??? ?????????? Dr. Philip B. Adamson, Director Congestive Heart Failure Treatment Program University of Oklahoma

1
?????????, ??????????????, ??????????? ? ???????
???

• ??? ?????????? Dr. Philip B. Adamson, Director
  Congestive Heart Failure Treatment Program
  University of Oklahoma
• Oklahoma City, Oklahoma

2
????? I ????????? ? ?????????????? ???
3
??? (HF) ???????????

• ??????? ??????????? ???????, ??? ??????? ??????
  ?? ? ????????? ???????????? ????????? ?????? ?
  ???????????? ? ??????????????? ?????????????
  ????????? ? ???????? ?????????.

4
??? ????????????? ? ??????????????????

• ??????????????????
• ? ???? - 22 ???1
• ??? - 5 ???2
• ?????????????
• ? ???? - 2 ??? ????? ??????? ????????1
• ??? 500 000 ????? ??????? ????????2
• ??? ? 10 ??? ?? 1 0000 ?????? 65 ??? ? ???2

1 World Health Statistics, World Health
Organization, 1995. 2 American Heart
Association, 2002 Heart and Stroke Statistical
Update.
5
??????? ???????? ? ????

• ??? 1988-94

Source NHANES III (1988-94), CDC/NCHS and the
American Heart Association
6
?????????????? ????????????? New York Heart
Association

• Class I ??? ????????? ??? ??????? ??????????
• Class II ?????? ??????????? ??? ??????????.
  ?????????? ???????????? ? ?????, ?? ???????
  ???????? ???????? ? ?????????, ??????,
  ????????????, ???????????.
• Class III ???????? ??????????? ???. ??????????.
  ?????????? ???????????? ? ?????, ?? ????????
  ???? ??????? ???????? ? ?????????, ??????,
  ????????????, ???????????.
• Class IV ?????????? ??? ????? ???. ????????.
  ???????? ??????????? ???? ? ?????.

7
????????????? ??? ???????? ? ????????

• ?????? ?????? ??? (ACC/AHA Guidelines)
• ?????? A ??????? ???? ??? ??? ???????????
  ????????? ??????
• ?????? B ??????????? ????????? ?????? ???
  ????????? ???
• ?????? C ???????? ??? ? ??????? ??? ?????????
  ??? ??????? ??????????? ????????? ??????
• ?????? D ???????? ??????, ??????? ???????
  ??????????? ???????????

Hunt, SA, et al ACC/AHA Guidelines for the
Evaluation and Management of Chronic Heart
Failure in the Adult, 2001
8
????????? ??????? ??????
NYHA II
NYHA III
???
???
12
??????
26
??????
59
???
24
???
64
15
n 103
n 103
NYHA IV
???
??????
33
56
???
11
n 27
MERIT-HF Study Group. Effect of Metoprolol CR/XL
in chronic heart failure Metoprolol CR/XL
randomized intervention trial in congestive heart
failure (MERIT-HF). LANCET. 19993532001-07.
9
????????? ???

• ?????? ??????? ????
• ?????? ???????????? ?????????? ????????????????
  ???????? ? ??????????
• ???
• ???
• ??????????????
• ???????? (???????? ?????????, ??????? Chagas)
• ??????? (???????? ? ????????????? ?????????)
• ????????? ?????????
• ??????????? ???????

10
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  ?????????? ????????? ???????? ? ?????

11
?????????? ?? (???)

• ????????????? ????????? ??????????
• ???????? 2\3 ????????? ? ??? ????? ?????????????
  ??????????
• ?????????????? ????????? ????????????\??????????

30
(EF gt 40 )
(EF lt 40)
70
?????. ??????????
????. ??????????
1 Lilly, L. Pathophysiology of Heart Disease.
Second Edition p 200
12
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• ?????????? ?????, ??????? ?? ??????????? ?
  ??????? ??????

?? ??? x ??
13
???????, ???????? ?? ???????????????? ??????????
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????????????
Stroke Volume

• ???????????? ??????? ??????
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??? ?? lt 40
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15
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16
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17
?????????? ?? ????????????? ? ??????????????

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• ?????? ??? ?????????
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• ??????????
• ??????
• ?????????????

• ????????
• ????????? ?????
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• S3 (???? ??????)
• ???????????
• ??????? Cheyne-Stokes

18
?????????? ?? ????????????? ? ??????????????

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19
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????????

• ? ??????? ?? (BP)
• ? ??
• x
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20
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• ???????? Frank-Starling
• ????????????????? ?????????
• ??????????????? ??

21
?????????????? ?????????

• ???????? ??????-?????????
• a. ? ?????, ??? ???
• b. ???
• c. ?????????? ???

22
?????????????? ?????????

• ????????????????? ?????????
• ????????? ???????????? ?????? ????????????
  ????????? ???
• ????????????? ??????? ??????? (SNS)
• ?????-???????????-??????????????? ??????? (RAAS)
• ??????????? (????????????????? ??????, ADH)

23
?????????????? ?????????????????????? ???????
???????
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? ????????????
??????????
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???? (??? x ????) x ?????
24
????????????? ????????? ??? ???
? ????. ????????????
???????????????? ???
Packer. Progr Cardiovasc Dis. 199839(suppl
I)39-52.
25
?????????????? ??????????????-???????????-??????
????? (RAAS)
???????????????
?????
??????????? I
???
??????????? II
AT I ?????????
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26
?????????????? ??????????????-???????????-??????
????? (RAAS)
?????-???????????-??????????? (? ????????
????????)
???????? ???? ? ????, ?????
????. ?????????
???????????????
????? (??? x ????) x ?????
27
?????????????? ???????????????????? (ADH)
???????? ?????????? ??
??????????? ?????????????
-
?????????? ????????????
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28
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29
?????????????? ?????????

• ???????????? ???????????????
• ????????? ????????? ????????, ?????, ????????? ?
  ??????? ? ?????????? ????????????
  ????????????????? ???????

Curry CW, et al. Mechanical dyssynchrony in
dilated cardiomyopathy with intraventricular
conduction delay as depicted by 3D tagged
magnetic resonance imaging. Circulation 2000 Jan
4101(1)E2.
30
?????? ????????????

• ??????-??????????? ??????? 3 ????????? ????
• ??????????? (ANP)
• ?????????????? ? ??????????
• ????????????? ? ???????????????? ??-??
• ???????? (hBNP)
• ?????????????? ? ?????????? ?????
• ????????????? ? ???????????????? ??-??
• C-??? (CNP)
• ?????????????? ? ???
• ????????? ??????-??????????? ? ????????????????
  ??-??

31
????????????????? ???????? hBNP
????????????? ???? ??????? ??????????
??????? ???????????? ??????????? ????????????
????? ?????? ??????-????


Abraham WT and Schrier RW, 1994
32
?????????????? ???????

• ????????????? ??????????.
• ?????????????? ????????????? ??????? (EDRF)
  ??????????????
• ????? ????? (NO)
• ??????????
• ????????????
• ?????????????? ????????????? ??????? (ED?F)
  ????????????????
• ?????????? I

33
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  ????????? ??????
• ???. ?????????? ??????
• ??????? ??????? ????????????? ? ?????? ?????????
• ???????
• Tumor necrosis factor (TNF)-alpha
• Interleukin 1-alpha
• Interleukin-2
• Interleukin-6
• Interferon-alpha

34
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??????????? ????. ???????? (???????????? ?
????????????)
???????? Frank-Starling ?????????.
????????? ???????????????
??????????? ?? ?? ???? ???????????? ?
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???????????????
35
????????????????? ????? ??? ???
??????? ????????????, ????? -????????????
????? ?????? ?????? ?????????? ??????
???????? ???? ? ???? ?????????? ???????????? ?????? ? ??????, ????????
??????????????? ?????????? ?? ??? ???????? ?????? ??????? ?????????? ???????? ?????????? (??????????? ????????????), ?????????? ??????? ???????
????. ?????????? ??????????? ??? ? ?? ?????????? ??????-???????
Jaski, B, MD Basics of Heart Failure A
Problem Solving Approach
36
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37
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38
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  ??????????????)
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40
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2D ?????
M-?????
41
????? III ??????????? ??????? ???
42
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?????? per os
???
43
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44
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47
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  ????????? ?????. ?????????
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48
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49
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• ????-?????????
• ?????????????????? ?????? ?? ???? ??????? ????.
  ??????????
• ????????????? ?????? ???????? ???????.
  ????????????, ?? ? ??????? 1-2 ??? ????????? ??
• ??? ????. ?????? ???????? ????????????1
• ? ?????????? ? ????????????? ??????????? ???????
  ????. ???? ?????????? ? ???????????????? ???1

1 Hunt, SA, et al ACC/AHA Guidelines for the
Evaluation and Management of Chronic Heart
Failure in the Adult, 2001 p. 20.
50
????-?????????

• ???????????? ???????? ??????, ??? ????????? ????

51
??????????????

• ??????????? ????????????
• ?????? ???????????
• ????????? ???? ??????, ????????? ? ???
• ?????? ????????????? ??? ????????? ? ?? III-IV
• ???. ??????? ???????? ????????????? ?
  ????????????. ????? ????????? ??????????????
  ??????? ????? ? ?????????? ?????????

52
??????????????

• ????????? ?????????? ???????????? (ARBs)
• ????????? ????????? AT1, ??????? ?????????
  ????????????? ??-II
• ??????? valsartan, candesartan, losartan
• ?? ??????????? ? ?? ??????????? ????
• ? ??????????? ???????? ?????????? ????????????
  ??? ?????????????? ? ???? ??? ??? ???????? ?? ??
  ???? ???????? ????? ??? ???????????

53
????????? ??- II
AT1
AT2

• ???????????????
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• ????-???????
• ???-??????
• ???-???????
• ???-????????

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• ???-???????
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54
????? IV??????????? ? ??????? ???
55
?????????????????? ???????

• ???????? ?????? ?????? ??????

56
?????????????????? ???????

• ?????????
• CRT
• ?????????? ??? (NYHA Class III/IV)
• ???????????? ??????? ??????????? ???. ???????
• QRS ? 130 ??
• ?? ? 35
• CRT ICD
• ????????? ? ???

57
?????????????????? ???????????? ??????????

• 2\3 ????????? ???????? ????????? (responders)1
• ? ????????? ????????? ????????? ?? ?????

NB CRT ???? ?????????? ? ????????????, ? ??
?????? ??
1 Abraham, WT, et. Al. Cardiac
Resynchronization in Chronic Heart Failure. N
Engl J Med 20023461845-53
58
?????????????????? ???????????? ??????????

• ????? ?????, ????? ??????? ? ????? ????????? ????
  ??? ?????????
• ?????? ?? ?????????
• ??????? ???? ???????
• ????? ??? ????????? ?? ????????? ?????
• ????? ??? ????????

59
?????? ????? ????? ???????????

• 7-10 ???? ????? ???????????
• ?????? ???????? ???? ?????????
• ?????? ????
• ????????? ??????
• ?????? ??????? ????????
• ?????? ?????? ????? ?????????? ????? ???????????
  CRT
• ??????????? ???????? ?????
• ?????? ??????????
• ???????? ????????????
• ???????? ????????!

This is not a complete list for many
practitioners and is presented here only as a
guideline.
60
????

• ??? ??????????? ??????????????? ?????????,
  ??????? ?????? ????????, ?? ????? ??????????????
• ???????????? ??????????? ?????? ?????,
  ?????????????? (????, ???, ???????? ? ?????????).
• ???????? 15 ????????? ? ??? ????? ????
  ??????????? ?? ?????????????????? ???????
• ?????????? ?????????? ?????????? ?? ??????
  ?????????? ? ????????????? ????????? ???????

61
Brief Statement for Cardiac Resynchronization
System (InSync 8040 Generator / InSync ICD 7272
/ Attain Models 2187, 2188, 4193 Leads /
9790/2090 Programmer )

• 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.