Transcript 1 – Dysfonction asymptomatique

Recommandation consensuelle du traitement
du patient avec dysfonction ventriculaire
gauche asymptomatique.
Dr Serge Lepage
cardiologue
CHUS
Dysfonction VG
Cardiomyopathie
FR
Post mi
Pré-angioplastie primaire
Post-angioplastie primaire
L ’insuffisance cardiaque (2)
Classification
Classes
(New York Heart Association)
Étapes de la maladie et
(périodes critiques
d ’organisation des services3)
I : Aucun symptôme
A : Avant
II : Symptômes pendant des
activités ordinaires
B : Émergence de l ’insuffisance
cardiaque
III : Symptômes pendant des
activités moins
qu’ordinaires
C : Relative autonomie
IV : Symptômes au repos
E: Fin de vie
NYHA2
D: Perte sévère d ’autonomie
Pronostic de l’IC
1,0
Survie
0,8
0,6
0,4
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)
0,2
0
1
2
3
4
5
Période après inclusion (années)
NYHA = New York Heart Association
6
Smith WM. Am J Cardiol 1985;55:3A-8A.
Diagnostic clinique
Critères de Framingham1
2 symptômes majeurs OU 1 majeur + 2 mineurs = diagnostic
Majeur
• DNP ou orthopnée
• DVC
• Râles
• Cardiomégalie
• Œdème pulmonaire aigu
• Bruits de galop
• PVC > 16 cm H2O
• Temps de circulation  25 sec.
• Reflux hépatojugulaire
PVC = pression veineuse centrale
PVJ = pression veineuse jugulaire
DVC = distention des veines du cou
DNP = dyspnée nocture paroxystique
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 traitement
1. McKee PA, et al. N Engl J Med 1971;285:1441-1446.
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.
McDonagh TA, Morrison CE, Lawrence A, Ford I, Tunstall-Pedoe H, McMurray JJ, Dargie HJ
•
•
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.
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].
Kaplan-Meier Curves for Survival of Participants From
the Framingham Study
Atherton, J. J. J Am Coll Cardiol Img 2010;3:421-428
Copyright ©2010 American College of Cardiology Foundation. Restrictions may apply.
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.
Quelle dose de médicament
doit-on utiliser?
* 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.
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
Mortality from All Causes (%)
SOLVD
Prevention Trial All Cause Mortality
25
Placebo
Enalapril
20
Risk Reduction 8%
15
10
P=0.30
5
0
0
6
12
18
24
30
36
42
48
Months
N Engl J Med 1992;327:685-91
% Events
SOLVD Prevention Trial
Death or Development of CHF
50
45
40
35
30
25
20
15
10
5
0
Placebo
Enalapril
Risk Reduction 29%
p<0.001
0
6
12
18
24
30
36
Months of Follow-up
42
48
N Engl J Med 1992;327:685-91
% Events
SOLVD Prevention Trial
First Hospitalization for CHF
18
16
14
12
10
8
6
4
2
0
Placebo
Enalapril
Risk Reduction 36%
p<0.001
0
6
12
18
24
30
36
42
48
Months of Follow-up
N Engl J Med 1992;327:685-91
SOLVD Prevention Trial
35
27,8
30
25
placebo
enalapril
22,3
20
months
15
13,2
8,3
10
5
0
Median length of time to first CHF
hospitalization
Median length of time to develop CHF
N Engl J Med 1992;327:685-91
SOLVD Prevention- Enalapril
Asymptomatic HF Patients w/ LVD (EF < 35%)
(NYHA Class I-II)
32% Fewer First
Hospitalizations
p<0.001
300
250
200
Placebo (n=2,177)
Enalapril (n=2,111)
150
100
50
0
273
184
Number of First Hospitalizations for Heart Failure
The SOLVD Investigators, N Engl J Med, 1992.
SOLVD Prevention Trial
Morbidity 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
First Hospitalization for
CHF
Multiple Hospitalization for
CHF
Death or Development of
CHF
Death or Hospitalization for
CHF
22.5
13.9
43%
<0.001
12.9
8.7
36%
<0.001
4.8
2.7
44%
<0.001
38.6
29.8
29%
<0.001
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 bêtabloquant, 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.
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.
Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.
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.
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,
post-IM
IC de classe IV
(NYHA)
du VG, sans IC
IC, dysfonctionnement
du VG
Risque CV élevé
sans dysfonctionnement
Résultats
RRR de mortalité
de 36 %
Survie générale
prolongée
Survie prolongée
de 9,4 mois
Réduction du nombre
d’événements CV majeurs de 50 %
et de nouveaux cas de diabète
Résumé
Importante réduction de
mortalité à long terme
avec le traitement IECA
post-IM
Effets bénéfiques
maintenus pendant
au moins 4 ans
Meilleure survie
à long terme
Avantages CV et
métaboliques à long
terme chez les patients
ne souffrant ni d’insuffisance
cardiaque ni d’un
dysfonctionnement du VG
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.
Les avantages à long terme des
inhibiteurs d’ECA sur la mortalité
Hall AS et al. Lancet 1997;349:1493-7.
Jong P et al. Lancet 2003;361:1843-8.
Les avantages à long terme des
inhibiteurs d’ECA sur la mortalité
Swedberg K et al. Eur Heart J 1999;20:136-9.
HOPE/HOPE-TOO Study Investigators. Circulation
2005;112:1339-46.
Quand utiliser les bêta-bloquants?
•
Chez tous les patients souffrant d’IC avec une FEVG ≤ 40 % (utiliser des bêtabloquants 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
Asymptomatique
Légère/Mod.
Grave
Réfractaire
CRT (LBBB), CPAP
Digoxine/Dérivés nitrés
Spironolactone
Risque de mort subit — AICD
Ajustement des BB
IECA/(ARA)
Aucun sel
ajouté
2 gm Na
Suivi clinique
de l’IC
Programme de
style de vie
personnalisé
Treatment Approach for the Patient
with Heart Failure
Stage A
Stage B
Stage C
Stage D
At high risk, no
structural disease
Structural heart
disease,
asymptomatic
Structural heart
disease with
prior/current
symptoms of HF
Refractory HF
requiring
specialized
interventions
Therapy
Therapy
Therapy
Therapy
• Treat Hypertension
• All measures under
stage A
• All measures under
stage A
• All measures under
stages A,B, and C
• ACE inhibitors in
appropriate
patients
Drugs:
• Mechanical assist
devices
• Treat lipid
disorders
• Encourage regular
exercise
• Discourage alcohol
intake
• ACE inhibition
• Beta-blockers in
appropriate
patients
• Diuretics
• ACE inhibitors
• Beta-blockers
• Digitalis
• Dietary salt
restriction
• Heart
transplantation
• Continuous (not
intermittent) IV
inotropic infusions
for palliation
• Hospice care
Hunt, SA et al. ACC/AHA Guidelines CHF, 2001.
Treatment Approach for the Patient
with Heart Failure
Stage A
Stage B
At high risk, no
structural disease
Structural heart
disease,
asymptomatic
Therapy
Therapy
• Treat Hypertension
• All measures under
stage A
• Treat lipid
disorders
• Encourage regular
exercise
• Discourage alcohol
intake
• ACE inhibition
• 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-II
V-HeFT-II
SOLVD-T
SOLVD-P
SAVE
AIRE
TRACE
ATLAS
Vasodilators
V-HeFT
FIRST
PRAISE-I/-II
Aldosterone
antagonists
RALES
EPHESUS
Slide courtesy of G. Francis
-Blockers
MDC
U.S. Carvedilol
ANZ Carvedilol
MERIT-HF
CIBIS-II
BEST
COPERNICUS
CAPRICORN
ARBs
ELITE-II
Val-HeFT
OPTIMAAL
CHARM
VALIANT
ACE/NEP Inhibitors
OVERTURE
Inotropic agents
PROMISE
VEST
DIG
OPTIME-II
Cytokine antagonists
RENAISSANCE
RECOVER
Endothelin antagonists
ENABLE-2
Sympatholytic agents
MOXCON
Positive
Borderline/Neutral
Negative
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 inhibition, angiotensin receptor
blockade and aldosterone antagonism
• 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).
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).
Practical tips
• Patients in NYHA class I or II can be safely initiated and
titrated with a beta-blocker by nonspecialist physicians.
New York Heart Association functional classification
Class Definition
I No symptoms
Consensus conference recommendations on heart failure 2006
Potential to Prevent HF Hospitalizations
Diet Noncompliance
24%
16%
Inappropriate Rx
Rx Noncompliance
24%
19%
Failure to Seek
Care
17%
Other