Tohru Izumi, Toshimi Koitabashi, Mototsugu Nishii, Takayuki Inomata

1
The 4 th China-Japan Cardiovascular Forum
(CJCF)
How to Prevent From Worsening of Chronic Heart
Failure
Tohru Izumi, Toshimi Koitabashi, Mototsugu
Nishii, Takayuki Inomata Department of
Cardio-Angiology, Kitasato University School of
Medicine, Sagamihara 288-8555, Japan
Oct 23rd, 2008, Beijing,
2
Chronic Heart Failure and Disease Burden
3
BNP guided therapy for CHF patient
Reduction of cardiac event (disease burden)
ACEIBB Tx
CHF
Comprehensive management
Indicator BNP
Diuretics
4
Plasma BNP level is titrated by RIA using
Shionoria (Shionogi, Osaka)
5
Inomata T, et al. Jpn Circ J 200165 (S-1A), 282.
In two years follow-up, there were significantly
lower cardiac events, readmission, in BNP guided
Tx in comparison with the clinical guided Tx.
Cumulative rate of the event within one year
reduced from 31.5 to 16.6.
6
Altered prognosis of Af Pts by introducing BNP
guided Tx
Group II BNP guided era(00-02)
Group I
Group II
SR
HF-event-free survival()
SR
Af
Group I Clin guided era (96-98)
Af
Koitabashi T, Inomata T, et al. ESC 2004
BNP guided Tx cancelled out prognostic
contribution by AF in CHF management
7
BNP and Arrhythmic Prognosis
KITASATO UNIVERSITY
8
Cost-effectiveness of BNP gTx
Morimoto T, Izumi T, Fukui T et al, Int J
Cardiol, 2004
9
Check Point for CHF Management
Care/Hospice
Clinical Indicator
Lethal/Disability
LVAD/HTX
Total Bililbin
Hospitalization
Default
New Index?
Reinforce TX
BNPlt200
DryWarm
Adjunctive TX
Fundamental TX
Therapeutic plan
10
(No Transcript)
11
Cardiac Resynchronization Therapy (CRT) vs.
Reverse Remodeling
Before CRT
Two weeks later
One year later
12
Echocardiogram(TMF)after CRT
Before CRT
One year later
13
Reverse Remodeling and ß-Blocker(Carvedilol)
14
Dilated Cardiomyopathy vs. Reverse Remodeling
15
Immunohistochemical Staining for NF?B
Wohlschlaeger J, Baba AH et al, Cardiovas Res?2005
16
(No Transcript)
17
Check Point for CHF Management
Care/Hospice
Clinical Indicator
Lethal/Disability
LVAD/HTX
Total Bililbin
Hospitalization
Default
Reverse Remodeling
Reinforce TX
BNPlt200
DryWarm
Adjunctive TX
Fundamental TX
Therapeutic plan
18
Anti-Remodeling and Reverse Remodeling
Acute Heart Failure
Chronic Heart Failure
Mancinid D Burkhoff,Circulation, 2005
19
Primary Endpoint (J-WIND)
Ejection Fraction (EF) in Chronic Stage
Nicorandil
hANP
()
()
()
()
48
48
48
48
p0.460
p0.460
p0.024
p0.024
44
44
44
44
?
?
?
?
?
?
?
?
?
?
?
?
?
?
?
?
?
?
?
40
?
40
40
40
43.2
42.5
44.7
42.5
36
36
36
36
0
0
0
0
Control
Nicorandil
ANP
Control
(
(
n187
n187
)
)
(
(
n199
n199
)
)
(
(
n155
n155
)
)
(
(
n190
n190
)
)
20
In
Anti-remodeling Perindopril
The PREAMI Investigators, Arch Intern Med 2006
21
Six Months BNP CV Events
Nishii M et al JACC 51(24)2329-35, 2008
22
Six Months BNP Reverse Remodeling
LVEF
LVDd
P0.005
at discharge
at 6 months
at discharge
at 6 months
Nishii M et al JACC 51(24)2329-35, 2008
23
Six Months BNP Reverse Remodeling
24
(No Transcript)
25

• Summary
• BNP guided therapy produces a superior and
  excellent outcome through physicians awareness
  toward their proper treatment.
• However, the BNP measurement is not almighty
  diagnostic tool leading to comprehensive CHF
  management.
• As a new check point, anti-remodeling/reverse
  remodeling should be selected with care as a
  strong candidate.