2013年美国心力衰竭管理指南(心衰指南)课件.ppt

2013accf ahaguidelineforthemanagementofheartfailure developedincollaborationwiththeamericanacademyoffamilyphysicians americancollegeofchestphysicians heartrhythmsociety andinternationalsocietyforheartandlungtransplantationendorsedbytheamericanassociationofcardiovascularandpulmonaryrehabilitation americancollegeofcardiologyfoundationandamericanheartassociation inc citation thisslidesetisadaptedfromthe2013accf ahaguidelineforthemanagementofheartfailure e publishedonjune5 2013 availableat http content onlinejacc org article aspx doi 10 1016 j jacc 2013 05 019andhttp circ ahajournals org lookup doi 10 1161 cir 0b013e31829e8776 thefull textguidelinesarealsoavailableonthefollowingwebsites acc www cardiosource org andaha my americanheart org clydew yancyandmarielljessupaccf ahaheartfailureguidelinewritingcommitteemembersclydew yancy md msc facc faha chair marielljessup md facc faha vicechair slideseteditors writingcommitteemembersarerequiredtorecusethemselvesfromvotingonsectionstowhichtheirspecificrelationshipswithindustryandotherentitiesmayapply seeappendix1forrecusalinformation accf aharepresentative accf ahataskforceonpracticeguidelinesliaison americancollegeofphysiciansrepresentative americancollegeofchestphysiciansrepresentative internationalsocietyforheartandlungtransplantationrepresentative accf ahataskforceonperformancemeasuresliaison americanacademyoffamilyphysiciansrepresentative heartrhythmsocietyrepresentative biykembozkurt md phd facc faha javedbutler mbbs facc faha donalde casey jr md mph mba facp faha markh drazner md msc facc faha greggc fonarow md facc faha stephena geraci md facc faha fccp tamarahorwich md facc jamesl januzzi md facc marylr johnson md facc faha edwardk kasper md facc faha waynec levy md facc fredericka masoudi md msph facc faha patricke mcbride md mph facc johnj v mcmurray md facc judithe mitchell md facc faha pamelan peterson md msph facc faha barbarariegel dnsc rn faha florasam md facc faha lynnew stevenson md facc w h wilsontang md facc emilyj tsai md facc brucel wilkoff md facc fhrs classificationofrecommendationsandlevelsofevidence arecommendationwithlevelofevidenceborcdoesnotimplythattherecommendationisweak manyimportantclinicalquestionsaddressedintheguidelinesdonotlendthemselvestoclinicaltrials althoughrandomizedtrialsareunavailable theremaybeaveryclearclinicalconsensusthataparticulartestortherapyisusefuloreffective dataavailablefromclinicaltrialsorregistriesabouttheusefulness efficacyindifferentsubpopulations suchassex age historyofdiabetes historyofpriormyocardialinfarction historyofheartfailure andprioraspirinuse forcomparativeeffectivenessrecommendations classiandiia levelofevidenceaandbonly studiesthatsupporttheuseofcomparatorverbsshouldinvolvedirectcomparisonsofthetreatmentsorstrategiesbeingevaluated stages phenotypesandtreatmentofhf initialandserialevaluationofthehfpatient includinghfpef ii treatmentofstageathrudheartfailure includinghfpef iii thehospitalizedpatientiv surgical percutaneous transcatheterinterventionaltreatmentsv coordinatingcareforpatientswithchronichfvi qualitymetrics performancemeasures outline clinicalevaluation initialandserialevaluationofthehfpatient definitionofheartfailure classificationofheartfailure initialandserialevaluationofthehfpatient guidelineforhf historyandphysicalexamination initialandserialevaluationofthehfpatient athoroughhistoryandphysicalexaminationshouldbeobtained performedinpatientspresentingwithhftoidentifycardiacandnoncardiacdisordersorbehaviorsthatmightcauseoracceleratethedevelopmentorprogressionofhf inpatientswithidiopathicdcm a3 generationalfamilyhistoryshouldbeobtainedtoaidinestablishingthediagnosisoffamilialdcm volumestatusandvitalsignsshouldbeassessedateachpatientencounter thisincludesserialassessmentofweight aswellasestimatesofjugularvenouspressureandthepresenceofperipheraledemaororthopnea historyandphysicalexamination riskscoring initialandserialevaluationofthehfpatient riskscoring validatedmultivariableriskscorescanbeusefultoestimatesubsequentriskofmortalityinambulatoryorhospitalizedpatientswithhf riskscorestopredictoutcomesinhf diagnostictests initialandserialevaluationofthehfpatient diagnostictests initiallaboratoryevaluationofpatientspresentingwithhfshouldincludecompletebloodcount urinalysis serumelectrolytes includingcalciumandmagnesium bloodureanitrogen serumcreatinine glucose fastinglipidprofile liverfunctiontests andthyroid stimulatinghormone serialmonitoring whenindicated shouldincludeserumelectrolytesandrenalfunction diagnostictests cont a12 leadecgshouldbeperformedinitiallyonallpatientspresentingwithhf screeningforhemochromatosisorhivisreasonableinselectedpatientswhopresentwithhf diagnostictestsforrheumatologicdiseases amyloidosis orpheochromocytomaarereasonableinpatientspresentingwithhfinwhomthereisaclinicalsuspicionofthesediseases biomarkersambulatory outpatient initialandserialevaluationofthehfpatient ambulatory outpatient inambulatorypatientswithdyspnea measurementofbnporn terminalpro b typenatriureticpeptide nt probnp isusefultosupportclinicaldecisionmakingregardingthediagnosisofhf especiallyinthesettingofclinicaluncertainty measurementofbnpornt probnpisusefulforestablishingprognosisordiseaseseverityinchronichf ambulatory outpatient cont bnp ornt probnpguidedhftherapycanbeusefultoachieveoptimaldosingofgdmtinselectclinicallyeuvolemicpatientsfollowedinawell structuredhfdiseasemanagementprogram theusefulnessofserialmeasurementofbnpornt probnptoreducehospitalizationormortalityinpatientswithhfisnotwellestablished measurementofotherclinicallyavailabletestssuchasbiomarkersofmyocardialinjuryorfibrosismaybeconsideredforadditiveriskstratificationinpatientswithchronichf biomarkershospitalized acute initialandserialevaluationofthehfpatient hospitalized acute measurementofbnpornt probnpisusefultosupportclinicaljudgmentforthediagnosisofacutelydecompensatedhf especiallyinthesettingofuncertaintyforthediagnosis measurementofbnpornt probnpand orcardiactroponinisusefulforestablishingprognosisordiseaseseverityinacutelydecompensatedhf hospitalized acute cont theusefulnessofbnp ornt probnpguidedtherapyforacutelydecompensatedhfisnotwell established measurementofotherclinicallyavailabletestssuchasbiomarkersofmyocardialinjuryorfibrosismaybeconsideredforadditiveriskstratificationinpatientswithacutelydecompensatedhf recommendationsforbiomarkersinhf causesforelevatednatriureticpeptidelevels noninvasivecardiacimaging initialandserialevaluationofthehfpatient noninvasivecardiacimaging patientswithsuspectedornew onsethf orthosepresentingwithacutedecompensatedhf shouldundergoachestx raytoassessheartsizeandpulmonarycongestion andtodetectalternativecardiac pulmonary andotherdiseasesthatmaycauseorcontributetothepatients symptoms a2 dimensionalechocardiogramwithdopplershouldbeperformedduringinitialevaluationofpatientspresentingwithhftoassessventricularfunction size wallthickness wallmotion andvalvefunction repeatmeasurementofefandmeasurementoftheseverityofstructuralremodelingareusefultoprovideinformationinpatientswithhfwhohavehadasignificantchangeinclinicalstatus whohaveexperiencedorrecoveredfromaclinicalevent orwhohavereceivedtreatment includinggdmt thatmighthavehadasignificanteffectoncardiacfunction orwhomaybecandidatesfordevicetherapy noninvasivecardiacimaging cont noninvasiveimagingtodetectmyocardialischemiaandviabilityisreasonableinpatientspresentingwithdenovohfwhohaveknowncadandnoanginaunlessthepatientisnoteligibleforrevascularizationofanykind viabilityassessmentisreasonableinselectsituationswhenplanningrevascularizationinhfpatientswithcad radionuclideventriculographyormagneticresonanceimagingcanbeusefultoassesslvefandvolumewhenechocardiographyisinadequate noninvasivecardiacimaging cont magneticresonanceimagingisreasonablewhenassessingmyocardialinfiltrativeprocessesorscarburden routinerepeatmeasurementoflvfunctionassessmentintheabsenceofclinicalstatuschangeortreatmentinterventionsshouldnotbeperformed nobenefit recommendationsfornoninvasiveimaging invasiveevaluation initialandserialevaluationofthehfpatient invasiveevaluation invasivehemodynamicmonitoringwithapulmonaryarterycathetershouldbeperformedtoguidetherapyinpatientswhohaverespiratorydistressorclinicalevidenceofimpairedperfusioninwhomtheadequacyorexcessofintracardiacfillingpressurescannotbedeterminedfromclinicalassessment invasivehemodynamicmonitoringcanbeusefulforcarefullyselectedpatientswithacutehfwhohavepersistentsymptomsdespiteempiricadjustmentofstandardtherapiesanda whosefluidstatus perfusion orsystemicorpulmonaryvascularresistanceisuncertain b whosesystolicpressureremainslow orisassociatedwithsymptoms despiteinitialtherapy c whoserenalfunctionisworseningwiththerapy d whorequireparenteralvasoactiveagents ore whomayneedconsiderationformcsortransplantation invasiveevaluation cont whenischemiamaybecontributingtohf coronaryarteriographyisreasonableforpatientseligibleforrevascularization endomyocardialbiopsycanbeusefulinpatientspresentingwithhfwhenaspecificdiagnosisissuspectedthatwouldinfluencetherapy invasiveevaluation cont routineuseofinvasivehemodynamicmonitoringisnotrecommendedinnormotensivepatientswithacutedecompensatedhfandcongestionwithsymptomaticresponsetodiureticsandvasodilators endomyocardialbiopsyshouldnotbeperformedintheroutineevaluationofpatientswithhf nobenefit harm recommendationsforinvasiveevaluation treatmentofstagesatod guidelineforhf stagea treatmentofstagesatod stagea hypertensionandlipiddisordersshouldbecontrolledinaccordancewithcontemporaryguidelinestolowertheriskofhf otherconditionsthatmayleadtoorcontributetohf suchasobesity diabetesmellitus tobaccouse andknowncardiotoxicagents shouldbecontrolledoravoided stageb treatmentofstagesatod stageb inallpatientswitharecentorremotehistoryofmioracsandreducedef aceinhibitorsshouldbeusedtopreventsymptomatichfandreducemortality inpatientsintolerantofaceinhibitors arbsareappropriateunlesscontraindicated inallpatientswitharecentorremotehistoryofmioracsandreducedef evidence basedbetablockersshouldbeusedtoreducemortality inallpatientswitharecentorremotehistoryofmioracs statinsshouldbeusedtopreventsymptomatichfandcardiovascularevents stageb cont inpatientswithstructuralcardiacabnormalities includinglvhypertrophy intheabsenceofahistoryofmioracs bloodpressureshouldbecontrolledinaccordancewithclinicalpracticeguidelinesforhypertensiontopreventsymptomatichf aceinhibitorsshouldbeusedinallpatientswithareducedeftopreventsymptomatichf eveniftheydonothaveahistoryofmi betablockersshouldbeusedinallpatientswithareducedeftopreventsymptomatichf eveniftheydonothaveahistoryofmi stageb cont topreventsuddendeath placementofanicdisreasonableinpatientswithasymptomaticischemiccardiomyopathywhoareatleast40dayspost mi haveanlvefof30 orless areonappropriatemedicaltherapyandhavereasonableexpectationofsurvivalwithagoodfunctionalstatusformorethan1year nondihydropyridinecalciumchannelblockerswithnegativeinotropiceffectsmaybeharmfulinasymptomaticpatientswithlowlvefandnosymptomsofhfaftermi harm recommendationsfortreatmentofstagebhf stagec treatmentofstagesatod nonpharmacologicalinterventions treatmentofstagesatod stagec nonpharmacologicalinterventions patientswithhfshouldreceivespecificeducationtofacilitatehfself care exercisetraining orregularphysicalactivity isrecommendedassafeandeffectiveforpatientswithhfwhoareabletoparticipatetoimprovefunctionalstatus sodiumrestrictionisreasonableforpatientswithsymptomatichftoreducecongestivesymptoms stagec nonpharmacologicalinterventions cont continuouspositiveairwaypressure cpap canbebeneficialtoincreaselvefandimprovefunctionalstatusinpatientswithhfandsleepapnea cardiacrehabilitationcanbeusefulinclinicallystablepatientswithhftoimprovefunctionalcapacity exerciseduration hrqol andmortality pharmacologicaltreatmentforstagechfref treatmentofstagesatod pharmacologicaltreatmentforstagechfref measureslistedasclassirecommendationsforpatientsinstagesaandbarerecommendedwhereappropriateforpatientsinstagec levelsofevidence a b andcasappropriate gdmtasdepictedinfigure1shouldbethemainstayofpharmacologicaltherapyforhfref seerecommendationsforstagesa b andcloeforloe pharmacologictreatmentforstagechfref pharmacologicaltreatmentforstagechfref cont diureticsarerecommendedinpatientswithhfrefwhohaveevidenceoffluidretention unlesscontraindicated toimprovesymptoms aceinhibitorsarerecommendedinpatientswithhfrefandcurrentorpriorsymptoms unlesscontraindicated toreducemorbidityandmortality arbsarerecommendedinpatientswithhfrefwithcurrentorpriorsymptomswhoareaceinhibitor intolerant unlesscontraindicated toreducemorbidityandmortality drugscommonlyusedforhfref stagechf drugscommonlyusedforhfref stagechf cont pharmacologicaltreatmentforstagechfref cont arbsarereasonabletoreducemorbidityandmortalityasalternativestoaceinhibitorsasfirst linetherapyforpatientswithhfref especiallyforpatientsalreadytakingarbsforotherindications unlesscontraindicated additionofanarbmaybeconsideredinpersistentlysymptomaticpatientswithhfrefwhoarealreadybeingtreatedwithanaceinhibitorandabetablockerinwhomanaldosteroneantagonistisnotindicatedortolerated pharmacologicaltreatmentforstagechfref cont routinecombineduseofanaceinhibitor arb andaldosteroneantagonistispotentiallyharmfulforpatientswithhfref useof1ofthe3betablockersproventoreducemortality i e bisoprolol carvedilol andsustained releasemetoprololsuccinate isrecommendedforallpatientswithcurrentorpriorsymptomsofhfref unlesscontraindicated toreducemorbidityandmortality harm pharmacologicaltreatmentforstagechfref cont aldosteronereceptorantagonists ormineralocorticoidreceptorantagonists mra arerecommendedinpatientswithnyhaclassii ivandwhohavelvefof35 orless unlesscontraindicated toreducemorbidityandmortality patientswithnyhaclassiishouldhaveahistoryofpriorcardiovascularhospitalizationorelevatedplasmanatriureticpeptidelevelstobeconsideredforaldosteronereceptorantagonists creatinineshouldbe2 5mg dlorlessinmenor2 0mg dlorlessinwomen orestimatedglomerularfiltrationrate 30ml min 1 73m2 andpotassiumshouldbelessthan5 0meq l carefulmonitoringofpotassium renalfunction anddiureticdosingshouldbeperformedatinitiationandcloselyfollowedthereaftertominimizeriskofhyperkalemiaandrenalinsufficiency pharmacologicaltreatmentforstagechfref cont aldosteronereceptorantagonistsarerecommendedtoreducemorbidityandmortalityfollowinganacutemiinpatientswhohavelvefof40 orlesswhodevelopsymptomsofhforwhohaveahistoryofdiabetesmellitus unlesscontraindicated inappropriateuseofaldosteronereceptorantagonistsispotentiallyharmfulbecauseoflife threateninghyperkalemiaorrenalinsufficiencywhenserumcreatininegreaterthan2 5mg dlinmenorgreaterthan2 0mg dlinwomen orestimatedglomerularfiltrationrate 30ml min 1 73m2 and orpotassiumabove5 0meq l harm pharmacologicaltreatmentforstagechfref cont thecombinationofhydralazineandisosorbidedinitrateisrecommendedtoreducemorbidityandmortalityforpatientsself describedasafricanamericanswithnyhaclassiii ivhfrefreceivingoptimaltherapywithaceinhibitorsandbetablockers unlesscontraindicated acombinationofhydralazineandisosorbidedinitratecanbeusefultoreducemorbidityormortalityinpatientswithcurrentorpriorsymptomatichfrefwhocannotbegivenanaceinhibitororarbbecauseofdrugintolerance hypotension orrenalinsufficiency unlesscontraindicated pharmacologicaltreatmentforstagechfref cont digoxincanbebeneficialinpatientswithhfref unlesscontraindicated todecreasehospitalizationsforhf patientswithchronichfwithpermanent persistent paroxysmalafandanadditionalriskfactorforcardioembolicstroke historyofhypertension diabetesmellitus previousstrokeortransientischemicattack or 75yearsofage shouldreceivechronicanticoagulanttherapy intheabsenceofcontraindicationstoanticoagulation pharmacologicaltreatmentforstagechfref cont theselectionofananticoagulantagent warfarin dabigatran apixaban orrivaroxaban forpermanent persistent paroxysmalafshouldbeindividualizedonthebasisofriskfactors cost tolerability patientpreference potentialfordruginteractions andotherclinicalcharacteristics includingtimeintheinternationalnormalizedratetherapeuticrationifthepatienthasbeentakingwarfarin chronicanticoagulationisreasonableforpatientswithchronichfwhohavepermanent persistent paroxysmalafbutarewithoutanadditionalriskfactorforcardioembolicstroke intheabsenceofcontraindicationstoanticoagulation pharmacologicaltreatmentforstagechfref cont anticoagulationisnotrecommendedinpatientswithchronichfrefwithoutaf apriorthromboembolicevent oracardioembolicsource statinsarenotbeneficialasadjunctivetherapywhenprescribedsolelyforthediagnosisofhfintheabsenceofotherindicationsfortheiruse omega 3polyunsaturatedfattyacid pufa supplementationisreasonabletouseasadjunctivetherapyinpatientswithnyhaclassii ivsymptomsandhfreforhfpef unlesscontraindicated toreducemortalityandcardiovascularhospitalizations nobenefit nobenefit pharmacologicaltreatmentforstagechfref cont nutritionalsupplementsastreatmentforhfarenotrecommendedinpatientswithcurrentorpriorsymptomsofhfref hormonaltherapiesotherthantocorrectdeficienciesarenotrecommendedforpatientswithcurrentorpriorsymptomsofhfref drugsknowntoadverselyaffecttheclinicalstatusofpatientswithcurrentorpriorsymptomsofhfrefarepotentiallyharmfulandshouldbeavoidedorwithdrawnwheneverpossible e g mostantiarrhythmicdrugs mostcalciumchannelblockingdrugs exceptamlodipine nsaids ortzds nobenefit nobenefit harm pharmacologicaltreatmentforstagechfref cont long termuseofinfusedpositiveinotropicdrugsispotentiallyharmfulforpatientswithhfref exceptaspalliationforpatientswithend stagediseasewhocannotbestabilizedwithstandardmedicaltreatment seerecommendationsforstaged calciumchannelblockingdrugsarenotrecommendedasroutinetreatmentforpatientswithhfref harm nobenefit pharmacologicaltreatmentforstagechfpef systolicanddiastolicbloodpressureshouldbecontrolledinpatientswithhfpefinaccordancewithpublishedclinicalpracticeguidelinestopreventmorbidity diureticsshouldbeusedforreliefofsymptomsduetovolumeoverloadinpatientswithhfpef coronaryrevascularizationisreasonableinpatientswithcadinwhomsymptoms angina ordemonstrablemyocardialischemiaisjudgedtobehavi