成人心力衰竭診斷和治療指南解讀

1、0,2009 ACCF/AHA成人心力衰竭診斷和治療指南解讀,山東大學(xué) 張 運(yùn),2009 ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: A Report of the American College of Cardiology Foundation/American Heart Association Task

2、Force on Practice Guidelines,Developed in Collaboration With:International Society for Heart and Lung Transplantation,Initial Clinical Assessment of Patients Presenting With Heart Failure,Recommendations for the Initial

3、 Clinical Assessment of Patients Presenting With Heart Failure,Identifying and Evaluating Noncardiac Disorders or Behaviors,Initial Assessment and Examination of Patients With HF,Recommendations for the Initial Clinical

4、 Assessment of Patients Presenting With Heart Failure,Initial Laboratory Evaluation,Recommendations for the Initial Clinical Assessment of Patients Presenting With Heart Failure,Two-Dimensional Echocardiography,Recomme

5、ndations for the Initial Clinical Assessment of Patients Presenting With Heart Failure,Coronary Revascularization,Recommendations for the Initial Clinical Assessment of Patients Presenting With Heart Failure,Noninvasiv

6、e Imaging and Exercise Testing,Recommendations for the Initial Clinical Assessment of Patients Presenting With Heart Failure,Initial Clinical Assessment of Patients Presenting With Heart Failure,Endomyocardial Biopsy,In

7、itial Clinical Assessment of Patients Presenting With Heart Failure,Measurement of BNP and Noninvasive Imaging,Documenting Ventricular Tachycardia Inducibility,Initial Clinical Assessment of Patients Presenting With Hear

8、t Failure,Measuring Circulating Levels of Neurohormones,Initial Clinical Assessment of Patients Presenting With Heart Failure,Patients With Reduced Left Ventricular Ejection Fraction,Patients With Reduced Left Ve

9、ntricular Ejection Fraction,Measures listed as Class I recommendations for patients in Stages A and B are also appropriate for patients in Stage C.,Measuring LVEF,Patients With Reduced Left Ventricular Ejection Fracti

10、on,Measuring LVEF,Patients With Reduced Left Ventricular Ejection Fraction,NO CHANGE,Angiotensin ll Receptor Blockers,Patients With Reduced Left Ventricular Ejection Fraction,Secondary Prevention: Implantable Cardiover

11、ter-Defibrillator,Patients With Reduced Left Ventricular Ejection Fraction,Primary Prevention: Implantable Cardioverter-Defibrillator,Patients With Reduced Left Ventricular Ejection Fraction,Resynchronization Therapy,P

12、atients With Reduced Left Ventricular Ejection Fraction,The Risks of Aldosterone Antagonists,Patients With Reduced Left Ventricular Ejection Fraction,Recommendations for Hydralazine and Nitrates,Patients With Reduced L

13、eft Ventricular Ejection Fraction,Recommendations for Atrial Fibrillation and Heart Failure,Patients With Reduced Left Ventricular Ejection Fraction,Measurement of Respiratory Gas Exchange,Patients With Reduced Left Ve

14、ntricular Ejection Fraction,The Benefits of Digitalis,Patients With Reduced Left Ventricular Ejection Fraction,Implantable Cardioverter-Defibrillator in Pts With Low LVEF,Patients With Reduced Left Ventricular Ejectio

15、n Fraction,ARB and Conventional Therapy,Patients With Reduced Left Ventricular Ejection Fraction,Infusion of Positive Inotropic Drugs,Patients With Reduced Left Ventricular Ejection Fraction,Patients With Heart Failure

16、 and Normal Left Ventricular Ejection Fraction,Patients With Heart Failure and Normal Left Ventricular Ejection Fraction,Normal Left Ventricular Ejection Fraction,Patients With Heart Failure and Normal Left Ventricular E

17、jection Fraction,Normal Left Ventricular Ejection Fraction,Patients With Heart Failure and Normal Left Ventricular Ejection Fraction,Normal Left Ventricular Ejection Fraction,Recommendations for the Hospitalized Patient

18、New Recommendations,The diagnosis of heart failure is primarily based on signs and symptoms derived from a thorough history and physical exam. Clinicians should determine the following:a. adequacy of systemic perfusion

19、;b. volume status;c. the contribution of precipitating factors and/or co-morbidities d. if the heart failure is new onset or an exacerbation of chronic disease; ande. whether it is associated with preserv

20、ed normal or reduced ejection fraction.Chest radiographs, electrocardiogram and echocardiography are key tests in this assessment.,The Hospitalized Patient,The Hospitalized Patient,Patients Being Evaluated for Dyspnea,T

21、he Hospitalized Patient,Precipitating Factors for Acute HF,The Hospitalized Patient,Oxygen Therapy and Rapid Intervention,The Hospitalized Patient,Treatment With Intravenous Loop Diuretics,The Hospitalized Patient,Monito

22、ring and Measuring Fluid Intake and Output,The Hospitalized Patient,Intensifying the Diuretic Regimen,Invasive hemodynamic monitoring should be performed to guide therapy in patients who are in respiratory distress or wi

23、th clinical evidence of impaired perfusion in whom the adequacy or excess of intracardiac filling pressures cannot be determined from clinical assessment.,In patients with clinical evidence of hypotension associated with

24、 hypoperfusion and obvious evidence of elevated cardiac filling pressures (e.g., elevated jugular venous pressure; elevated pulmonary artery wedge pressure), intravenous inotropic or vasopressor drugs should be administe

25、red to maintain systemic perfusion and preserve end-organ performance while more definitive therapy is considered.,The Hospitalized Patient,Preserving End-Organ Performance,New,New,The Hospitalized Patient,Reconciling an

26、d Adjusting Medications,Medications should be reconciled in every patient and adjusted as appropriate on admission to and discharge from the hospital.,In patients with reduced ejection fraction experiencing a symptomat

27、ic exacerbation of HF requiring hospitalization during chronic maintenance treatment with oral therapies known to improve outcomes, particularly ACE inhibitors or ARBs and beta-blocker therapy, it is recommended that the

28、se therapies be continued in most patients in the absence of hemodynamic instability or contraindications.,New,New,The Hospitalized Patient,The Hospitalized Patient,The Hospitalized Patient,The Hospitalized Patient,Sever

29、e Symptomatic Fluid Overload,Invasive hemodynamic monitoring can be useful for carefully selected patients with acute HF who have persistent symptoms despite empiric adjustment of standard therapies, and a. whose fluid

30、status, perfusion, or systemic orpulmonary vascular resistances are uncertain;b. whose systolic pressure remains low, pr is associated with symptoms, despite initialtherapy;c. whose renal function is worsening with t

31、herapy;d. who require parenteral vasoactive agents; ore. who may need consideration for advanced device therapy or transplantation.,The Hospitalized Patient,Invasive Hemodynamic Monitoring,Ultrafiltration is reasonable

32、 for patients with refractory congestion not responding to medical therapy.,The Hospitalized Patient,Intravenous inotropic drugs such as dopamine, dobutamine or milrinone might be reasonable for those patients presenting

33、 with documented severe systolic dysfunction, low blood pressure and evidence of low cardiac output, with or without congestion, to maintain systemic perfusion and preserve end-organ performance.,Ultrafiltration and Intr