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1 순환기내과 조구영

2 Disorder causing dyspnea Pulmonary Air flow limitation, restrictive, chest wall, pulmonary circulation Cardiac Coronary Valvular Myocardial: systolic or diastolic disorder Anemia Peripheral circulation Obesity Psychogenic or malingering Deconditioning

3 Dyspnea Work of breathing Respiratory rate Low cardiac output Anemia Hypoxia Metabolic acidosis Lung compliance Pulmonary edema Cardiogenic Non-cardiogenic Other parenchymal diseases

4 History Quality of sensation, timing, positional disposition Persistent vs. intermittent General appearance Vital sign Chest Cardiac exam Extremities At this point, diagnosis may be evident if not, proceed Chest X-ray, BNP Low CO Respiratory High CO

5 Skeletal muscle hypothesis in chronic HF LV dysfunction Increased ergo receptor activity Skeletal and respiratory myopathy

6 Case presentation Case 1 F/73. DOE for 3 weeks, HTN Case 2 63/M. DOE for 2 weeks, DM, HCC Case 3 67/M. DOE for 5 years, recently aggravated Case 4 69/F. DCMP for 11 years Case 5 F/50. recurrent HF, DM, CRF

7 Systolic and diastolic function Case 1, 2, 5: diastolic dysfunction Different manifestation and different diagnosis Case 3, 4: both had severe LV dysfunction, but quite different in QoL What s difference? Case 5 Normal LV function, normal CAG Why recurred heart failure?

9 Systolic function Provides the initial clues or information necessary for diagnosis, treatment, and prognosis of almost all cardiac conditions Quantitative assessment of systolic function based on changes in ventricular size and volume

10 Powerful predictor of survival in HF Improvement of EF

11 LV contractility using MR AVo Aorta IVCT LV MVc LA Pressure Velocity 4 mmhg 1 m/s dt MR jet 36 mmhg 3 m/s dp/dt = 32/sec mmhg/s

12 dp/dt = 556 mmhg/s dp/dt = 2543 mmhg/s

13 Diastolic Heart Failure in the Framingham Study Population-Based Cohort EF <50 49% EF >50 51% Vasan et al: JACC, 1999

14 Systolic function by gender among Subjects with HF Men Women 31% 10% 42% 23% 27% 67% Normal Kitzman et al: AJC, 2001 Mild Mod/Sev

15 Diastolic Heart Failure (HF with preserved EF; HFpEF) Signs and symptoms of CHF Normal EF Abnormal LV relaxation, filling, diastolic distensibility or diastolic stiffness

16 Mechanism of Augmented Rate of Left Ventricular Filling During Exercise Cheng CP et al. Circ Res 1992;70:9

17 Population-based N Engl J Med 2006;355: HR: 1.13 (95% CI, 0.94 to 1.36) P=0.18 N Engl J Med 2006;355:260-9.

18 Diastolic function Normal? Abnormal?

19 Assessment of diastolic function

20 Ao AVO IRT AVC ICT LA LV MVO MVC E A

21 LV diastolic pressure (cath.) vs transmitral flow (E/A ratio, Echo.)

22 Abnormal relaxation Pseudo- normal Restriction (reversible) Restriction (irreversible) 40 0 Mean LAP N Grade diastolic dysfunction I II III >25 IV

23 Applying TDI to measuring PCWP E α PCWP e α 1 relaxation relaxation E e α PCWP relaxation X relaxation 1 Thus E e α PCWP : Powerful predictor of survival in CHF, and ---

24 LAVI vs Diastolic Dysfunction LAVI (m ml/m2) r=0.78 N= Normal Abnormal Pseudo- Restrictive relaxation normal Diastolic function grade

25 CHARM-preserved LVEF > 40% Conventional therapy candesartan 32mg or not f/u with 36.6 mo. Mortality: hazard ratio (H R) = 0.95, p = Readm. For HF: HR = 0.84, p =

26 I-preserve Age > 60yrs withef > 45% Conventional therapy irbesartan 300mg or not mean f/u with49.5 mo. Mortality: HR = 1.0, p = 0.98 Readmission for CV cause: H R = 0.95, p = 0.44

27 Unknown field RAAS 차단제가이완기기능과관계된 myocardial hyp ertrophy, fibrosis, myocardial calcium handling, ventri culo-vascular coupling등에좋은효과가입증되었음에도불구하고, PEP-CHF, CHARM-Preserved, I-PRESER VE와같이대규모임상적연구에서는모두생존율을향상시키지못한것은아직이완기심부전에대한생리학적및병리학적기전이완전히밝혀지지않았음을시사한다.

28 Exercise in HF LV dysfunction Vascular injuries Arterial resistance Endothelial dysfunction Heart failure Neurohormonal stimulation RAA sym./parasym. BNP a. Better Myopathy perfusion and extraction of O2 by the muscle b. Increase in stroke volume Muscluar mass Fat infiltration Oxidative muscle metabolism in Ventilatory HR in response injuries to a given exercise O2 uptake Dead space VE/VCO2 slope Respiratory efficiency

29 ACC/AHA 지침 Hypertension AF: ventricular rate AF: restoration to sinus rhythm Diuretics Physicians should control systolic and diastolic hypertension, in accordance with published guidelines (class I, level A evidence) Physicians should control ventricular rate in pati ents with AF (class I, level C evidence) Restoration and maintenance of sinus rhythm in patients with AF might be useful to improve sym ptoms (class IIb, level C evidence) Physicians should use diuretics to control pulmonary congestion and peripheral edema (class I, level C evidence)

30 ACC/AHA 지침 Coronary revascularization Drug therapy In whom symptomatic or demonstrable myocardial ischemia is judged to be having an adverse effect on cardiac function (class IIa, level C evidence) The use of β-adrenergic blocking agents, ACE inhibitors, ARB or calcium-channel blockers in patients with controlled hypertension might be effective to minimize symptoms of heart failure (class IIb, level C evidence) The use of digitalis to minimize symptoms of heart failure is not well established (class IIb, level C evidence)

(Microsoft PowerPoint - S13-3_\261\350\273\363\307\366 [\310\243\310\257 \270\360\265\345])

$(Microsoft PowerPoint - S13-3_\261\350\273\363\307\366 [\310\243\310\257 \270\360\265\345])$ Cardiovascular Disease in Metabolic Syndrome 김상현 보라매병원내과 서울대학교의과대학내과학교실 Contents Metabolic syndrome and Cardiovascular system CVD Mortality Coronary artery disease Heart failure Atrial fibrillation Management