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Therapie der fortgeschrittenen Herz - insuffizienz: medikamentös, Resynchronisation (CRT), Operation

Treatment of Progressive Heart Failure: Pharmacotherapy, Resynchronization (CRT), Surgery

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Zusammenfassung

Die Therapie der fortgeschrittenen Herzinsuffizienz folgt dem Primat der kausalen Therapie der Grundkrankheit als wichtigstem Prinzip der Behandlung. Dies setzt eine umfassende Kenntnis der Ätiologie und Pathophysiologie voraus. Das gilt für die koronare Herzerkrankung ebenso wie für die arterielle Hypertonie, die Herzklappenerkrankungen, die Kardiomyopathien mit und ohne Inflammation und die mikrobielle Infektion. Die medikamentöse Behandlung stützt sich sowohl bei der chronischen Herzinsuffizienz mit eingeschränkter als auch weitgehend uneingeschränkter linksventrikulärer Funktion auf herzentlastende Maßnahmen und Medikamente (Angiotensin-converting-Enzym-Hemmer, Angio tensinantagonisten, β-Blocker, Diuretika, Antiarrhythmika sowie Antikoagulazien), wenn erforderlich. Sie wird in späteren oder schweren Stadien gefolgt von einer Device-Therapie zur Resynchronisation und/ oder Defibrillation. Sind alle diese Maßnahmen ausgeschöpft, verbleiben Herztransplantation und linksventrikuläre Unterstützungssysteme als letzte Optionen der Behandlung der terminalen Herzinsuffizienz.

Abstract

The treatment of progressive and terminal heart failure follows the principle of causative therapy. Therefore, etiology and pathophysiology of the underlying disease and its hemodynamic conditions are indispensable. This applies to coronary artery disease, hypertension, valvular heart disease, the cardiomyopathies with and without inflammation, and microbial persistence similarly. The classic treatment algorithms both in heart failure with and without reduced ejection fraction are based on measures onloading the heart (angiotensin-converting enzyme inhibitors, angiotensin antagonists, β-blockers, diuretics) and on antiarrhythmics and anticoagulation, when needed. Device therapy for cardiac resynchronization in left bundle branch block and permanent stimulation therapy may contribute to the hemodynamic benefit. ICD (implantable cardioverter defibrillator) therapy prevents sudden cardiac death, which is often associated with progressive heart failure. Heart transplantation and left ventricular assist devices are final options in the treatment repertoire of terminal heart failure.

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Literatur

  1. Ardehali H, Qasim A, Cappola T, et al. Endomyocardial biopsy plays a role in diagnosing patients with unexplained cardiomyopathy. Am Heart J 2004;147:919–923.

    Article  PubMed  Google Scholar 

  2. Aretz HT, Billingham ME, Edwards WD, et al. Myocarditis: a histopathologic definition and classification. Am J Cardiovasc Pathol 1987;1:3–14.

    CAS  PubMed  Google Scholar 

  3. Chan PS, Soto G, Jones PG, et al. Patient health status and costs in heart failure. Insights from the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS). Circulation 2009;119:398–407.

    Article  PubMed  Google Scholar 

  4. CHARM Programme Investigators, Swedberg K, Pfeffer M, Granger C, et al. Candesartan in heart failure: assessment of reduction in mortality and morbidity (CHARM) — rationale and design. J Card Fail 1999;5:276–282.

    Article  Google Scholar 

  5. CIBIS-II Investigators and Committees. The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II). A randomised trial. Lancet 1999;353:9–13.

    Article  Google Scholar 

  6. Cleland JG, Tendera M, Adamus J, et al. The Perindopril in Elderly People with Chronic Heart Failure (PEP-CHF) study. Eur Heart J 2006;27:2338–2345.

    Article  CAS  PubMed  Google Scholar 

  7. Collaborative Group on ACE Inhibitor Trials, Garg R, Yusuf S. Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and mobidity in patients with heart failure. JAMA 1995;273:1450–1456.

    Article  CAS  PubMed  Google Scholar 

  8. The CONSENSUS Trial Study Group. Effects of enalapril on mortality in severe congestive heart failure: results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). N Engl J Med 1987;316:1429–1435.

    Google Scholar 

  9. Costanzo-Nordin MR, O'Connell JB, Subramanian R, et al. Myocarditis confirmed by biopsy presenting as acute myocardial infarction. Br Heart J 1985;53:25–29.

    Article  CAS  PubMed  Google Scholar 

  10. Davis BR, Kostis JB, Simpson LM, et al., the ALLHAT Collaborative Research Group. Heart failure with preserved and reduced left ventricular ejection fraction in ALLHAT. Circulation 2008;118:2259–2267.

    Article  CAS  PubMed  Google Scholar 

  11. Dickstein K, Cohen-Solal A, Filippatos G, et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008. Eur Heart J 2008;29:2388–2442.

    Article  CAS  PubMed  Google Scholar 

  12. Dorian P. Effective and efficient use of implantable defibrillators: sometimes it's over when it's over. CMAJ 2009;180:599–600.

    PubMed  Google Scholar 

  13. Drucker NA, Coland SD, Lewis AB, et al. Gammaglobulin treatment of acute myocarditis in the pediatric population. Circulation 1994;89:252–257.

    CAS  PubMed  Google Scholar 

  14. Elliott P, Andersson B, Arbustinie E, et al. Classification of the cardiomyopathies: a position statement from the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J 2008;29:270–276.

    Article  PubMed  Google Scholar 

  15. Flather MD, Shibata MC, Coats AJ, et al. Randomized trial to determine the effect of nebivolol on mortality and cardiovascular hospital admission in elderly patients with heart failure (SENIORS). Eur Heart J 2005;26:215–225.

    Article  CAS  PubMed  Google Scholar 

  16. Follath F. Newer treatments for decompensated heart failure: focus on levosimendan. Drug Des Dev Ther 2009;3:75–78.

    Google Scholar 

  17. Friedrich MG, Sechtem U, Schulz-Menger J, et al. Cardiovascular magnetic resonance in myocarditis: a JACC white paper. J Am Coll Cardiol 2009;53:1475–1487.

    Article  PubMed  Google Scholar 

  18. Friedrich MG, Strohm O, Schulz-Menger J, et al. Contrast media-enhanced magnetic resonance imaging visualizes myocardial changes in the course of viral myocarditis. Circulation 1998;97:1802–1809.

    CAS  PubMed  Google Scholar 

  19. Frustaci A, Chimenti C, Calabrese F, et al. Immunosuppressive therapy for active lymphocytic myocarditis: virological and immunologic profile of responders versus nonresponders. Circulation 2003;107:857–863.

    Article  PubMed  Google Scholar 

  20. Frustaci A, Russo MA, Cimenti C. Randomized study on the efficacy of immunosuppressive therapy in patients with virus-negative inflammatory cardiomyopathy: the TIMIC study. Eur Heart J 2009;30:1995–2002.

    Article  CAS  PubMed  Google Scholar 

  21. Fujioka S, Kitaura Y, Ukimura A, et al. Evaluation of viral infection in the myocardium of patients with idiopathic dilated cardiomyopathy. J Am Coll Cardiol 2000;36:1920–1926.

    Article  CAS  PubMed  Google Scholar 

  22. Gasparini M, Regoli F, Galimberti P, et al. Cardiac resynchronization therapy in heart failure patients with atrial fibrillation. Europace 2009;11:v82–v86. ((n 34))

    Article  PubMed  Google Scholar 

  23. Ghio S, Magrini G, Serio A, et al. Effects of nebivolol in elderly heart failure patients with or without systolic left ventricular dysfunction: results of the SENIORS echocardiographic substudy. Eur Heart J 2006;27:562–568.

    Article  CAS  PubMed  Google Scholar 

  24. Grimm W, Christ M, Bach J, et al. Noninvasive arrhythmia risk stratification in idiopathic dilated cardiomyopathy: results of the Marburg Cardiomyopathy Study. Circulation 2003;108:2883–2891.

    Article  PubMed  Google Scholar 

  25. Hoppe UC, Böhm M, Dietz R, et al. Leitlinien zur Therapie der chronischen Herzinsuffizienz. Z Kardiol 2005;94:488–509.

    Article  CAS  PubMed  Google Scholar 

  26. Hunt SA, Abraham WT, Chin MH, et al. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure); developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation; endorsed by the Heart Failure Society. Circulation 2005;112:e154–e235.

    Article  PubMed  Google Scholar 

  27. Hunt SA, Baker DW, Chin MH, et al. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation; endorsed by the Heart Failure Society of America. Circulation 2001;104:2996–3007.

    Article  CAS  PubMed  Google Scholar 

  28. Janousek J, Gebauer RA, Abdul-Khaliq H, et al., for the Working Group for Cardiac Dysrhythmias and Electrophysiology of the Association for European Paediatric Cardiology. Cardiac resynchronisation therapy in pediatric and congenital heart disease: differential effects in various anatomical and functional substrates. Heart 2009;95:1165–1171.

    Article  CAS  PubMed  Google Scholar 

  29. Jeevanantham V, Daubert JP, Zareba W. Cardiac resynchronization therapy in heart failure patients: an update. Cardiol J 2009;16:197–209.

    PubMed  Google Scholar 

  30. Kühl U, Pauschinger M, Bock T, et al. Parvovirus B19 infection mimicking acute myocardial infarction. Circulation 2003;108:945–950.

    Article  PubMed  CAS  Google Scholar 

  31. Kühl U, Pauschinger M, Noutsias M, et al. High prevalence of viral genomes and multiple viral infections in the myocardium of adults with “idiopathic” left ventricular dysfunction. Circulation 2005;111:887–893.

    Article  PubMed  Google Scholar 

  32. Kühl U, Pauschinger M, Seeberg B, et al. Viral persistence in the myocardium is associated with progressive cardiac dysfunction. Circulation 2005;112:1965–1970.

    Article  PubMed  Google Scholar 

  33. Mahrholdt H, Goedecke C, Wagner A, et al. Multimedia article. Cardiovascular magnetic resonance assessment of human myocarditis: a comparison to histology and molecular pathology. Circulation 2004;109:1250–1258.

    Article  PubMed  Google Scholar 

  34. Mahrholdt H, Wagner A, Deluigi CC, et al. Presentation, patterns of myocardial damage, and clinical course of viral myocarditis. Circulation 2006;114:1581–1590.

    Article  PubMed  Google Scholar 

  35. Maisch B, Bauer E, Cirsi M, Kochsiek K. Cytolytic cross-reactive antibodies directed against the cardiac membrane and viral proteins in coxsackievirus B3 and B4 myocarditis. Characterization and pathogenetic relevance. Circulation 1993;87:Suppl:IV49–IV65.

    CAS  PubMed  Google Scholar 

  36. Maisch B, Bültmann B, Factor S, et al. Committee reports of the World Heart Federation Council on Cardiomyopathies: Committee on Histology: World Heart Federation consensus conferences’ definition of inflammatory cardiomyopathy (myocarditis): report from 2 expert committees on histology and viral cardiomyopathy. Heart Beat 1999;4:3–4.

    Google Scholar 

  37. Maisch B, Camerini F, Schultheiss H-P. Immunosuppressive therapy for myocarditis. N Engl J Med 1995;333:1713–1714.

    Article  CAS  PubMed  Google Scholar 

  38. Maisch B, Drexler H. Der Kardiologie von morgen auf der Spur. Herz 2009;34:87–88.

    Article  PubMed  Google Scholar 

  39. Maisch B, Hufnagel G, Koelsch S, et al. Treatment of inflammatory dilated cardiomyopathy and (peri)myocarditis with immunosuppression and intravenous immunoglobulins. Herz 2004;29:624–636.

    Article  PubMed  Google Scholar 

  40. Maisch B, Hufnagel G, Schönian U, Hengstenberg C, for the ESETCID Investigators. The European Study of Epidemiology and Treatment of Cardiac Inflammatory Disease (ESETCID). Eur Heart J 1995;16:Suppl O:173–175.

    PubMed  Google Scholar 

  41. Maisch B, Portig I, Ristic A, et al. Definition of inflammatory cardiomyopathy (myocarditis): on the way to consensus. Herz 2000;25:200–209.

    Article  CAS  PubMed  Google Scholar 

  42. Maisch B, Richter A, Koelsch S, et al. Management of patients with suspected (peri-)myocarditis and inflammatory dilated cardiomyopathy. Herz 2006;31:881–890.

    Article  PubMed  Google Scholar 

  43. Maisch B, Ristic AD, Hufnagel G, Pankuweit S. Pathophysiology of viral myocarditis: the role of humoral immune response. Cardiovasc Pathol 2002;11:112–122.

    Article  CAS  PubMed  Google Scholar 

  44. Maisch B, Seferovic PM, Ristic AD, et al., Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. Guidelines on the diagnosis and management of pericardial diseases, executive summary; the Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. Eur Heart J 2004;25:587–610.

    Article  PubMed  Google Scholar 

  45. Maron BJ, Towbin JA, Thiene G, et al. Contemporary definitions and classification of the cardiomyopathies. Circulation 2006;113:1807–1816.

    Article  PubMed  Google Scholar 

  46. Mason JW. Myocarditis and dilated cardiomyopathy: an inflammatory link. Cardiovasc Res 2003;60:5–10.

    Article  CAS  PubMed  Google Scholar 

  47. Mason JW, O'Connell JB, Herskowitz A, et al. A clinical trial of immunosuppressive therapy for myocarditis. The Myocarditis Treatment Trial Investigators. N Engl J Med 1995;333:269–275.

    Article  CAS  PubMed  Google Scholar 

  48. Massie BM, Carson PE, McMurray JJ, et al., for the I-PRESERVE Investigators. Irbesartan in patients with heart failure and preserved ejection fraction. N Engl J Med 2008;359:2456–2467.

    Article  CAS  PubMed  Google Scholar 

  49. Matsumori A, Igata H, Ono K, et al. High doses of digitalis increase the myocardial production of proinflammatory cytokines and worsen myocardial injury in viral myocarditis: a possible mechanism of digitalis toxicity. Jpn Circ J 1999;63:934–940.

    Article  CAS  PubMed  Google Scholar 

  50. McAlister FA, Wiebe N, Ezekowitz JA, et al. Meta-analysis: beta-blocker dose, heart rate reduction, and death in patients with heart failure. Ann Intern Med 2009;150:784–794.

    PubMed  Google Scholar 

  51. McNamara DM, Holubkov R, Starling RC, et al. Controlled trial of intravenous immune globulin in recent-onset dilated cardiomyopathy. Circulation 2001;103:2254–2259.

    CAS  PubMed  Google Scholar 

  52. McNamara DM, Rosenblum WD, Janosko KM, et al. Intravenous immune globulin in the therapy of myocarditis and acute cardiomyopathy. Circulation 1997;95:2476–2478.

    CAS  PubMed  Google Scholar 

  53. MERIT-HF Study Group. Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF). Lancet 1999;353:2001–2007.

    Article  Google Scholar 

  54. Meyer AL, Strüber M. Chronische Therapie durch linksventrikuläre Unterstützungssysteme bei terminaler Herzinsuffizienz. Indikation, Ergebnisse, Risiken. Herz 2009;34:148–153.

    Article  PubMed  Google Scholar 

  55. Packer M, Fowler MG, Roecker EB, et al. Effect of carvedilol on the morbidity of patients with severe chronic heart failure: results of Carvedilol Prospective Randomized Cumulative Survival (COPERNICUS) study. Circulation 2002;106:2194–2199.

    Article  PubMed  Google Scholar 

  56. Pankuweit S, Baandrup U, Moll R, et al. Prevalence of parvovirus B 19 genome in endomyocardial biopsy specimen. Hum Pathol 2003;34:80–86.

    Article  Google Scholar 

  57. Pankuweit S, Ruppert V, Eckhardt H, et al. Pathophysiology and etiological diagnosis of inflammatory myocardial diseases with a special focus on parvovirus B 19. J Vet Med B Infect Dis Vet Public Health. 2005;52:344–347.

    CAS  PubMed  Google Scholar 

  58. Pankuweit S, Richter A, Ruppert V, Maisch B. Familiäre Prädisposition und mikrobielle Ätiologie bei dilatativer Kardiomopathie. Herz 2009;34:110–116.

    Article  PubMed  Google Scholar 

  59. Paul M, Zumhagen S, Stallmeyer B, et al. Genes causing inherited forms of cardiomyopathies. A current compendium. Herz 2009;34:98–109.

    Article  PubMed  Google Scholar 

  60. Poole JE, Johnson GW, Hellkamp AS, et al. Prognostic importance of defibrillator shocks in patients with heart failure. N Engl J Med 2008;359:1009–1017.

    Article  CAS  PubMed  Google Scholar 

  61. Richardson P, McKenna W, Bristow M, et al. Report of the 1995 World Health Organization/International Society and Federation of Cardiology Task Force on the Definition and Classification of Cardiomyopathies. Circulation 1996;93:841–845.

    CAS  PubMed  Google Scholar 

  62. Shioji K, Matsuura Y, Iwase T, et al. Successful immunoglobulin treatment for fulminant myocarditis and serial analysis of serum thioredoxin — a case report. Circ J 2002;66:977–980.

    Article  PubMed  Google Scholar 

  63. The SOLVD Investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med 1991;325:293–302.

    Article  Google Scholar 

  64. The SOLVD Investigators. Effect on enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. N Engl J Med 1992;327:685–691.

    Article  Google Scholar 

  65. Strüber M, Meyer AL, Malehsa D, et al. The current status of heart transplantation and the development of “artificial heart systems”. Dtsch Ärztebl Int 2009;106:471–477.

    PubMed  Google Scholar 

  66. Takeda Y, Yasuda S, Miyazaki S, et al. High-dose immunoglobulin G therapy for fulminant myocarditis. Jpn Circ J 1998;62:871–872.

    Article  CAS  PubMed  Google Scholar 

  67. Tschöpe C, Kasner M, Westermann D. Heart failure with normal ejection fraction. Pathophysiology, diagnosis, and treatment. Herz 2009;34:89–96.

    Article  PubMed  Google Scholar 

  68. US Carvedilol Heart Failure Study Group, Packer M, Bristow MR, Cohn JN, et al. The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. N Engl J Med 1996;353:1349–1355.

    Article  Google Scholar 

  69. Van der Meer P, Lipsic E, Westenbrink BD, et al. Levels of hematopoiesis inhibitor N-acetyl-seryl-aspartyl-lysyl-proline partially explain the occurrence of anemia in heart failure. Circulation 2005;112:1743–1747.

    Article  CAS  Google Scholar 

  70. Yip GW, Wang M, Wang T, et al. The Hong Kong diastolic heart failure study: a randomised controlled trial of diuretics, irbesartan and ramipril on quality of life, exercise capacity, left ventricular global and regional function in heart failure with a normal ejection fraction. Heart 2008;94:573–580.

    Article  CAS  PubMed  Google Scholar 

  71. Yusuf S, Pfeffer MA, Swedberg K, et al. Effects of candesartan in patients with chronic heart failure and preserved left-ventricular ejection fraction: the CHARM-Preserved Trial. Lancet 2003;362:777–781.

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Klinik für Innere Medizin – Kardiologie, Philipps-Universität, Marburg und UKGM GmbH, Standort Marburg, Marburg, Germany

    Bernhard Maisch & Sabine Pankuweit

  2. Direktor der Klinik für Innere Medizin – Kardiologie UKGM GmbH, Standort Marburg und Philipps-Universität Marburg, Baldingerstraße, 35043, Marburg, Germany

    Bernhard Maisch

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Correspondence to Bernhard Maisch.

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Maisch, B., Pankuweit, S. Therapie der fortgeschrittenen Herz - insuffizienz: medikamentös, Resynchronisation (CRT), Operation. Herz 35, 94–101 (2010). https://doi.org/10.1007/s00059-010-3329-z

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