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1 2017 KSC 개원의를위한심장혈관심포지엄 :30-16:50 심부전치료 ; 변하는것과변하지않는것 Jaewon Oh, MD Cardiology Division, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea

diseases Highest rehospitalization rate and economic cost in

2 Heart Failure (HF) (1) Shortness of breath, generalized edema One of the most poor prognostic cardiovascular diseases Highest rehospitalization rate and economic cost in developed countries in addition to healthimportant in economy and society

3 Heart Failure (HF) (2) Various etiologies (e.g. myocardial infarction, valvular heart disease, chemotherapy like doxorubicin) and clinical presentations make hard to develop new drug for heart failure Only one drug was approved for HF treatment within the last 10 years by FDA (in July 2015)

4 Acute Heart Failure When HF was aggravated, HF patients need admission for dyspnea control 5-10% of acute HF patients die in hospital without discharge 1/3~1/2 of acute HF patients die within 5 years after the first diagnosis Lower survival rate than breast or prostate cancer European Society of Cardiology predict 25% increase in HF prevalence in 2030

5 Definition

6 HF is a clinical syndrome characterized by typical symptoms that may be accompanied by signs caused by a structural and/or functional cardiac abnormality, resulting in a reduced cardiac output and/or elevated intracardiac pressures at rest or during stress.

7 2016 ESC HF Guideline

8 Diagnosis

9 용적과부하 : 심부전의특징 Pulmonary congestion 폐부종, 폐울혈, 흉막삼출, 발목부종, 복수등전신부종

10 Chest X-ray finding of ADHF Cardiomegaly Pleural effusion Pulmonary edema - Batwing pattern - Increased bronchial marking

11 BNP B-type Natriuretic Peptide NT-proBNP N-terminal pro B-type Natriuretic Peptide

12 2016 ESC HF Guideline

13 HFrEF >>> Systolic HF Heart Failure with Reduced Ejection Fraction HFpEF >>> Diastolic HF Heart Failure with Preserved Ejection Fraction

14 2016 ESC HF Guideline

15 Etiology

16 2016 ESC HF Guideline

17 Epidemiology

18 심부전의유병률은향후 빠르게증가할것임 노령화사회로의짂입 고혈압, 관상동맥질홖, 당뇨병등원인질홖의빠른증가 심부전유병률증가 수술 / 치료기술발달로판막질홖, 관상동맥질홖자의장기생존증가

19 Prevalence (%) 한국에서의심부전유병률 2.0 (104% 증가, 2002 년평균 0.75% 에서 2013 년 1.53% 로증가 ) Men 1.5 Women Year 국민건강의료보험공단자료, 임남규등 ( 대한심장학회지, 2015, in press)

20 유병율 (%) 우리나라 60 세이상의심부전유병율 국민건강의료보험공단자료 ( ) 연령 심부전은주로노인에서발병하며, 심부전발생은 60 세이상에서연령이증가함에따라기하급수적으로증가한다 국민건강의료보험공단자료, 대한민국 ( 미발표 )

21 심장질홖의종착역! 1.53 %

22 How to Assess

23 심부전홖자의평가 주관적방법 1. NYHA classification 2. Questionnaire 객관적방법 1. 6MWT 2. CPX (cardiopulmonary exercise test)

24 NYHA Classification NYHA Class I II III IV 정의 일상적활동시증상없음 일상적활동시증상있음 일상적인활동보다정도가낮은활동시에도증상있음 안정시에도증상있음

25 6-minute walk test (6MWT) Eur Respir J 2011; 37:

26 Cardiopulmonary Exercise Test (CPX/CPET)

27 Treatment Medical vs. Device

28 Guideline for Heart Failure Circulation. 2013;128:e240-e327

29 Circulation. 2013;128:e240-e327

30 ESC 2016 HF Guideline

31 ACEI or ARB + BB + MRA

32 2016 ESC HF Guideline

33 2016 ESC HF Guideline

34 ESC 2016 HF Guideline

36 Ivabradine (procoralan) LVEF < 35% Sinus rhythm HR > 75/min On top of ACEI/ARB & BB

37 2016 ACC/AHA Update of HF Guideline

38 First in Class Drug ARNI (Angiotensin Receptor + Neprilysin Inhibitor)

39 Valsartan + Sacubitril (Entresto) 2017 년 10 월급여인정!!! LVEF < 35% On Top (4wks) of ACEI/ARB or MRA

40 2016 ACC/AHA Update of HF Guideline

41 ESC 2016 HF Guideline

42 2016 ESC HF Guideline

43 Device Therapy

44 ICD (Implantable Cardioverter Defibrillator)

45 ICD LVEF < 35% On Top (3Ms) of ACEI/ARB or BB

46 WHAT IS CRT? (Cardiac Resynchronization Therapy) Asynchronous contraction Synchronize Biventricular pacing which incorporates both a standard RV lead and a LV lead to synchronize contraction of both ventricles

47 CRT (Cardiac Resynchronization Therapy) NYHA III, QRS 142ms EF : 20% LVEDD/LVESD : 63/56mm NYHA I, QRS 120ms EF : 50% LVEDD/LVESD : 50/37mm

48 CRT LVEF < 35% QRS > 130ms On Top (3Ms) of ACEI/ARB or BB

49 ESC 2016 HF Guideline

50 HFpEF

51 HR % CI P=0.18 Bhatia et al. NEJM 2006;355:260-9

52 2017 ACC/AHA Update of HF Guideline

53 2017 ACC/AHA Update of HF Guideline

54 2017 ACC/AHA Update of HF Guideline

55 심장재활 (Cardiac Rehabilitation) 2017 년 2 월급여인정!!! Life Saved Life Worthy Event driven Tx Medication Procedure / Surgery Comprehensive Tx Nutrition, BP, Lipid, DM, Smoking, Psychosocial, Physical activity, Exercise training

56 심장재활의효과 1. 생존율향상 2. 심장질환위험요인감소

57 심장재활의현황 의료선진국에서는의무적시행 국내의경우 2017년부터급여인정 대상 : 심장질환관련시술 / 수술심부전, 혈관질환, 부정맥등

58 CV Mortality 26% Anderson et al. JACC 2016;67:1

59 Hospitalization 18% Anderson et al. JACC 2016;67:1

60 Aragan et al. JACC 2015;65:

61 세브란스심장혈관병원심장웰니스센터 Y o n s e i U n i v e r s i t y H e a l t h S y s t e m S e v e r a n c e C a r d i o v a s c u l a r H o s p i t a l The First and the Best

안정시심전도에서는발견할수없는중강도유산소운동중다양한심장질홖여부를검사하여퇴원후안전하게운동을실시할수있는상태인지를확인 2.

62 심장재홗치료 1. 유산소운동중치명적부정맥검사 - 퇴원전 / 외래방문시중강도유산소운동동안부정맥등심각한심장문제가발생하는지검사 - 안정시심전도에서는발견할수없는중강도유산소운동중다양한심장질홖여부를검사하여퇴원후안전하게운동을실시할수있는상태인지를확인 2. 하지근력운동 - 입원중심장재홗치료과정을통해하지근력운동을 직접실시하여장기적으로하지근력감소증을예방 3. 전문적인교육자료제공및운동교육 - 홖자개개인의질홖 ( 협심증, 심근경색, 관상동맥질홖, 심부전, 고혈압, 당뇨, 고지혈증 ) 을관리하기위한최적의운동법을교육

63 Take Home Message BNP (NTproBNP) HFrEF vs. HFpEF Medical (Ivabradine/ARNI) Device (ICD/CRT) Cardiac Rehabilitation

64 Thank You for Your Attention

66 2017 ACC/AHA Update of HF Guideline

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<4D F736F F F696E74202D20B0B3BFF8C0C7BFACBCF6B0ADC1C220B0ADC0C7B7CF5FC1B6B1B8BFB5> 순환기내과 조구영 Disorder causing dyspnea Pulmonary Air flow limitation, restrictive, chest wall, pulmonary circulation Cardiac Coronary Valvular Myocardial: systolic or diastolic disorder Anemia Peripheral circulation