metabolism and peripheral vasodilation; renal mechanisms including passive congestion leading to renal impairment, changes in neurohormonal axis activation, hypertension, abnormal fluid homeostasis, eventual oliguria/renal insufficiency; ventricularvascular mechanisms including ventricular stiffening leading to systolic and diastolic impairment, diminished systolic reserve, increased cardiac energetic demands, and fluid-pressure shift sensitivity. Illustration credit: Ben Smith.

Disfuncin Diastlica.

Definicin:Paciente con sntomas de ICC clsicos pero con fraccin de eyeccin igual o mayor de 45%-50%. En ausencia de patologa valvular que explique los sntomas.

Vasan RS, Levy D. Defining diastolic heart failure: a call for standarized diagnostic criteria. Circulation. 2000;101:2118-21.Hunt SA et al. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult. Circulation 112: e154e235

Epidemiologia:How do patients with heart failure with preserved ejection fraction die?

European Journal of Heart FailureVolume 15, Issue 6, pages 604-613, 27 JAN 2014 DOI: 10.1093/eurjhf/hft062http://onlinelibrary.wiley.com/doi/10.1093/eurjhf/hft062/full#ejhfhft062-fig-0001

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Pronostico:

Owan TE. NEJM. 2006;355:251-9. / Bhatia RS. NEJM. 2006;355:260-9.

EPIDEMIOLOGIAReadmisiones en un ao 50% por descompensacin aguda

Causas de la descompensacin : sobrecarga de volumen, hipertensin no controlada, isquemia miocrdica aguda, enfermedad valvular progresiva (estenosis artica), y taquiarritmias de nueva aparicin o no controlada. Hunt, et al. 2009 ACCF/AHA Heart Failure Guidelines. (Circulation. 2009;119:e391-e479.Owan T, et al. NEJM. 2006;355:251-9

Como factor de riesgo:Alto riesgo de infarto del miocardio y evento cerebrovascularMortalidad a cinco aos 25%6 meses 13%Predictores de mortalidadCrCL74 aos Hunt, et al. ACCF/AHA Heart Failure Guidelines. Circulation. 2009;119:e391-e479.Owan T, et al. NEJM. 2006;355:251-9

Figure3. Effect of classification by causes (left) vs. modes (right) of death in heart failure with preserved ejection fraction (adapted from TIME-CHF[Open in figure viewer]). All numbers represent the approximate percentage of total deaths. Under causes of death, cardiac deaths are further separated into acute myocardial infarction (AMI) and LV dysfunction. Under modes of death, cardiac deaths are further separated into sudden cardiac death or circulatory failure.How do patients with heart failure with preserved ejection fraction die?European Journal of Heart FailureVolume 15, Issue 6, pages 604-613, 27 JAN 2014 DOI: 10.1093/eurjhf/hft062

Diagnostico:clnico.

A Snchez M et al. Tratamiento mdico de la insuficiencia cardiaca por disfuncin diastlica. Rev Esp Cardiol Supl. 2006;6:53F-8F

Herramientas para el diagnostico:Invasivos:Cateterismo/ ventriculografa.No invasivos:Ecocardiografia doppler.RNMPronsticos:QRS.Pptido natriouretico.

Ecocardiograma en disfuncin diastlica.

How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Associations of the European Society of Cardiology.Paulus WJ, Tschpe C, Sanderson JE, Rusconi C, Flachskampf FA, Rademakers FE, Marino P, Smiseth OA, De Keulenaer G, Leite-Moreira AF, et al.Eur Heart J. 2007 Oct; 28(20):2539-50. Epub 2007 Apr 11.

Tratamiento.

Tratamiento

Reduccin de sntomas

Reduccin de presin venosa pulmonar

Disminur volmen

Restriccin Nitratos y diurticos

Disminucin del consumo de oxgeno miocrdico

Control de tensin arterial

BB, CA, IECA, ARA

Mantener la contraccin auricular

Mantener ritmo sinusal

Cardioversin, marcapaso

Patologa de base

Reemplazo valvular

Prevenir/tratar isquemia miocrdica

BB, CA, nitratosRevascularizacin

Prevenir/revertir remodelacin

Terapia antihipertensiva, espironolactona, IECA, ARAGarca J. Diagnosis and therapeutic guidance of diastolic heart failure. Rev Esp Cardiol.2003 Apr;56(4):396-406

Lam CSP. Ann Acad Med. 2009;38(8): 663-666.

22% de los pacientes tratados con candesartn descontinuaron la terapia debido a la hipotensin , aumento de la creatinina srica e hiperpotasemia.

Hubo una elevada tasa de abandono del frmaco del estudio en este ensayo (33%), as como una alta tasa de iniciacin posterior a la aleatorizacin de IECA (20%) y espironolactona (10%)

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