欧洲心衰院前及院内管理

1、年欧洲年欧洲急性心力衰竭院前和院内早期处理共识急性心力衰竭院前和院内早期处理共识由欧洲心脏学会（European Society of Cardiology，ESC）、心力衰竭委员会（Heart Failure Association，HFA）、欧洲急诊学会和理论急诊医学会联合制定ICU 张高峰 Acute heart failure is a syndrome in which emergency physicians,cardiologists, intensivists, nurses, and other healthcare providers have to cooperate t

2、o provide rapid benefit to the patients. 新共识，特别强调了“及时治疗” 的理念，并将该理念贯穿新共识始终，包括院前及院内的处理（pre-hospital and early hospital management） 。Definition and epidemiology of acute heart failure Acute heart failure (AHF) is the term used to describe the rapid onset of or acute worsening of symptoms and signs of H

3、F, associated with elevated plasma levels of natriuretic peptides. It is a lifethreatening condition that requires immediate medical attention and usually leads to urgent hospital admission.心衰心衰定义及流行病学定义及流行病学Definition and epidemiology of acute heart failure 新共识中，定义为：心力衰竭（以下简称“心衰”）症状急性发作或加重，并伴有血浆脑利钠

4、肽水平的升高。与以往相比，该定义强调了脑利钠肽的价值。 Most of the patients with AHF present with normal or high blood pressure and with symptoms and/or signs of congestion rather than low cardiac output.Definition and epidemiology of acute heart failure大型研究中不同初次医疗接触和处理地点的急性心大型研究中不同初次医疗接触和处理地点的急性心衰的临床特点衰的临床特点Table 1 compares

5、the characteristics among patients whose initial management was performed in cardiology/CCU, emergency department (ED), or pre-hospital setting. Clinical characteristics are somewhat different; AHF patients seen early, in the pre-hospital setting or in the ED not only have higher blood pressure but

6、also are more frequently female and older.Pre-hospital and early management strategies in acute heart failureAs for acute coronary syndromes, the time-to-treatmentconcept may be important in patients with AHF. Hence, all AHF patients should receive appropriate therapy as early as possible. 新共识指出，研究表

7、明，尽早接受治疗会有更多的潜在获益 acute coronary syndromes：急性冠脉综合症 Pre-hospital and early management strategies in acute heart failure In the pre-hospital setting, AHF patients should benefit from: Non-invasive monitoring, including pulse oximetry, blood pressure, respiratory rate, and a continuous ECG, instituted

8、within minutes of patient contact and in the ambulance if possible -尽早进行无创监测，包括脉氧饱和度、血压、呼吸频率及连续心电监测等 Non-invasive monitoring：无创检测 pulse oximetry：脉氧 blood pressure：血压 respiratory rate：呼吸频率 ECG（Electrocardiograph ）：心电图Pre-hospital and early management strategies in acute heart failure In the pre-hospi

9、tal setting, AHF patients should benefit from: Oxygen therapy given based on clinical judgment unless oxygen saturation 90% in which case oxygen therapy should be routinely administered. -根据临床情况决定是否氧疗，若血氧饱和度，常规氧疗。 oxygen therapy：氧疗 oxygen saturation：氧饱和度Pre-hospital and early management strategies i

10、n acute heart failure In the pre-hospital setting, AHF patients should benefit from: -Non-invasive ventilation, in patients with respiratory distress. - -呼吸困难的患者给予无创通气，即使诊断不明确，因为这种措施可以降低气管插管几率，并且改善近期预后。 non-invasive ventilation：无创通气 respiratory distress：呼吸窘迫Pre-hospital and early management strategi

11、es in acute heart failure In the pre-hospital setting, AHF patients should benefit from: Medical treatment should be initiated based on blood pressure and/or the degree of congestion using vasodilators and/or diuretics (i.e. furosemide). - -根据血压和或充血的程度决定是否应用药物血管扩张剂和或利尿剂（如呋塞米）。 vasodilators：血管扩张剂 diu

12、retics ：利尿剂 furosemide：呋塞米Pre-hospital and early management strategies in acute heart failure In the pre-hospital setting, AHF patients should benefit from: -Rapid transfer to the nearest hospital, preferably to a site with a cardiology department and/or CCU/ICU. - -应尽快转运患者至最近的有心血管病房和或的医院。Pre-hospit

13、al and early management strategies in acute heart failure On arrival in the ED/CCU/ICU, initial clinical examination, investigations and treatment should be started immediately and concomitantly. 到达急诊病房或后立即行病情评估及治疗。Initial clinical evaluation and investigations at arrival in the emergency department

14、/coronary care unit/intensive care unit In the initial evaluation of suspected AHF (excluding cardiogenic shock), the critical first step is determination of the severity of cardiopulmonary instability based on the level of dyspnoea, haemodynamic status, and heart rhythm. To facilitate this, results

15、 of the following assessments should be recorded :关键的第一步是判断心肺状态，根据呼吸困难程度、血流动力学情况以及心脏节律。为了帮助判断这些，需要记录以下评估结果：cardiogenic shock：心源性休克 dyspnoea：呼吸困难 haemodynamic：血流动力学的 heart rhythm：心律 Objective measurement of dyspnoea severity, including the respiratory rate, intolerance of the supine position, effort

16、of breathing, and degree of hypoxia. Systolic and diastolic blood pressure. Heart rate and rhythm.客观的评估呼吸困难严重程度，包括呼吸频率，对仰卧位的耐受程度，呼吸费力及缺氧的程度；收缩压与舒张压；supine position：仰卧位 hypoxia：缺氧Systolic /diastolic blood pressure：收缩/舒张压 Objective determination of body temperature and signs/symptoms of hypoperfusion

17、(cool extremities, narrow pulse pressure,mental status)客观的评价、提问和低灌注相关的症状或体征（手足发冷，脉压变小，精神状态）body temperature：体温 hypoperfusion：低灌注extremity：末梢 The next step should include a search for congestion including peripheral oedema, audible rales (especially in the absence of fever),and elevated jugular venou

18、s pressure有无充血症状，包括外周水肿，啰音，颈静脉充盈peripheral oedema：外周水肿, rale：啰音 jugular vena：颈静脉 ECG, recognizing that in AHF this is rarely normal, and rarely diagnostic but necessary to exclude ST segment elevation myocardial infarction Laboratory tests -在患者中，心电图经常异常，且无特异性的临床价值，但是必须排除段抬高型急性心肌梗死-实验室检查ST segment elevation myocardial infarction：ST段抬高的心梗 Laboratory tests ：实验室检查 Immediate echocardiography is not needed during the initial evaluation in most cases except when haemodynamic instabil