KALP YETMEZLİĞİ
Prof.Dr. Cemil GÜRGÜN
Kardiyoloji Anabilim Dalı
Olgu 1
•
•
•
•
•
•
•
60 y K
Efor dispnesi
Ayak bileğinde ödem
Tip 2 DM (diyetle regüle)
TA: 150/95 mmHg
Amlodipin 10 mg 1x1 kullanıyor
LDL: 143 mg/dl
Olgunun Tedavisi ?
EKO:
• LVEF %55
• LVH
• Diyastolik
Disfonksiyon
Kalp Yetersizliğinin Evreleri ve Tedavisi
At Risk for Heart Failure
Heart Failure
STAGE A
STAGE B
STAGE C
At high risk for HF but
without structural heart
disease or symptoms of HF
Structural heart disease
but without signs or
symptoms of HF
Structural heart disease
with prior or current
symptoms of HF
e.g., Patients with:
· HTN
· Atherosclerotic disease
· DM
· Obesity
· Metabolic syndrome
or
Patients
· Using cardiotoxins
· With family history of
cardiomyopathy
Structural heart
disease
e.g., Patients with:
· Previous MI
· LV remodeling including
LVH and low EF
· Asymptomatic valvular
disease
Development of
symptoms of HF
e.g., Patients with:
· Known structural heart disease and
· HF signs and symptoms
HFpEF
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
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
STAGE D
Refractory 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
Refractory
symptoms of HF
at rest, despite
GDMT
e.g., Patients with:
· Marked HF symptoms at
rest
· Recurrent hospitalizations
despite GDMT
HFrEF
THERAPY
Goals
· 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
2013 ACCF/AHA Guideline for the Management of Heart Failure
THERAPY
Goals
· Control symptoms
· Improve HRQOL
· Reduce hospital
readmissions
· Establish patient’s endof-life goals
Options
· Advanced care
measures
· Heart transplant
· Chronic inotropes
· Temporary or permanent
MCS
· Experimental surgery or
drugs
· Palliative care and
hospice
· ICD deactivation
Tedavi
• Ramipril 5 mg/12.5 mg hidroklorotiazid 1x1
• Atorvastatin 20 mg 1x1
• Coraspin 100 mg 1x1
ACE İnhibitörleri
İlaç İsmi
Günlük Başlangıç Dozu
Hedef Doz
Captopril
6.25 mg tid
50 mg tid
Enalapril
2.5 mg bid
10 mg bid
Lisinopril
2.5-5 mg qd
20 mg qd
Ramipril
1.25-2.5 mg qd
10 mg qd
Trandolapril
1 mg qd
4 mg qd
Olgu 2
•
•
•
•
47 y E
NYHA Sınıf II
3 haftadır persistan kuru öksürük
FM de AC’de krepitan ral, hepatomegali, pretibial
ödem bulgusu yok
Tıbbi öykü:
• Hipertansiyon ve KAH öyküsü
• Metoprolol 50 mg 1x1
• Ramipril 5 mg 1x1
• Atorvastatin 20 mg 1x1
Olgu 2
EKO: LV EF %45
Renal fonksiyonlar normal
NT-proBNP: 86 pg/dl
TEDAVİ ??
Kalp Yetersizliğinin Evreleri ve Tedavisi
At Risk for Heart Failure
Heart Failure
STAGE A
STAGE B
STAGE C
At high risk for HF but
without structural heart
disease or symptoms of HF
Structural heart disease
but without signs or
symptoms of HF
Structural heart disease
with prior or current
symptoms of HF
e.g., Patients with:
· HTN
· Atherosclerotic disease
· DM
· Obesity
· Metabolic syndrome
or
Patients
· Using cardiotoxins
· With family history of
cardiomyopathy
Structural heart
disease
e.g., Patients with:
· Previous MI
· LV remodeling including
LVH and low EF
· Asymptomatic valvular
disease
Development of
symptoms of HF
e.g., Patients with:
· Known structural heart disease and
· HF signs and symptoms
HFpEF
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
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
STAGE D
Refractory 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
Refractory
symptoms of HF
at rest, despite
GDMT
e.g., Patients with:
· Marked HF symptoms at
rest
· Recurrent hospitalizations
despite GDMT
HFrEF
THERAPY
Goals
· 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
2013 ACCF/AHA Guideline for the Management of Heart Failure
THERAPY
Goals
· Control symptoms
· Improve HRQOL
· Reduce hospital
readmissions
· Establish patient’s endof-life goals
Options
· Advanced care
measures
· Heart transplant
· Chronic inotropes
· Temporary or permanent
MCS
· Experimental surgery or
drugs
· Palliative care and
hospice
· ICD deactivation
Olgu 2
Tedavi:
• Metoprolol 50 mg 1x1
• Valsartan 160 mg 1x1
• Atorvastatin 20 mg 1x1
• Aspirin 100 mg 1x1
Anjiotensin Reseptör Blokerleri
İlaç İsmi
Günlük Başlangıç Dozu
Hedef Doz
Candesartan
4-8 mg qd
32 mg qd
Losartan
12.5-25 mg qd
150 mg qd
Valsartan
40 mg bid
160 mg bid
Olgu 3
• 64 y E
• 2 gündür artan nefes darlığı ile başvuruyor
• 1 ay önce STEMI tanısıyla primer perkutan
koroner anjioplasti uygulanmış
Kullandığı ilaçlar
1.
2.
3.
4.
5.
Aspirin 100 mg 1x1
Clopidogrel 75 mg 1x1
Metoprolol 50 mg 1x1
Lisinopril 20 mg 1x1
Atorvastatin 40 mg 1x1
Olgu 3
• Progresif dispne
• Efor intoleransı
• NHYA sınıf III
• TA: 100/60 mmHg
• Nb: 84/dk
•
•
•
•
JVD
Taşikardi
S3 gallo ritmi
AC bazalinde krepitan ral
• BNP: 1200 ng/ml
• EKO LVEF: %35
• Yoğun bakım ünitesinde izlem
• O2, İV diüretik
• İlaç dozları yeniden düzenlendi
Kalp Yetersizliğinin Evreleri ve Tedavisi
At Risk for Heart Failure
Heart Failure
STAGE A
STAGE B
STAGE C
At high risk for HF but
without structural heart
disease or symptoms of HF
Structural heart disease
but without signs or
symptoms of HF
Structural heart disease
with prior or current
symptoms of HF
e.g., Patients with:
· HTN
· Atherosclerotic disease
· DM
· Obesity
· Metabolic syndrome
or
Patients
· Using cardiotoxins
· With family history of
cardiomyopathy
Structural heart
disease
e.g., Patients with:
· Previous MI
· LV remodeling including
LVH and low EF
· Asymptomatic valvular
disease
Development of
symptoms of HF
e.g., Patients with:
· Known structural heart disease and
· HF signs and symptoms
HFpEF
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
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
STAGE D
Refractory 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
Refractory
symptoms of HF
at rest, despite
GDMT
e.g., Patients with:
· Marked HF symptoms at
rest
· Recurrent hospitalizations
despite GDMT
HFrEF
THERAPY
Goals
· 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
2013 ACCF/AHA Guideline for the Management of Heart Failure
THERAPY
Goals
· Control symptoms
· Improve HRQOL
· Reduce hospital
readmissions
· Establish patient’s endof-life goals
Options
· Advanced care
measures
· Heart transplant
· Chronic inotropes
· Temporary or permanent
MCS
· Experimental surgery or
drugs
· Palliative care and
hospice
· ICD deactivation
Rp
1.
Aspirin 100 mg 1x1
2.
Clopidogrel 75 mg 1x1
3.
Ramipril 2.5 mg 1x1
4.
Carvedilol 6.25 mg 2x1/2
5.
Furosemid 40 mg 1x1
6.
Spiranolakton 25 mg 1x1
7.
Atorvastatin 40 mg 1x1
Beta Blokerler
İlaç İsmi
Günlük Başlangıç Dozu
Hedef Doz
Bisoprolol
1.25 mg qd
10 mg qd
Carvedilol
3.125 mg bid
25 mg bid
Metoprolol succinate
12.5-25 mg qd
200 mg qd
Nebivolol
1.25 mg od
10 mg od
Rp
1.
2.
3.
4.
5.
Aspirin 100 mg 1x1
Perindopril 5 mg 1x1
Metoprolol 50 mg 1x1
Furosemid 40 mg 1x1
spirinolakton 25 mg 1x1
Olgu 4
Kalp yetersizliği tedavisi almakta
iken akut gelişen nefes darlığı,
çarpıntı
Acil servise başvuru
EKO: LVEF %35, MY 2, TY 2-3
Kardiyoversiyon denenmiş ancak
başarısız
Olgu 4
Rp
1.
2.
3.
4.
5.
6.
7.
Aspirin 100 mg 1x1
Perindopril 5 mg 1x1
Metoprolol 50 mg 1x1
Furosemid 40 mg 1x1
Spiranolakton 25 mg 1x1
Digoksin 0.5 mg 1x1
Coumadin 5 mg 1x1/2
• Rp
1.
2.
3.
4.
5.
6.
Aspirin 100 mg 1x1
Ramipril 5 mg 1x1
Carvedilol 6.25 mg 2x1/2
Furosemid 1x1
Spiranolakton 25 mg 1x1
Atorvastatin 20 mg 1x1
• Semtomatik Kalp yetersizliği
• Olguda şiddetli KOAH nedeniyle
• beta bloker dozu artırılamamakta
EKG ve Resim dikkate alınarak yeni
Tedavisi ???
Olgu 5
• Rp
1.
2.
3.
4.
5.
Aspirin 100 mg 1x1
Ramipril 5 mg 1x1
Carvedilol 6.25 mg 2x1/2
Furosemid 40 mg 1x1
Atorvastatin 20 mg 1x1
6.
7.
Eplerenon 25 mg 1x1
İvabradin 5 mg 2x1
JİNEKOMASTİ !
KALP HIZI > 80 atım/dk
Olgu 5
Kalp yetersizliği (korunmuş ya da düşük ejeksiyon fraksiyonlu, kronik ya
da akut) tedavisinde yaygın kullanılan diüretik dozları
Olgu 6
İLAÇ TEDAVİSİ ??
Rp
1.
2.
3.
4.
5.
6.
7.
8.
Aspirin 100 mg 1x1
Ramipril 5/12.5 mg 1x1
Karvedilol 6.25 mg 2x1
İsosorbid mononitrat 20 mg 2x1
Furosemid 40 mg 1x1
Spiranolakton 25 mg 1x1
Rosuvastatin 10 mg 1x1
Digoksin 1x1
Olgu Semptomatik KKY
Objektif koroner iskemi bulgusu yok
EKO LVEF % 30
EKG: SR, LBBB, QRS ≥ 130 msn
Kardiyak Resenkronizasyon Tedavisi (CRT)
Kalp
ESC 2012
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Kalp Yetmezliği - Cemil Gürgün