心力衰竭指南第1頁/共44頁第2頁/共44頁第3頁/共44頁第4頁/共44頁LVEF降低的心力衰竭的治療第5頁/共44頁P(yáng)atientsWithReduced

LeftVentricularEjectionFraction對(duì)于當(dāng)前或以前有HF癥狀和有體液潴留而LVEF減少的患者，需給予利尿劑或限制鈉的攝入對(duì)于當(dāng)前或以前有HF癥狀和LVEF減少的患者，除非有禁忌癥，建議應(yīng)用ACEIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIcIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIANOCHANGENOCHANGE第6頁/共44頁利尿劑應(yīng)用的推薦布美他尼托噻米速尿氯噻嗪氯噻酮美托拉宗第7頁/共44頁靜脈注射利尿劑的應(yīng)用推薦布美他尼速尿托噻米美托拉宗第8頁/共44頁心力衰竭ACEI的選擇推薦第9頁/共44頁P(yáng)atientsWithReduced

LeftVentricularEjectionFraction對(duì)于當(dāng)前或以前有HF癥狀和LVEF減少的患者，除非有禁忌癥，都應(yīng)使用B阻滯劑(bisoprolol，carvedilol，metoprololsuccinate三者之一)IIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIANOCHANGE第10頁/共44頁心力衰竭倍他受體阻斷劑選擇推薦DrugStagAStageBStageC

第11頁/共44頁P(yáng)atientsWithReduced

LeftVentricularEjectionFraction對(duì)于當(dāng)前或以前有HF癥狀和LVEF減少而不能耐受ACEI的HF患者，可給予血管緊張素II受體阻滯劑（ARB）對(duì)當(dāng)前或以前有HF癥狀和LVEF減少的患者臨床情況有不利影響的藥物盡可能避免應(yīng)用或撤換(非甾類抗炎藥，大多數(shù)抗心律失常藥，大多數(shù)鈣通道阻滯劑）IIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIAIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIBNOCHANGENOCHANGE第12頁/共44頁心力衰竭ARB的選擇推薦DrugStagAStageBStageC第13頁/共44頁心力衰竭各期治療藥物的選擇藥物 A期 B期C期坎地沙坦

H －

HF依普沙坦 H －

－厄貝沙坦 H,DN － －氯沙坦 H,DNCVRisk －奧美沙坦 H －

－

替米沙坦 H －

－CVRisk:未來心血管事件減少；H:高血壓；DN:糖尿病腎??；HF:心力衰竭和無癥狀左室功能障礙；PostMI:心梗后心力衰竭及其他心臟事件減少纈沙坦 H,DN Post-MIPost-MI,HF

ACC/AHA成人慢性心力衰竭診斷治療指南：代文?——擁有最多適應(yīng)證的ARBHuntSA,etal.JAmCollCardiol2005;46(6):e1-82.第14頁/共44頁ACEIARBBB應(yīng)用劑量推薦第15頁/共44頁P(yáng)atientsWithReduced

LeftVentricularEjectionFraction對(duì)當(dāng)前或以前有HF癥狀和LVEF減少患者，運(yùn)動(dòng)煅練是改善臨床狀況一種有益的補(bǔ)充方法IIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIBNOCHANGE第16頁/共44頁P(yáng)atientsWithReduced

LeftVentricularEjectionFraction對(duì)于MI后至少40天，LVEF不高于35%（30%），給予最佳藥物治療后NYHA分級(jí)II或III級(jí)，有理由期望患者保持良好的功能存活達(dá)一年以上的非缺血性心肌病或心臟缺血患者，推薦把ICD作為主要的預(yù)防措施以減少因心源性猝死而致的總死亡率對(duì)當(dāng)前或以前有HF癥狀和LVEF減少，曾有心臟停博、室顫、血流動(dòng)力學(xué)不穩(wěn)的室性心動(dòng)過速的患者，推薦使用ICD作為二級(jí)預(yù)防措施，可以延長生存時(shí)間IIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIAIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIAModifiedClarifiedRec第17頁/共44頁P(yáng)atientsWithReduced

LeftVentricularEjectionFraction對(duì)于LVEF不高于35%，竇性心律，盡管給予藥物治療NYHA分級(jí)III或不固定IV級(jí)患者和心臟不同步，QRS間期長于0.12秒的進(jìn)行或沒進(jìn)行ICD治療的患者，應(yīng)接受再同步治療,除非有禁忌癥對(duì)于中重度或重度HF患者及LVEF也降低但可以嚴(yán)密監(jiān)測腎功能及鉀濃度的患者，加用醛固酮拮抗劑。肌肝在男性不高于2.5mg/dL或在女性不高于2.0mg/L，鉀不高于5.0mEq/L。在不能監(jiān)測高鉀或腎功能紊亂的情況下，其風(fēng)險(xiǎn)會(huì)抵消醛固酮拮抗劑帶來的好處IIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIAIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIBNOCHANGENOCHANGE第18頁/共44頁P(yáng)atientsWithReduced

LeftVentricularEjectionFraction對(duì)于接受ACEI，BB，與利尿劑最佳治療情況下仍有中重度癥狀非裔美國患者推薦應(yīng)用肼苯噠嗪與硝酸鹽類藥物聯(lián)合治療對(duì)于房顫與心衰患者維持竇性心率或單純控制心室率是合理的IIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIAClarifiedRecIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIANew第19頁/共44頁P(yáng)atientsWithReduced

LeftVentricularEjectionFraction對(duì)于輕至中度HF和LVEF降低的患者，特別是因其它原因已使用ARBs的患者，血管緊張素II受體阻滯劑可代替ACEI作為一線藥物對(duì)于當(dāng)前或以前有HF癥狀和LVEF降低的患者，使用洋地黃對(duì)降低住院率有益NOCHANGENOCHANGEIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIAIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIB第20頁/共44頁P(yáng)atientsWithReduced

LeftVentricularEjectionFraction對(duì)于LVEF降低有癥狀的HF而給予ACEI和B阻滯劑的且癥狀持續(xù)的患者可加用肼苯達(dá)嗪和硝酸甘油患者LVEF≤35%，心功能NYHAIII級(jí)或步行試驗(yàn)IV級(jí),應(yīng)用最佳治療，并經(jīng)常依靠心室起搏的癥狀性心衰患者，CRT是合理的NOCHANGEIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIAIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICNew第21頁/共44頁P(yáng)atientsWithReduced

LeftVentricularEjectionFraction對(duì)于當(dāng)前或以前有HF癥狀和LVEF降低且不能耐受ACEI或ARB，高血壓，腎功能不全的患者，應(yīng)加用肼苯達(dá)嗪和硝酸鹽類藥物對(duì)于已給予傳統(tǒng)治療，LVEF降低的持續(xù)癥狀患者，可考慮加入ARBNOCHANGEIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIBNOCHANGE第22頁/共44頁P(yáng)atientsWithReduced

LeftVentricularEjectionFraction對(duì)于當(dāng)前或以前有HF癥狀和LVEF降低的患者，不推薦常規(guī)聯(lián)用ACEI，ARB及醛固酮拮抗劑對(duì)于當(dāng)前或以前有HF癥狀和LVEF降低的患者，不需要常規(guī)應(yīng)用鈣通道阻滯劑治療NOCHANGENOCHANGEIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIA第23頁/共44頁P(yáng)atientsWithReduced

LeftVentricularEjectionFraction對(duì)于當(dāng)前或以前有HF癥狀和LVEF降低的患者，長期注射正性肌力藥是有害的，并不建議使用，除外標(biāo)準(zhǔn)的藥物治療病情不穩(wěn)定的終末期患者對(duì)于當(dāng)前或以前有HF癥狀和LVEF降低的患者，不需要補(bǔ)充營養(yǎng)NOCHANGENOCHANGE第24頁/共44頁P(yáng)atientsWithReduced

LeftVentricularEjectionFraction除非缺乏，對(duì)于當(dāng)前或以前有HF癥狀和LVEF降低的患者，不推薦激素治療且有害NOCHANGE第25頁/共44頁左室射血分?jǐn)?shù)降低的心力衰竭的治療第26頁/共44頁P(yáng)atientsWithNormalLeftVentricularEjectionFraction對(duì)于正常LVEF心衰患者應(yīng)該根據(jù)有關(guān)指南有效控制收縮壓和舒張壓有效控制心衰患者心室率尤其房顫應(yīng)用利尿劑控制肺淤血和周圍水腫IIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIAIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICNOCHANGENOCHANGEIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICNOCHANGE第27頁/共44頁P(yáng)atientsWithNormalLeftVentricularEjectionFraction對(duì)于有癥狀或確認(rèn)心肌缺血并判斷對(duì)心功能有加重的冠心病患者，行冠脈重建術(shù)是合理的房顫患者恢復(fù)和維持竇性心率對(duì)改善癥狀是有益的NOCHANGENOCHANGEIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIC第28頁/共44頁P(yáng)atientsWithNormalLeftVentricularEjectionFraction應(yīng)用倍他受體阻斷劑，ACEI，ARB,鈣拮抗劑控制血壓以減輕心衰癥狀可能有效洋地黃制劑是否可減輕癥狀尚未確立NOCHANGENOCHANGEIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIC第29頁/共44頁晚期心力衰竭的治療第30頁/共44頁P(yáng)atientsWithRefractoryEnd-StageHeartFailure密切觀察和控制頑固性終末期心衰患者的體液儲(chǔ)溜符合心臟移植標(biāo)準(zhǔn)的頑固性終末期心衰患者推薦心臟移植治療IIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIBIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIBNOCHANGENOCHANGE第31頁/共44頁P(yáng)atientsWithRefractoryEnd-StageHeartFailure給予各種積極的治療后，仍有嚴(yán)重心衰癥狀的頑固性終末期心衰患者的臨終治療方案的選擇，應(yīng)該由醫(yī)生與病人及其家屬討論決定有植入除顫起搏器指征的頑固性終末期心衰患者應(yīng)被告知通過植入除顫起搏器可控制室顫的發(fā)生，由病人自愿選擇是否安裝除顫起搏器IIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICNOCHANGENOCHANGE第32頁/共44頁P(yáng)atientsWithRefractoryEnd-StageHeartFailure因接受藥物治療的頑固性終末期心衰患者一年內(nèi)的死亡率大于50％，所以對(duì)于終末期心衰患者來說，左室輔助裝置治療是一種永久和有效的治療方法有持續(xù)嚴(yán)重心衰癥狀的頑固性終末期心衰患者,可通過放置肺動(dòng)脈導(dǎo)管來指導(dǎo)治療NOCHANGENOCHANGEIIIIIaIIaIIaIIbIIbIIbIIIIIIIII