Update heart failure-2021.pptx
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Heart failure is a condition where the heart cannot pump enough blood to meet the body's needs. It can be caused by conditions that damage the heart muscle such as hypertension, diabetes, and cardiomyopathy. Symptoms include dyspnea, edema, and fatigue. Over time, the heart undergoes remodeling which worsens cardiac function and leads to neurohormonal activation of the sympathetic nervous and renin-angiotensin-aldosterone systems to maintain cardiac output. Long term activation of these systems exacerbates heart failure. Treatment focuses on blocking these compensatory mechanisms using beta blockers, ACE inhibitors, ARBs, and MRAs to slow the progression of heart failure.
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Heart failure management - role of arni
1. A Case report of Heart Failure
2. Discussion on Heart Failure
3. Role of Peptides in Heart Failure
4. Importance of 30 days in heart failure
5. Role of ENTRESTO in Stable Heart Failure patient (PARADIGM-HF study)(HFrEF)
6. Biomarkers in Heart Failure
7. Role of ARNI in Hospitalized Heart Failure patient (PIONEER-HF study)
8. Role of ARNI in HFpEF (PARAMOUNT Trial)
9. Safety and usefulness of ACEI/ARB/ARNI
10. Role of SGPL2 inhibitors in HF with/without DM
20. Heart Failure.pptx
Heart failure is a clinical syndrome where the heart is unable to pump enough blood to meet the body's needs. It is becoming an increasingly common problem. The prevalence of heart failure in Indonesia is around 0.13% and is increasing due to rises in hypertension, improved survival of heart attacks, and increased life expectancy. In the US, over 5 million people have heart failure with an expected increase of 25% by 2030. It is a major cause of death. Heart failure can be due to various structural heart diseases, myocardial diseases, or other conditions that impair the heart's function. The document discusses the definitions, classifications, diagnostic methods including physical exam, labs, ECG, chest x-ray, echocardiogram and
Ufpresenterslides
The document discusses heart failure (HF), its epidemiology, pathophysiology, and management. Some key points:
- HF is a major public health problem costing $29.6 billion annually in the US. Hospitalizations are a major driver of costs, and rates are increasing.
- Over 90% of acute decompensated HF hospitalizations are due to fluid overload. Diuretics are standard first-line treatment but resistance limits their effectiveness in many patients.
- Even mild reductions in renal function correlate with increased HF morbidity and mortality. Diuretics can further impair renal function, worsening outcomes.
- Ultrafiltration is an alternative fluid removal method that may benefit patients where diure
ACE-I in heart failure
Heart failure is a common condition that significantly impacts quality of life. It occurs when the heart can no longer pump enough blood to meet the body's needs. ACE inhibitors are commonly used to treat heart failure by inhibiting the renin-angiotensin system, which promotes heart failure progression over time through ventricular remodeling. Numerous clinical trials have shown that ACE inhibitors reduce mortality and morbidity for patients with heart failure, as well as attenuating disease progression in both symptomatic and asymptomatic patients. However, more research is still needed on their effects in different types of heart failure patients.
Heart Failure with Preserved Ejection Fraction(HFpEF).ptx
Heart failure with preserved ejection fraction (HFpEF) is not one disease but a clinical syndrome presenting with symptoms of Heart Failure with a left ventricular ejection fraction (LVEF) ≥50 percent and evidence of cardiac diastolic dysfunction. (abnormal LV filling pattern and elevated filling pressures)
It is more common among older patients and women, and results from abnormalities of active ventricular relaxation and passive ventricular compliance. HFpEF should be part of differential diagnosis in patients with typical symptoms such as fatigue, weakness, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema and clinical signs of chronic heart failure. Echocardiography features of normal ejection fraction with impaired diastolic function confirm the diagnosis.
The Indian Consensus Document on Cardiac Biomarker
Despite recent advances, the diagnosis and management of heart failure evades the clinicians. The etiology of congestive heart failure (CHF) in the Indian scenario comprises of coronary artery disease, diabetes mellitus and hypertension. With better insights into the pathophysiology of CHF, biomarkers have evolved rapidly and received diagnostic and prognostic value. In CHF biomarkers prove as measures of the extent of pathophysiological derangement; examples include biomarkers of myocyte necrosis, myocardial remodeling,
neurohormonal activation, etc.
Ojchd.000524
Despite major advances in the cardiovascular medicine in the 20th century, heart failure (HF) is an exceptional with estimated prevalence of >37.7 million globally caused by secondary aetiologies ultimately affecting their quality of life, including dyspnoea, poor exercise tolerance, fatigue, and fluid retention. Currently, angiotensin receptor blockers (ARBs), angiotensin converting enzyme (ACE) inhibitors, mineralocorticoid receptor antagonists, β blockers, angiotensin receptor blocker neprilysin inhibitors (ARNIs) and advanced device therapies have been administered to patients with reduced ejection fraction (EF).
Heart failure
- The diagnosis of heart failure is a staged process involving risk assessment, initial diagnostic workup, and more detailed testing as needed.
- The initial workup includes clinical assessment, biomarkers like BNP and NT-proBNP, chest x-ray, and echocardiogram. Biomarkers can help determine if heart failure is likely or unlikely.
- For HFrEF, the diagnosis requires symptoms, signs of heart failure, and reduced left ventricular ejection fraction. For HFpEF, normal or mildly reduced ejection fraction is needed in addition to relevant structural heart disease or diastolic dysfunction.
- Further testing like stress echocardiography, invasive tests, cardiac MRI may be used
Recommended
Heart failure management - role of arni
1. A Case report of Heart Failure
2. Discussion on Heart Failure
3. Role of Peptides in Heart Failure
4. Importance of 30 days in heart failure
5. Role of ENTRESTO in Stable Heart Failure patient (PARADIGM-HF study)(HFrEF)
6. Biomarkers in Heart Failure
7. Role of ARNI in Hospitalized Heart Failure patient (PIONEER-HF study)
8. Role of ARNI in HFpEF (PARAMOUNT Trial)
9. Safety and usefulness of ACEI/ARB/ARNI
10. Role of SGPL2 inhibitors in HF with/without DM
20. Heart Failure.pptx
Heart failure is a clinical syndrome where the heart is unable to pump enough blood to meet the body's needs. It is becoming an increasingly common problem. The prevalence of heart failure in Indonesia is around 0.13% and is increasing due to rises in hypertension, improved survival of heart attacks, and increased life expectancy. In the US, over 5 million people have heart failure with an expected increase of 25% by 2030. It is a major cause of death. Heart failure can be due to various structural heart diseases, myocardial diseases, or other conditions that impair the heart's function. The document discusses the definitions, classifications, diagnostic methods including physical exam, labs, ECG, chest x-ray, echocardiogram and
Ufpresenterslides
The document discusses heart failure (HF), its epidemiology, pathophysiology, and management. Some key points:
- HF is a major public health problem costing $29.6 billion annually in the US. Hospitalizations are a major driver of costs, and rates are increasing.
- Over 90% of acute decompensated HF hospitalizations are due to fluid overload. Diuretics are standard first-line treatment but resistance limits their effectiveness in many patients.
- Even mild reductions in renal function correlate with increased HF morbidity and mortality. Diuretics can further impair renal function, worsening outcomes.
- Ultrafiltration is an alternative fluid removal method that may benefit patients where diure
ACE-I in heart failure
Heart failure is a common condition that significantly impacts quality of life. It occurs when the heart can no longer pump enough blood to meet the body's needs. ACE inhibitors are commonly used to treat heart failure by inhibiting the renin-angiotensin system, which promotes heart failure progression over time through ventricular remodeling. Numerous clinical trials have shown that ACE inhibitors reduce mortality and morbidity for patients with heart failure, as well as attenuating disease progression in both symptomatic and asymptomatic patients. However, more research is still needed on their effects in different types of heart failure patients.
Heart Failure with Preserved Ejection Fraction(HFpEF).ptx
Heart failure with preserved ejection fraction (HFpEF) is not one disease but a clinical syndrome presenting with symptoms of Heart Failure with a left ventricular ejection fraction (LVEF) ≥50 percent and evidence of cardiac diastolic dysfunction. (abnormal LV filling pattern and elevated filling pressures)
It is more common among older patients and women, and results from abnormalities of active ventricular relaxation and passive ventricular compliance. HFpEF should be part of differential diagnosis in patients with typical symptoms such as fatigue, weakness, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema and clinical signs of chronic heart failure. Echocardiography features of normal ejection fraction with impaired diastolic function confirm the diagnosis.
The Indian Consensus Document on Cardiac Biomarker
Despite recent advances, the diagnosis and management of heart failure evades the clinicians. The etiology of congestive heart failure (CHF) in the Indian scenario comprises of coronary artery disease, diabetes mellitus and hypertension. With better insights into the pathophysiology of CHF, biomarkers have evolved rapidly and received diagnostic and prognostic value. In CHF biomarkers prove as measures of the extent of pathophysiological derangement; examples include biomarkers of myocyte necrosis, myocardial remodeling,
neurohormonal activation, etc.
Ojchd.000524
Despite major advances in the cardiovascular medicine in the 20th century, heart failure (HF) is an exceptional with estimated prevalence of >37.7 million globally caused by secondary aetiologies ultimately affecting their quality of life, including dyspnoea, poor exercise tolerance, fatigue, and fluid retention. Currently, angiotensin receptor blockers (ARBs), angiotensin converting enzyme (ACE) inhibitors, mineralocorticoid receptor antagonists, β blockers, angiotensin receptor blocker neprilysin inhibitors (ARNIs) and advanced device therapies have been administered to patients with reduced ejection fraction (EF).
Heart failure
- The diagnosis of heart failure is a staged process involving risk assessment, initial diagnostic workup, and more detailed testing as needed.
- The initial workup includes clinical assessment, biomarkers like BNP and NT-proBNP, chest x-ray, and echocardiogram. Biomarkers can help determine if heart failure is likely or unlikely.
- For HFrEF, the diagnosis requires symptoms, signs of heart failure, and reduced left ventricular ejection fraction. For HFpEF, normal or mildly reduced ejection fraction is needed in addition to relevant structural heart disease or diastolic dysfunction.
- Further testing like stress echocardiography, invasive tests, cardiac MRI may be used
Are+all+sartans+equal
The document discusses the renin-angiotensin-aldosterone system (RAAS) and its role in cardiovascular diseases. It describes how inappropriate activation of RAAS can lead to hypertension, diabetes, obesity, heart failure and kidney diseases. RAAS modulators like angiotensin converting enzyme inhibitors and angiotensin receptor blockers are effective in managing these conditions by inhibiting RAAS. Clinical trials have shown that drugs like losartan, valsartan and candesartan reduce blood pressure and cardiovascular events.
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The document discusses erectile dysfunction (ED), including its association with other medical conditions, risk factors, diagnosis, and management. It notes that ED screening can detect underlying diseases like diabetes and cardiovascular issues. Treatment includes lifestyle changes, medications like PDE5 inhibitors, counseling, and other therapies to help improve patients' quality of life and sexual functioning.
Reversing cardiac remodeling with HFtreatment
1. This document summarizes research on reversing cardiac remodeling through heart failure treatment. It discusses what remodeling is, the history of the term in medical literature, and types of remodeling (pathological vs physiological).
2. Studies show treatments that lead to "reverse remodeling" like sacubitril/valsartan improve outcomes for heart failure patients. Trials like PARADIGM-HF and PROVE-HF found sacubitril/valsartan reduced biomarkers and improved ejection fraction, indicating reverse remodeling.
3. Subgroup analyses in PROVE-HF found consistent reverse remodeling effects in newly diagnosed and ACE-ARB naive patients as well as those not reaching target sacubitril/vals
CARDIOMYOPATHIES-by MWEBAZA VICTOR.pptx
Cardiomyopathies are diseases of the heart muscle that weaken the heart's ability to pump blood. The document discusses several types of cardiomyopathy including dilated cardiomyopathy, hypertrophic cardiomyopathy, restrictive cardiomyopathy, and arrhythmogenic right ventricular dysplasia. Symptoms include shortness of breath, fatigue, and leg swelling. Causes can be genetic, due to alcohol use, viruses, or other medical conditions. Diagnosis involves physical exams, tests like echocardiograms and genetic testing. Treatments depend on the type and symptoms but may include medications to manage heart failure.
Sacubitril valsartan EK
LCZ696 was more effective than enalapril in reducing the risks of CV death and HF hospitalization, CV death, HF hospitalization, and all-cause mortality in patients with heart failure with reduced ejection fraction. LCZ696 also provided incremental improvements in symptoms and physical limitations. LCZ696 was better tolerated than enalapril with lower rates of symptomatic hypotension, hyperkalemia, renal impairment, and cough.
Aki crs
This document discusses cardiorenal syndrome and provides details about a patient case. It defines cardiorenal syndrome as disorders of the heart and kidneys that can cause acute or chronic dysfunction in one organ and induce dysfunction in the other. The document summarizes the patient's history of rheumatic heart disease, heart failure, and acute kidney injury. It also reviews pathophysiology, types, prevalence, risk factors, prognosis, diagnosis, and treatment approaches for cardiorenal syndrome.
Heart failure update
Heart failure Update as per, 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the
Management of Heart Failure and 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
Syncope
Syncope, or fainting, is a relatively common problem that is often misdiagnosed. It is caused by a temporary drop in blood pressure and loss of consciousness but typically resolves quickly without medical intervention. The most common causes are neurally-mediated, due to an overactive vagus nerve, or cardiac-related such as arrhythmias. A thorough history and physical exam can help determine the underlying reason, while tilt table testing or carotid sinus massage may be used for diagnosis. Treatment depends on the identified cause but may include lifestyle changes, medication, or a pacemaker for recurrent episodes caused by bradycardia. Driving restrictions apply depending on the frequency and severity of syncopal episodes to prevent injury.
Syncope
Syncope, or fainting, is a relatively common problem that is often misdiagnosed. It is caused by a temporary drop in blood pressure and loss of consciousness. The most common causes are neurally-mediated syncope, cardiac arrhythmias, and orthostatic hypotension. A thorough history, physical exam, and diagnostic tests like carotid sinus massage and tilt table testing can help identify the underlying cause. Treatment depends on the cause but may include lifestyle changes, medications, or pacemaker implantation in severe cases. Proper diagnosis and management of syncope is important as it can occasionally lead to injuries or accidents.
Pulmonary Arterial Hypertension in Rural Communities: Early Diagnosis and Int...
Pulmonary Arterial Hypertension in Rural Communities: Early Diagnosis and Intervention to Improve Outcomes
Learning Objectives
-Identify the signs, symptoms, and risk factors associated with PAH to facilitate timely referral of patients to specialized pulmonary hypertension centers for early diagnosis and treatment
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Péptidos natriuréticos, nuestra protección endógena frente a la IC
CARDIOTalks: La IC vuelve a escena
22/05/2015 17:45h - 19:30h
Hotel Sevilla Center. Sala Giralda I, Sevilla (XII Reunión Anual de la Sección de Insuficiencia Cardiaca y Trasplante de la SEC)
http://cardiotalks.secardiologia.es
Péptidos natriuréticos, nuestra protección endógena frente a la IC
Dr. Antonio Bayés-Genis, Badalona
HF presentation
The document defines heart failure as a clinical syndrome characterized by typical symptoms such as breathlessness and swelling caused by structural or functional abnormalities of the heart. This results in reduced cardiac output and elevated pressures in the heart at rest or during stress. Heart failure is classified based on ejection fraction and other factors, and can involve either the left or right side of the heart. Long term, heart failure leads to neurohormonal activation and pathological remodeling of the heart muscle over time.
Management of Hypertension in Critical Illness
This document provides an overview of the management of hypertension, including hypertensive emergencies. It discusses the prevalence and pathophysiology of hypertension, outlines treatment goals, and reviews pharmacologic treatment options. Key points include:
1) Hypertensive emergencies require rapid blood pressure control to prevent end-organ damage, while avoiding precipitous drops in pressure.
2) Intravenous antihypertensive agents discussed include labetalol, esmolol, nicardipine, sodium nitroprusside, and fenoldopam.
3) Nicardipine is highlighted as an effective option for hypertensive emergencies due to its rapid onset, titratability, and limited
The Relevance of Natriuretic Peptide in Medical Laboratory Diagnosis
Natriuretic peptides (NPs) are hormones that regulate blood pressure, cardiovascular homeostasis, and long bone growth. They are hormones which are mainly secreted from cardiac organ and have important natriuretic and kaliuretic characteristics. It is classified into four including; atrial NP, Brain-type NP (BNP), C-type NP and dendroaspis NP, a D-type NP, each with its own characteristic roles. The NP system involves three ligands and three receptors and result in situations such as diuresis, natriuresis, vasodilation, and inhibition of aldosterone synthesis and renin secretion as a circulating hormone The N-terminal part of the prohormone of BNP is produced alongside BNP. This has indeed play a diagnostic value in cardiac attack. NPs or their fragments have been subjected to scientific observation for their diagnostic value.
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Gregg L. Semenza discusses hypoxia-inducible factors (HIFs) and their role in physiology and medicine. HIFs control oxygen homeostasis by regulating erythropoietin production and red blood cell production. They also play a role in cardiovascular disease by mediating vascularization and in cancer by promoting tumor growth and metastasis. HIFs activate genes involved in angiogenesis, cancer stem cell maintenance, immune evasion, and premetastatic niche formation. Inhibiting HIF activity has been shown to reduce tumor growth and improve outcomes for cancer and cardiovascular disease.
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1) The document discusses heart failure, including definitions, classifications, epidemiology, and treatment. It summarizes key findings from the PARADIGM-HF trial which compared the drug Entresto to enalapril.
2) The PARADIGM-HF trial found Entresto reduced the risk of cardiovascular death or hospitalization for heart failure by 20% compared to enalapril.
3) Specifically, Entresto reduced the risk of cardiovascular death by 20% and first hospitalization for heart failure by 21% compared to enalapril.
Cardiorenal syndrome DR Osama EL-Shahat
1. Cardio-renal syndrome (CRS) describes conditions where acute or chronic dysfunction in one organ induces acute or chronic dysfunction in the other organ.
2. Management of CRS is challenging and involves diuretics, ACE inhibitors, beta blockers, and dialysis. However, treatment outcomes remain poor, with high mortality and rates of rehospitalization.
3. While advances have been made, CRS continues to significantly impact morbidity and mortality. Early multidisciplinary management may help improve outcomes, but effective new therapies are still needed to better treat and prevent this challenging condition.
CARDIOMYOPATHIES-by MWEBAZA VICTOR.pptx
DIFFERENT TYPES OF CARDIOMYOPATHIES WITH CLINICAL MANAGEMENT.
FOR MORE INFORMATION mwebazavictor1997@gmail.com
Cardiorenal syndrome prof.osama el-shahat
1. The document discusses cardiorenal syndrome (CRS), where acute or chronic dysfunction of the heart or kidneys can cause dysfunction in the other organ.
2. CRS is classified into 5 types depending on the rapidity of onset and primary organ affected. Various biomarkers can help classify CRS along with clinical evaluation.
3. Management of CRS is challenging and includes diuretics, ACE inhibitors, ARBs, beta-blockers, and renal replacement therapy. However, many treatments require careful use in patients with kidney disease.
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Syncope, or fainting, is a relatively common problem that is often misdiagnosed. It is caused by a temporary drop in blood pressure and loss of consciousness. The most common causes are neurally-mediated syncope, cardiac arrhythmias, and orthostatic hypotension. A thorough history, physical exam, and diagnostic tests like carotid sinus massage and tilt table testing can help identify the underlying cause. Treatment depends on the cause but may include lifestyle changes, medications, or pacemaker implantation in severe cases. Proper diagnosis and management of syncope is important as it can occasionally lead to injuries or accidents.
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CARDIOTalks: La IC vuelve a escena
22/05/2015 17:45h - 19:30h
Hotel Sevilla Center. Sala Giralda I, Sevilla (XII Reunión Anual de la Sección de Insuficiencia Cardiaca y Trasplante de la SEC)
http://cardiotalks.secardiologia.es
Péptidos natriuréticos, nuestra protección endógena frente a la IC
Dr. Antonio Bayés-Genis, Badalona
HF presentation
The document defines heart failure as a clinical syndrome characterized by typical symptoms such as breathlessness and swelling caused by structural or functional abnormalities of the heart. This results in reduced cardiac output and elevated pressures in the heart at rest or during stress. Heart failure is classified based on ejection fraction and other factors, and can involve either the left or right side of the heart. Long term, heart failure leads to neurohormonal activation and pathological remodeling of the heart muscle over time.
Management of Hypertension in Critical Illness
This document provides an overview of the management of hypertension, including hypertensive emergencies. It discusses the prevalence and pathophysiology of hypertension, outlines treatment goals, and reviews pharmacologic treatment options. Key points include:
1) Hypertensive emergencies require rapid blood pressure control to prevent end-organ damage, while avoiding precipitous drops in pressure.
2) Intravenous antihypertensive agents discussed include labetalol, esmolol, nicardipine, sodium nitroprusside, and fenoldopam.
3) Nicardipine is highlighted as an effective option for hypertensive emergencies due to its rapid onset, titratability, and limited
The Relevance of Natriuretic Peptide in Medical Laboratory Diagnosis
Natriuretic peptides (NPs) are hormones that regulate blood pressure, cardiovascular homeostasis, and long bone growth. They are hormones which are mainly secreted from cardiac organ and have important natriuretic and kaliuretic characteristics. It is classified into four including; atrial NP, Brain-type NP (BNP), C-type NP and dendroaspis NP, a D-type NP, each with its own characteristic roles. The NP system involves three ligands and three receptors and result in situations such as diuresis, natriuresis, vasodilation, and inhibition of aldosterone synthesis and renin secretion as a circulating hormone The N-terminal part of the prohormone of BNP is produced alongside BNP. This has indeed play a diagnostic value in cardiac attack. NPs or their fragments have been subjected to scientific observation for their diagnostic value.
sodapdf-converted.pptx
Gregg L. Semenza discusses hypoxia-inducible factors (HIFs) and their role in physiology and medicine. HIFs control oxygen homeostasis by regulating erythropoietin production and red blood cell production. They also play a role in cardiovascular disease by mediating vascularization and in cancer by promoting tumor growth and metastasis. HIFs activate genes involved in angiogenesis, cancer stem cell maintenance, immune evasion, and premetastatic niche formation. Inhibiting HIF activity has been shown to reduce tumor growth and improve outcomes for cancer and cardiovascular disease.
Presentation 2 - Andrew Ludman_0_0.pptx
1) The document discusses heart failure, including definitions, classifications, epidemiology, and treatment. It summarizes key findings from the PARADIGM-HF trial which compared the drug Entresto to enalapril.
2) The PARADIGM-HF trial found Entresto reduced the risk of cardiovascular death or hospitalization for heart failure by 20% compared to enalapril.
3) Specifically, Entresto reduced the risk of cardiovascular death by 20% and first hospitalization for heart failure by 21% compared to enalapril.
Cardiorenal syndrome DR Osama EL-Shahat
1. Cardio-renal syndrome (CRS) describes conditions where acute or chronic dysfunction in one organ induces acute or chronic dysfunction in the other organ.
2. Management of CRS is challenging and involves diuretics, ACE inhibitors, beta blockers, and dialysis. However, treatment outcomes remain poor, with high mortality and rates of rehospitalization.
3. While advances have been made, CRS continues to significantly impact morbidity and mortality. Early multidisciplinary management may help improve outcomes, but effective new therapies are still needed to better treat and prevent this challenging condition.
CARDIOMYOPATHIES-by MWEBAZA VICTOR.pptx
DIFFERENT TYPES OF CARDIOMYOPATHIES WITH CLINICAL MANAGEMENT.
FOR MORE INFORMATION mwebazavictor1997@gmail.com
Cardiorenal syndrome prof.osama el-shahat
1. The document discusses cardiorenal syndrome (CRS), where acute or chronic dysfunction of the heart or kidneys can cause dysfunction in the other organ.
2. CRS is classified into 5 types depending on the rapidity of onset and primary organ affected. Various biomarkers can help classify CRS along with clinical evaluation.
3. Management of CRS is challenging and includes diuretics, ACE inhibitors, ARBs, beta-blockers, and renal replacement therapy. However, many treatments require careful use in patients with kidney disease.
Similar to Update heart failure-2021.pptx (20)
Pulmonary Arterial Hypertension in Rural Communities: Early Diagnosis and Int...
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Péptidos natriuréticos, nuestra protección endógena frente a la IC
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The Relevance of Natriuretic Peptide in Medical Laboratory Diagnosis
The Relevance of Natriuretic Peptide in Medical Laboratory Diagnosis
PATOFISIOLOGIA DE IC CON FRACCION DE EYECCION PRESERVADA
PATOFISIOLOGIA DE IC CON FRACCION DE EYECCION PRESERVADA
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一比一原版(UO毕业证)渥太华大学毕业证如何办理
UO毕业证录取书【微信95270640】购买（渥太华大学毕业证成绩单硕士学历）Q微信95270640代办UO学历认证留信网伪造渥太华大学学位证书精仿渥太华大学本科/硕士文凭证书补办渥太华大学 diplomaoffer,Transcript购买渥太华大学毕业证成绩单购买UO假毕业证学位证书购买伪造渥太华大学文凭证书学位证书,专业办理雅思、托福成绩单，学生ID卡，在读证明，海外各大学offer录取通知书，毕业证书，成绩单，文凭等材料:1:1完美还原毕业证、offer录取通知书、学生卡等各种在读或毕业材料的防伪工艺（包括 烫金、烫银、钢印、底纹、凹凸版、水印、防伪光标、热敏防伪、文字图案浮雕，激光镭射，紫外荧光，温感光标）学校原版上有的工艺我们一样不会少，不论是老版本还是最新版本，都能保证最高程度还原，力争完美以求让所有同学都能享受到完美的品质服务。
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查询留服认证是国内鉴别留学生海外学历的唯一途径但认证只是个体行为不是所有留学生都操作所以没有办理认证的留学生的学历在国内也是查询不到的他们也仅仅只有一张文凭。所以这时候我们提供的和学校颁发的一模一样的毕业证成绩单就有了使用价值。只硕大的蛇皮袋手里拎着长铁钩正站在门口朝黑色的屋内张望不好坏人小偷山娃一怔却也灵机一动立马仰起头双手拢在嘴边朝楼上大喊：“爸爸爸——有人找——那人一听朝山娃尴尬地笑笑悻悻地走了山娃立马“嘭的一声将铁门锁死心却咚咚地乱跳当山娃跟父亲说起这事时父亲很吃惊抚摸着山娃的头说还好醒得及时要不家早被人掏空了到时连电视也没得看啰不过父亲还是夸山娃能临危不乱随机应变有胆有谋山娃笑笑说那都是书上学的看童话和小说时多
Learn SQL from basic queries to Advance queries
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Join us on this journey to enhance your data analysis capabilities and unlock the full potential of SQL. Perfect for data enthusiasts, analysts, and anyone eager to harness the power of data!
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University of New South Wales degree offer diploma Transcript
澳洲UNSW毕业证书制作新南威尔士大学假文凭定制Q微168899991做UNSW留信网教留服认证海牙认证改UNSW成绩单GPA做UNSW假学位证假文凭高仿毕业证申请新南威尔士大学University of New South Wales degree offer diploma Transcript
Analysis insight about a Flyball dog competition team's performance
Insight of my analysis about a Flyball dog competition team's last year performance. Find more: https://github.com/rolandnagy-ds/flyball_race_analysis/tree/main
原版制作(unimelb毕业证书)墨尔本大学毕业证Offer一模一样
学校原件一模一样【微信：741003700 】《(unimelb毕业证书)墨尔本大学毕业证》【微信：741003700 】学位证，留信认证（真实可查，永久存档）原件一模一样纸张工艺/offer、雅思、外壳等材料/诚信可靠,可直接看成品样本，帮您解决无法毕业带来的各种难题！外壳，原版制作，诚信可靠，可直接看成品样本。行业标杆！精益求精，诚心合作，真诚制作！多年品质 ,按需精细制作，24小时接单,全套进口原装设备。十五年致力于帮助留学生解决难题，包您满意。
本公司拥有海外各大学样板无数，能完美还原。
1:1完美还原海外各大学毕业材料上的工艺：水印，阴影底纹，钢印LOGO烫金烫银，LOGO烫金烫银复合重叠。文字图案浮雕、激光镭射、紫外荧光、温感、复印防伪等防伪工艺。材料咨询办理、认证咨询办理请加学历顾问Q/微741003700
【主营项目】
一.毕业证【q微741003700】成绩单、使馆认证、教育部认证、雅思托福成绩单、学生卡等！
二.真实使馆公证(即留学回国人员证明,不成功不收费)
三.真实教育部学历学位认证（教育部存档！教育部留服网站永久可查）
四.办理各国各大学文凭(一对一专业服务,可全程监控跟踪进度)
如果您处于以下几种情况：
◇在校期间，因各种原因未能顺利毕业……拿不到官方毕业证【q/微741003700】
◇面对父母的压力，希望尽快拿到；
◇不清楚认证流程以及材料该如何准备；
◇回国时间很长，忘记办理；
◇回国马上就要找工作，办给用人单位看；
◇企事业单位必须要求办理的
◇需要报考公务员、购买免税车、落转户口
◇申请留学生创业基金
留信网认证的作用:
1:该专业认证可证明留学生真实身份
2:同时对留学生所学专业登记给予评定
3:国家专业人才认证中心颁发入库证书
4:这个认证书并且可以归档倒地方
5:凡事获得留信网入网的信息将会逐步更新到个人身份内，将在公安局网内查询个人身份证信息后，同步读取人才网入库信息
6:个人职称评审加20分
7:个人信誉贷款加10分
8:在国家人才网主办的国家网络招聘大会中纳入资料，供国家高端企业选择人才
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"Financial Odyssey: Navigating Past Performance Through Diverse Analytical Lens"
Embark on a captivating financial journey with 'Financial Odyssey,' our hackathon project. Delve deep into the past performance of two companies as we employ an array of financial statement analysis techniques. From ratio analysis to trend analysis, uncover insights crucial for informed decision-making in the dynamic world of finance."
原版一比一利兹贝克特大学毕业证(LeedsBeckett毕业证书)如何办理
原版制作【微信:41543339】【利兹贝克特大学毕业证(LeedsBeckett毕业证书)】【微信:41543339】《成绩单、外壳、雅思、offer、真实留信官方学历认证（永久存档/真实可查）》采用学校原版纸张、特殊工艺完全按照原版一比一制作（包括：隐形水印，阴影底纹，钢印LOGO烫金烫银，LOGO烫金烫银复合重叠，文字图案浮雕，激光镭射，紫外荧光，温感，复印防伪）行业标杆！精益求精，诚心合作，真诚制作！多年品质 ,按需精细制作，24小时接单,全套进口原装设备，十五年致力于帮助留学生解决难题，业务范围有加拿大、英国、澳洲、韩国、美国、新加坡，新西兰等学历材料，包您满意。
【我们承诺采用的是学校原版纸张（纸质、底色、纹路）我们拥有全套进口原装设备，特殊工艺都是采用不同机器制作，仿真度基本可以达到100%，所有工艺效果都可提前给客户展示，不满意可以根据客户要求进行调整，直到满意为止！】
【业务选择办理准则】
一、工作未确定，回国需先给父母、亲戚朋友看下文凭的情况，办理一份就读学校的毕业证【微信41543339】文凭即可
二、回国进私企、外企、自己做生意的情况，这些单位是不查询毕业证真伪的，而且国内没有渠道去查询国外文凭的真假，也不需要提供真实教育部认证。鉴于此，办理一份毕业证【微信41543339】即可
三、进国企，银行，事业单位，考公务员等等，这些单位是必需要提供真实教育部认证的，办理教育部认证所需资料众多且烦琐，所有材料您都必须提供原件，我们凭借丰富的经验，快捷的绿色通道帮您快速整合材料，让您少走弯路。
留信网认证的作用:
1:该专业认证可证明留学生真实身份
2:同时对留学生所学专业登记给予评定
3:国家专业人才认证中心颁发入库证书
4:这个认证书并且可以归档倒地方
5:凡事获得留信网入网的信息将会逐步更新到个人身份内，将在公安局网内查询个人身份证信息后，同步读取人才网入库信息
6:个人职称评审加20分
7:个人信誉贷款加10分
8:在国家人才网主办的国家网络招聘大会中纳入资料，供国家高端企业选择人才
留信网服务项目：
1、留学生专业人才库服务（留信分析）
2、国（境）学习人员提供就业推荐信服务
3、留学人员区块链存储服务
【关于价格问题（保证一手价格）】
我们所定的价格是非常合理的，而且我们现在做得单子大多数都是代理和回头客户介绍的所以一般现在有新的单子 我给客户的都是第一手的代理价格，因为我想坦诚对待大家 不想跟大家在价格方面浪费时间
对于老客户或者被老客户介绍过来的朋友，我们都会适当给一些优惠。
选择实体注册公司办理，更放心，更安全！我们的承诺：客户在留信官方认证查询网站查询到认证通过结果后付款，不成功不收费！
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在线办理(英国UCA毕业证书)创意艺术大学毕业证在读证明一模一样
学校原件一模一样【微信：741003700 】《(英国UCA毕业证书)创意艺术大学毕业证》【微信：741003700 】学位证，留信认证（真实可查，永久存档）原件一模一样纸张工艺/offer、雅思、外壳等材料/诚信可靠,可直接看成品样本，帮您解决无法毕业带来的各种难题！外壳，原版制作，诚信可靠，可直接看成品样本。行业标杆！精益求精，诚心合作，真诚制作！多年品质 ,按需精细制作，24小时接单,全套进口原装设备。十五年致力于帮助留学生解决难题，包您满意。
本公司拥有海外各大学样板无数，能完美还原。
1:1完美还原海外各大学毕业材料上的工艺：水印，阴影底纹，钢印LOGO烫金烫银，LOGO烫金烫银复合重叠。文字图案浮雕、激光镭射、紫外荧光、温感、复印防伪等防伪工艺。材料咨询办理、认证咨询办理请加学历顾问Q/微741003700
【主营项目】
一.毕业证【q微741003700】成绩单、使馆认证、教育部认证、雅思托福成绩单、学生卡等！
二.真实使馆公证(即留学回国人员证明,不成功不收费)
三.真实教育部学历学位认证（教育部存档！教育部留服网站永久可查）
四.办理各国各大学文凭(一对一专业服务,可全程监控跟踪进度)
如果您处于以下几种情况：
◇在校期间，因各种原因未能顺利毕业……拿不到官方毕业证【q/微741003700】
◇面对父母的压力，希望尽快拿到；
◇不清楚认证流程以及材料该如何准备；
◇回国时间很长，忘记办理；
◇回国马上就要找工作，办给用人单位看；
◇企事业单位必须要求办理的
◇需要报考公务员、购买免税车、落转户口
◇申请留学生创业基金
留信网认证的作用:
1:该专业认证可证明留学生真实身份
2:同时对留学生所学专业登记给予评定
3:国家专业人才认证中心颁发入库证书
4:这个认证书并且可以归档倒地方
5:凡事获得留信网入网的信息将会逐步更新到个人身份内，将在公安局网内查询个人身份证信息后，同步读取人才网入库信息
6:个人职称评审加20分
7:个人信誉贷款加10分
8:在国家人才网主办的国家网络招聘大会中纳入资料，供国家高端企业选择人才
原版一比一多伦多大学毕业证(UofT毕业证书)如何办理
原版制作【微信:41543339】【多伦多大学毕业证(UofT毕业证书)】【微信:41543339】《成绩单、外壳、雅思、offer、真实留信官方学历认证（永久存档/真实可查）》采用学校原版纸张、特殊工艺完全按照原版一比一制作（包括：隐形水印，阴影底纹，钢印LOGO烫金烫银，LOGO烫金烫银复合重叠，文字图案浮雕，激光镭射，紫外荧光，温感，复印防伪）行业标杆！精益求精，诚心合作，真诚制作！多年品质 ,按需精细制作，24小时接单,全套进口原装设备，十五年致力于帮助留学生解决难题，业务范围有加拿大、英国、澳洲、韩国、美国、新加坡，新西兰等学历材料，包您满意。
【我们承诺采用的是学校原版纸张（纸质、底色、纹路）我们拥有全套进口原装设备，特殊工艺都是采用不同机器制作，仿真度基本可以达到100%，所有工艺效果都可提前给客户展示，不满意可以根据客户要求进行调整，直到满意为止！】
【业务选择办理准则】
一、工作未确定，回国需先给父母、亲戚朋友看下文凭的情况，办理一份就读学校的毕业证【微信41543339】文凭即可
二、回国进私企、外企、自己做生意的情况，这些单位是不查询毕业证真伪的，而且国内没有渠道去查询国外文凭的真假，也不需要提供真实教育部认证。鉴于此，办理一份毕业证【微信41543339】即可
三、进国企，银行，事业单位，考公务员等等，这些单位是必需要提供真实教育部认证的，办理教育部认证所需资料众多且烦琐，所有材料您都必须提供原件，我们凭借丰富的经验，快捷的绿色通道帮您快速整合材料，让您少走弯路。
留信网认证的作用:
1:该专业认证可证明留学生真实身份
2:同时对留学生所学专业登记给予评定
3:国家专业人才认证中心颁发入库证书
4:这个认证书并且可以归档倒地方
5:凡事获得留信网入网的信息将会逐步更新到个人身份内，将在公安局网内查询个人身份证信息后，同步读取人才网入库信息
6:个人职称评审加20分
7:个人信誉贷款加10分
8:在国家人才网主办的国家网络招聘大会中纳入资料，供国家高端企业选择人才
留信网服务项目：
1、留学生专业人才库服务（留信分析）
2、国（境）学习人员提供就业推荐信服务
3、留学人员区块链存储服务
【关于价格问题（保证一手价格）】
我们所定的价格是非常合理的，而且我们现在做得单子大多数都是代理和回头客户介绍的所以一般现在有新的单子 我给客户的都是第一手的代理价格，因为我想坦诚对待大家 不想跟大家在价格方面浪费时间
对于老客户或者被老客户介绍过来的朋友，我们都会适当给一些优惠。
选择实体注册公司办理，更放心，更安全！我们的承诺：客户在留信官方认证查询网站查询到认证通过结果后付款，不成功不收费！
一比一原版(GWU,GW文凭证书)乔治·华盛顿大学毕业证如何办理
毕业原版【微信:176555708】【(GWU,GW毕业证书)乔治·华盛顿大学毕业证】【微信:176555708】成绩单、外壳、offer、留信学历认证（永久存档真实可查）采用学校原版纸张、特殊工艺完全按照原版一比一制作（包括：隐形水印，阴影底纹，钢印LOGO烫金烫银，LOGO烫金烫银复合重叠，文字图案浮雕，激光镭射，紫外荧光，温感，复印防伪）行业标杆！精益求精，诚心合作，真诚制作！多年品质 ,按需精细制作，24小时接单,全套进口原装设备，十五年致力于帮助留学生解决难题，业务范围有加拿大、英国、澳洲、韩国、美国、新加坡，新西兰等学历材料，包您满意。
【我们承诺采用的是学校原版纸张（纸质、底色、纹路），我们拥有全套进口原装设备，特殊工艺都是采用不同机器制作，仿真度基本可以达到100%，所有工艺效果都可提前给客户展示，不满意可以根据客户要求进行调整，直到满意为止！】
【业务选择办理准则】
一、工作未确定，回国需先给父母、亲戚朋友看下文凭的情况，办理一份就读学校的毕业证【微信176555708】文凭即可
二、回国进私企、外企、自己做生意的情况，这些单位是不查询毕业证真伪的，而且国内没有渠道去查询国外文凭的真假，也不需要提供真实教育部认证。鉴于此，办理一份毕业证【微信176555708】即可
三、进国企，银行，事业单位，考公务员等等，这些单位是必需要提供真实教育部认证的，办理教育部认证所需资料众多且烦琐，所有材料您都必须提供原件，我们凭借丰富的经验，快捷的绿色通道帮您快速整合材料，让您少走弯路。
留信网认证的作用:
1:该专业认证可证明留学生真实身份
2:同时对留学生所学专业登记给予评定
3:国家专业人才认证中心颁发入库证书
4:这个认证书并且可以归档倒地方
5:凡事获得留信网入网的信息将会逐步更新到个人身份内，将在公安局网内查询个人身份证信息后，同步读取人才网入库信息
6:个人职称评审加20分
7:个人信誉贷款加10分
8:在国家人才网主办的国家网络招聘大会中纳入资料，供国家高端企业选择人才
留信网服务项目：
1、留学生专业人才库服务（留信分析）
2、国（境）学习人员提供就业推荐信服务
3、留学人员区块链存储服务
→ 【关于价格问题（保证一手价格）】
我们所定的价格是非常合理的，而且我们现在做得单子大多数都是代理和回头客户介绍的所以一般现在有新的单子 我给客户的都是第一手的代理价格，因为我想坦诚对待大家 不想跟大家在价格方面浪费时间
对于老客户或者被老客户介绍过来的朋友，我们都会适当给一些优惠。
选择实体注册公司办理，更放心，更安全！我们的承诺：客户在留信官方认证查询网站查询到认证通过结果后付款，不成功不收费！
STATATHON: Unleashing the Power of Statistics in a 48-Hour Knowledge Extravag...
"Join us for STATATHON, a dynamic 2-day event dedicated to exploring statistical knowledge and its real-world applications. From theory to practice, participants engage in intensive learning sessions, workshops, and challenges, fostering a deeper understanding of statistical methodologies and their significance in various fields."
Experts live - Improving user adoption with AI
Bekijk de slides van onze sessie Enhancing Modern Workplace Efficiency op Experts Live 2024.
一比一原版巴斯大学毕业证(Bath毕业证书)学历如何办理
原版办理【微信号:BYZS866】【巴斯大学毕业证(Bath毕业证书)】【微信号:BYZS866】《成绩单、外壳、雅思、offer、真实留信官方学历认证（永久存档/真实可查）》采用学校原版纸张、特殊工艺完全按照原版一比一制作（包括：隐形水印，阴影底纹，钢印LOGO烫金烫银，LOGO烫金烫银复合重叠，文字图案浮雕，激光镭射，紫外荧光，温感，复印防伪）行业标杆！精益求精，诚心合作，真诚制作！多年品质 ,按需精细制作，24小时接单,全套进口原装设备，十五年致力于帮助留学生解决难题，业务范围有加拿大、英国、澳洲、韩国、美国、新加坡，新西兰等学历材料，包您满意。
【关于学历材料质量】
我们承诺采用的是学校原版纸张（原版纸质、底色、纹路、）我们工厂拥有全套进口原装设备，特殊工艺都是采用不同机器制作，仿真度基本可以达到100%，所有成品以及工艺效果都可提前给客户展示，不满意可以根据客户要求进行调整，直到满意为止！
【业务选择办理准则】
一、工作未确定，回国需先给父母、亲戚朋友看下文凭的情况，办理一份就读学校的毕业证【微信号BYZS866】文凭即可
二、回国进私企、外企、自己做生意的情况，这些单位是不查询毕业证真伪的，而且国内没有渠道去查询国外文凭的真假，也不需要提供真实教育部认证。鉴于此，办理一份毕业证【微信号BYZS866】即可
三、进国企，银行，事业单位，考公务员等等，这些单位是必需要提供真实教育部认证的，办理教育部认证所需资料众多且烦琐，所有材料您都必须提供原件，我们凭借丰富的经验，快捷的绿色通道帮您快速整合材料，让您少走弯路。
留信网认证的作用:
1:该专业认证可证明留学生真实身份
2:同时对留学生所学专业登记给予评定
3:国家专业人才认证中心颁发入库证书
4:这个认证书并且可以归档倒地方
5:凡事获得留信网入网的信息将会逐步更新到个人身份内，将在公安局网内查询个人身份证信息后，同步读取人才网入库信息
6:个人职称评审加20分
7:个人信誉贷款加10分
8:在国家人才网主办的国家网络招聘大会中纳入资料，供国家高端企业选择人才
留信网服务项目：
1、留学生专业人才库服务（留信分析）
2、国（境）学习人员提供就业推荐信服务
3、留学人员区块链存储服务
【关于价格问题（保证一手价格）】
我们所定的价格是非常合理的，而且我们现在做得单子大多数都是代理和回头客户介绍的所以一般现在有新的单子 我给客户的都是第一手的代理价格，因为我想坦诚对待大家 不想跟大家在价格方面浪费时间
对于老客户或者被老客户介绍过来的朋友，我们都会适当给一些优惠。
选择实体注册公司办理，更放心，更安全！我们的承诺：客户在留信官方认证查询网站查询到认证通过结果后付款，不成功不收费！
The Ipsos - AI - Monitor 2024 Report.pdf
According to Ipsos AI Monitor's 2024 report, 65% Indians said that products and services using AI have profoundly changed their daily life in the past 3-5 years.
ViewShift: Hassle-free Dynamic Policy Enforcement for Every Data Lake
Dynamic policy enforcement is becoming an increasingly important topic in today’s world where data privacy and compliance is a top priority for companies, individuals, and regulators alike. In these slides, we discuss how LinkedIn implements a powerful dynamic policy enforcement engine, called ViewShift, and integrates it within its data lake. We show the query engine architecture and how catalog implementations can automatically route table resolutions to compliance-enforcing SQL views. Such views have a set of very interesting properties: (1) They are auto-generated from declarative data annotations. (2) They respect user-level consent and preferences (3) They are context-aware, encoding a different set of transformations for different use cases (4) They are portable; while the SQL logic is only implemented in one SQL dialect, it is accessible in all engines.
#SQL #Views #Privacy #Compliance #DataLake
一比一原版(UMN文凭证书)明尼苏达大学毕业证如何办理
毕业原版【微信:176555708】【(UMN毕业证书)明尼苏达大学毕业证】【微信:176555708】成绩单、外壳、offer、留信学历认证（永久存档真实可查）采用学校原版纸张、特殊工艺完全按照原版一比一制作（包括：隐形水印，阴影底纹，钢印LOGO烫金烫银，LOGO烫金烫银复合重叠，文字图案浮雕，激光镭射，紫外荧光，温感，复印防伪）行业标杆！精益求精，诚心合作，真诚制作！多年品质 ,按需精细制作，24小时接单,全套进口原装设备，十五年致力于帮助留学生解决难题，业务范围有加拿大、英国、澳洲、韩国、美国、新加坡，新西兰等学历材料，包您满意。
【我们承诺采用的是学校原版纸张（纸质、底色、纹路），我们拥有全套进口原装设备，特殊工艺都是采用不同机器制作，仿真度基本可以达到100%，所有工艺效果都可提前给客户展示，不满意可以根据客户要求进行调整，直到满意为止！】
【业务选择办理准则】
一、工作未确定，回国需先给父母、亲戚朋友看下文凭的情况，办理一份就读学校的毕业证【微信176555708】文凭即可
二、回国进私企、外企、自己做生意的情况，这些单位是不查询毕业证真伪的，而且国内没有渠道去查询国外文凭的真假，也不需要提供真实教育部认证。鉴于此，办理一份毕业证【微信176555708】即可
三、进国企，银行，事业单位，考公务员等等，这些单位是必需要提供真实教育部认证的，办理教育部认证所需资料众多且烦琐，所有材料您都必须提供原件，我们凭借丰富的经验，快捷的绿色通道帮您快速整合材料，让您少走弯路。
留信网认证的作用:
1:该专业认证可证明留学生真实身份
2:同时对留学生所学专业登记给予评定
3:国家专业人才认证中心颁发入库证书
4:这个认证书并且可以归档倒地方
5:凡事获得留信网入网的信息将会逐步更新到个人身份内，将在公安局网内查询个人身份证信息后，同步读取人才网入库信息
6:个人职称评审加20分
7:个人信誉贷款加10分
8:在国家人才网主办的国家网络招聘大会中纳入资料，供国家高端企业选择人才
留信网服务项目：
1、留学生专业人才库服务（留信分析）
2、国（境）学习人员提供就业推荐信服务
3、留学人员区块链存储服务
→ 【关于价格问题（保证一手价格）】
我们所定的价格是非常合理的，而且我们现在做得单子大多数都是代理和回头客户介绍的所以一般现在有新的单子 我给客户的都是第一手的代理价格，因为我想坦诚对待大家 不想跟大家在价格方面浪费时间
对于老客户或者被老客户介绍过来的朋友，我们都会适当给一些优惠。
选择实体注册公司办理，更放心，更安全！我们的承诺：客户在留信官方认证查询网站查询到认证通过结果后付款，不成功不收费！
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Update heart failure-2021.pptx
- 1. HEART FAILURE AN UPDATE DR MUSTIKA MAHBUBI SP.JP FIHA
- 3. 3
- 4. Symptoms and Signs Heart Failure Ponikowski et al. Eur Heart J 2016; 37(27): 2129-2200 McMurray et al. Eur Heart J 2012;33:1787–847 4
- 6. 6 Before…
- 7. Etiology *Others: Including hypertension, diabetes, exposure to cardiotoxic agents, peripartum cardiomyopathy, etc. 7
- 8. LV=left ventricular McMurray. N Engl J Med 2010;362:228–38; Francis et al. Ann Intern Med 1984;101:370–7; Krum, Abraham. Lancet 2009;373:941–55 The pathophysiology of chronic HF HF symptoms dyspnea, edema, fatigue Remodeling and progressive worsening of LV function Morbidity and mortality arrhythmias, pump failure Hemodynamic alterations, salt and water retention These changes lead to systemic neurohormonal imbalance Damage to cardiac myocytes and extracellular matrix leads to changes in the size, shape and function of the heart (remodeling) and cardiac wall stress This may lead to fibrosis, apoptosis, hypertension, hypertrophy, cellular and molecular alterations, myotoxicity 8
- 9. Cardiac dysfunction triggers the activation of three compensatory neurohormonal systems Cardiac structure/function abnormality Activation of compensatory mechanisms to maintain cardiac output and organ perfusion1 Activated in response to reduced cardiac output1 Short-term effects are beneficial in early HF1 Long-term activation exerts unfavourable effects1,3 NP=natriuretic peptide; RAAS=renin angiotensin aldosterone system;SNS=sympathetic nervous system 1. Francis et al. Ann Intern Med 1984;101:370–7; 2. Clerico et al. Am J Physiol Heart Circ Physiol 2011;301:H12–H20; 3. Von Lueder et al. Circ Heart Fail 2013;6:594–605 4. Luchner & Schunkert. Cardiovasc Res 2004;63:443–9; 5. Thysgesen et al. Eur Heart J 2012;33:2001–6 Release of NPs in response to cardiac stress2 Opposes the actions of the RAAS2 and SNS4,5 SNS RAAS NP system 9
- 14. bisoprolol, carvedilol, nebifolol Pharmacological treatment was developed to counter 2 core pathophysiology pathway Cardiac structure/function abnormality Activation of compensatory mechanisms to maintain cardiac output and organ perfusion1 NP=natriuretic peptide; RAAS=renin angiotensin aldosterone system;SNS=sympathetic nervous system 1. Francis et al. Ann Intern Med 1984;101:370–7; 2. Clerico et al. Am J Physiol Heart Circ Physiol 2011;301:H12–H20; 3. Von Lueder et al. Circ Heart Fail 2013;6:594–605 4. Luchner & Schunkert. Cardiovasc Res 2004;63:443–9; 5. Thysgesen et al. Eur Heart J 2012;33:2001–6 SNS RAAS NP system 14 β blocker RAAS blocker ACEi : captopril, Lisinopril ARB : valsartan, candesartan MRA : spironolactone What can we do? Threatment
- 15. 15 ARNI: enhancement of natriuretic and other vasoactive peptides, with simultaneous RAAS suppression Evolution of pharmacologic approaches in HF: ARNI is a new agent in HFrEF treatment1 ACEI=angiotensin-converting enzyme inhibitor; Ang=angiotensin; ARB=angiotensin receptor blocker; AT1R=angiotensin II type 1 receptor; HF=heart failure; HFrEF=heart failure with reduced ejection fraction; MRA=mineralocorticoid receptor antagonist; NP=natriuretic peptide; NPRs=natriuretic peptide receptors; RAAS=renin-angiotensin-aldosterone system; SNS=sympathetic nervous system 1. McMurray et al. Eur J Heart Fail 2013;15:1062–73 Figure references: Levin et al. N Engl J Med 1998;339:321–8 Nathisuwan & Talbert. Pharmacotherapy 2002;22:27–42 Kemp & Conte. Cardiovascular Pathology 2012;365–71 Schrier & Abraham. N Engl J Med 2009;341:577–85 SNS RAAS Vasoconstriction Blood pressure Sympathetic tone Aldosterone Hypertrophy Fibrosis Ang II AT1R HF SYMPTOMS & PROGRESSION INACTIVE FRAGMENTS NP system Vasodilation Blood pressure Sympathetic tone Natriuresis/diuresis Vasopressin Aldosterone Fibrosis Hypertrophy NPRs NPs Epinephrine Norepinephrine α1, β1, β2 receptors Vasoconstriction RAAS activity Vasopressin Heart rate Contractility Neprilysin inhibitors β-blockers ARNI RAAS inhibitors (ACEI, ARB, MRA)
- 19. 19
- 20. 20 ESC 2021 HFpEF & HFmrEF
- 30. THANK YOU
- 31. 31
- 32. Compensatory Mechanisms: Renin-Angiotensin-Aldosterone System Renin + Angiotensinogen Angiotensin I Angiotensin II Peripheral Vasoconstriction Afterload Cardiac Output Heart Failure Cardiac Workload Preload Plasma Volume Salt & Water Retention Edema Aldosterone Secretion ACE Kaliuresis Fibrosis