ACC/AHA 成人慢性心力衰竭的诊断和治疗指南
发布于:2007-12-12 09:55
（2005年8月） ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult（2005） Sharon Ann Hunt, MD, FACC, FAHA, Chair 北京安贞医院：韩智红 姚海木 张晓霞 吕 强 译 北京安贞医院：吴学思 审校 1目录 序言 1. 前言 2. 心力衰竭作为临床综合征的特点 2.1. 心力衰竭的定义 2.2. 心力衰竭是一种症状性疾病 2.3. 心力衰竭是一种不断发展的疾病 3. 有心力衰竭表现患者的临床评价 3.1. 患者的最初评价 3.1.1. 识别心力衰竭患者 3.1.2. 识别患者结构与功能的异常 3.1.3. 引起心力衰竭的原因评价 3.1.3.1. 病史与体格检查 3.1.3.2. 实验室检查 3.1.3.3. 冠心病可能性的评价 3.1.3.4. 心肌病可能性的评价 3.2. 患者的进一步评价 3.2.1. 功能评价 3.2.2. 容量状态评价 3.2.3. 实验室评价 3.2.4. 预后评估 4. 治疗 4.1. 有发展为心力衰竭高度危险的患者（阶段A） 4.1.1. 控制危险因素 4.1.1.1. 治疗高血压 4.1.1.2. 治疗糖尿病 4.1.1.3. 治疗代谢综合征 4.1.1.4. 治疗粥样硬化性疾病 4.1.1.5. 控制可能引起心肌损伤的情况 4.1.1.6. 其他措施 4.1.2. 结构异常的早期识别 4.2. 有心脏结构异常或重塑但尚无心力衰竭症状的患者（阶段B） 4.2.1. 心血管事件的预防 4.2.1.1. 急性心肌梗死的患者 4.2.1.2. 有心肌梗死病史但LVEF正常的患者 4.2.1.3. 高血压与左室肥厚的患者 4.2.1.4. 没有症状的慢性左室收缩功能不良患者 4.2.1.5. 无症状的严重瓣膜病患者 4.2.2. 心力衰竭的早期识别 4.3. 目前或曾经有心力衰竭症状的患者（阶段C） 4.3.1. LVEF减低的患者 4.3.1.1. 一般措施 4.3.1.2. 常规药物 4.3.1.2.1. 利尿剂 2 4.3.1.2.2. 肾素-血管紧张素-醛固酮系统抑制剂 4.3.1.2.2.1. 血管紧张素转化酶抑制剂 4.3.1.2.2.2. 血管紧张素受体阻滞剂 4.3.1.2.2.3. 醛固酮受体拮抗剂 4.3.1.2.3. β-肾上腺素能受体阻滞剂 4.3.1.2.4. 洋地黄 4.3.1.2.5. 抗室性心律失常药物与猝死的预防 4.3.1.3. 特定的患者可考虑应用的方法 4.3.1.3.1. 硝酸异山梨酯 4.3.1.3.2. 肼苯哒嗪 4.3.1.3.3. 肼苯哒嗪与硝酸异山梨酯 4.3.1.3.4. 心脏再同步化治疗 4.3.1.3.5. 运动训练 4.3.1.4. 正在进行研究的药物与治疗 4.3.1.4.1. 呼吸支持技术 4.3.1.4.2. 体外反搏 4.3.1.4.3. 加压素受体拮抗剂 4.3.1.4.4. 植入式血流动力学监测 4.3.1.4.5. 心脏支持装置 4.3.1.4.6. 正在研究的外科方法 4.3.1.4.7. 奈西立肽 4.3.1.5. 未证实有效与不支持应用的药物和治疗 4.3.1.5.1. 营养补充与激素治疗 4.3.1.5.2. 间断静脉正性肌力药物 4.3.2. LVEF正常的心力衰竭患者 4.3.2.1. 患者的识别 4.3.2.2. 诊断 4.3.2.3. 治疗原则 4.4. 终末期顽固性心力衰竭患者（阶段D） 4.4.1. 体液潴留的治疗 4.4.2. 神经体液抑制剂的使用 4.4.3. 静脉血管扩张剂和正性肌力药物 4.4.4. 机械和外科方法 5. 特殊人群的治疗 5.1. 女性和男性 5.2. 种族问题 5.3. 老年患者 6. 有伴随疾病的心力衰竭患者 6.1. 心血管疾病 6.1.1. 高血压、高脂血症与糖尿病 6.1.2. 冠状动脉疾病 6.1.3. 室上性心律失常 6.1.4. 血栓栓塞事件的预防 6.2. 非心血管疾病 3 6.2.1. 肾功能不全 6.2.2. 肺部疾病 6.2.3. 肿瘤 6.2.4. 甲状腺疾病 6.2.5. 丙型肝炎与HIV 6.2.6. 贫血 7. 终末期问题 8. 临床指南的实施 8.1.医疗人员个人的治疗干预 8.2.疾病治疗系统 8.3.工作实绩检测 8.4.全科医生与心脏科医生的作用 参考文献 －－－－－－－－－－－－－－－－－－－－－－－－－ 序 言 疾病的诊断、治疗或预防手段应用于临床的过程中，医务人员对这些诊断步骤与治疗的评价起重要的作用。严谨专业地分析正性或负性的相关资料有助于制定指南，从而提高治疗的有效性，改善患者的预后，并通过最有效的治疗而降低医疗费用。 美国心脏病学会（ACC）和美国心脏学会（AHA）从1980年开始联合制定心血管领域的指南，具体工作由ACC/AHA临床指南专家委员会实施，其作用是建立并修改心血管领域重要的疾病与措施的实施指南。相关专题的专家来自这两个学会，负责综合相关资料并撰写或修改相应的指南。该过程还包括了其他一些医务工作者和相关组织的成员。撰写组重点负责完成正式的文献综述，权衡支持与反对某项治疗或措施的证据和综合已有资料估测预后。患者的特殊情况、伴随疾病和患者对某些观念的喜好可能对检查和治疗的选择、随访的频率及效费比产生影响。如果可能，还应考虑研究中的花费情况，但是，有效性与临床预后是制定指南最首要的依据。ACC/AHA临床指南专家委员会尽量避免偏袒有争议的观点或编写人员的个人观点，特别是要求所有编写人员公开评价不同的观点。这些观点经过高级专家委员会评审，并在每次会议中口头告知所有编写人员，如有变化，编写组会根据情况进行制定。 临床指南制定的目的是指导帮助临床医生对于特定疾病与临床状态的诊断、治疗或预防。这些指南反映的是专家根据目前有证据的资料达成的一致建议，目的是尽量满足大多数患者在大多数情况下的需要，改善患者的治疗情况及使患者获得最大益处，对于某个特定患者的最终判断应根据患者的具体情况由医生与患者决定。 这些指南有ACC和AHA管理部门批准发行，并通过美国胸科学会、国际心肺移植学会与心脏节律学会的同意。ACC/AHA指南工作组在指南发行后每年回顾一次，直至重新制定、修改或撤出。本指南的摘要将同时发表在2005年9月20日的美国心脏病学会杂志（JACC）与循环杂志（Circulation）上。其全文公布在ACC（www.acc.org）与AHA（www.my.american-heart.org）网站上，可通过上述两个组织获得全文和摘要。 ACC/AHA临床指南专家委员会主席Elliott M. Antman，MD，FACC，FAHA 1. 前言 心力衰竭已成为美国主要的公共卫生问题。美国的心力衰竭患者约有500万，每年新增55万[1]，并可造成每年1200-1500万次临床就诊，总住院天数达650万[2]。1990年至1999年，以心力衰竭作为首要诊断的年住院次数由81万增加到100万，作为首要诊断或次要诊断的由240万增加到360万[3]，2001年，死于心力衰竭的患者约有5.3万。尽管心力衰竭的治疗有很大的进展，但死于心力衰竭的患者数目还在逐步上升，其部分原因是由于急性心肌梗死治疗的进步，存活者增多[1]。 心衰竭主要是一种老年人疾病[4]，因此人口的老龄化也是心力衰竭发生率增加的原因。年龄超过65岁的老年人中，心力衰竭的发生率约为1%[1]，因心力衰竭住院的患者约80%年龄大于65岁[5]。心力衰竭已成为最常见的医疗卫生诊断相关人群（dignosis-related group），用于心力衰竭诊断与治疗的医疗支出高于其他疾病[6]。2005年其直接与间接花费约为279亿美元[1]，每年应用于心力衰竭药物治疗的花费约为29亿美元[1]。 ACC与AHA于1995年首次公布了心力衰竭的诊断与治疗指南，并于2001年进行了修订[7]，从那时起，围绕此种常见、花费高、致残并潜在致死的疾病，开展了大量有关药物与非药物治疗的研究，可选择的治疗方法增加，这种增加使得临床决策更难作出，起始治疗的时机、次序，以及各种治疗合用的合理性尚未确定。对于存在LVEF正常的心力衰竭患者这一认识也在不断增加，对于这一部分重要人群的有证据依据的治疗还很少这一事实，也广为重视。由于这些原因，两个组织认为应该重新评价并修订指南，对于心力衰竭治疗最佳选择的认识尚不完善，有待于不断补充与修订。 写作组包括15名成员，代表了ACC与AHA，以及美国胸科医师学会、美国心力衰竭学会、国际心肺移植学会、美国家庭医生学会和美国内科医师学会。包括学术与个人实践中的问题。该指南的审阅人包括ACC指定的3名、AHA指定的3名、美国家庭医生学会指定的1名、美国胸科医生学会指定的2名、美国内科医生学会指定的1名、美国心力衰竭学会指定的4名、国际心肺移植学会指定的1名，还有的9名来自ACC/AHA心力衰竭执行委员会、ACC/AHA急性心肌梗死指南制定修改委员会、ACC/AHA/ESC房颤指南制定委员会、ACC/AHA 冠脉旁路手术指南委员会、ACC心力衰竭标准委员会、AHA治疗质量与预后研究委员会、AHA心力衰竭与移植委员会。在ACC与AHA的网站上，有2个版本的指南全文，其中1个版本将建议中的变化作为重点，即只将2005年版与2001年版中建议的不同点罗列出来，而省去了那些支持改变的证据与图表。 在2001年版中，撰写组采用了一种新的心力衰竭的分级方法，该方法同时强调心力衰竭的发生与进展，因此它将心力衰竭分为4个阶段。前2个阶段（阶段A与B）的患者并无心衰，但是医务工作者应该重视的发生心力衰竭的高危人群，阶段A与B最好的定义是具有发生心力衰竭高度危险的患者，例如，冠心病、高血压、糖尿病而未有左室功能受损、心肌肥厚或心腔几何形态变形的患者属于阶段A；而有左室肥厚和/或左室功能受损的无症状患者属于阶段B；阶段C为过去或目前有心力衰竭症状并有心脏结构改变的患者（大多数的心衰患者属于此类）；阶段D为顽固性心力衰竭需要特殊加强的治疗者，如应用机械循环支持、液体移出操作、持续静脉正性肌力药物、心脏移植或新发明的与正在研究的外科方法、临终关怀等。 该分级方法包括了将会发展为心力衰竭的有危险因素和心脏结构变化的阶段，在左室功能不全或症状出现之前便采取治疗措施可降低心力衰竭的病残率和死亡率。该分级方法是纽约心脏病协会（NYHA）心功能分级方法的补充而不是替代，NYHA分级是对该分级中的阶段C与D的患者症状严重性的分级。多年来已经认识到NYHA分级具有医生的主观判断，而且短时间内可以有很大变化，不同级别的病情治疗差异不大。因此，委员会认为需要一种稳定的阶段分级系统来客观地评价患者饿的病情进展情况，针对不同阶段进行相应的治疗。根据新的分阶段方法，患者的病情可能不进展或只能向更高一级进展，疾病可通过治疗减慢或停止进展，但一般不会发生自发的逆转。例如，一个有临床症状的心力衰竭患者（阶段C）随着治疗或疾病的进展可以有不同的症状分级（NYHA），但他永远也不会回到阶段B（从未发生心力衰竭），阶段C所推荐的治疗他全部适用，尽管他的NYHA分级是Ⅰ级。这种新的分级方案扩展了我们对心力衰竭的思路，与其他一些疾病的分级方法有些类似（例如肿瘤的分级方法）。 ACC/AHA对于建议分类与证据等级的描述如下。 建议分类： Ⅰ类：有证据和／或共识证实采取的诊断措施／治疗实用并有效。 Ⅱ类：采取的措施／治疗的实用性和有效性的证据有矛盾和／或观点有分歧。 Ⅱa类：证据／观点倾向于实用／有效。 Ⅱb类：证据／观点不倾向于实用／有效。 Ⅲ类：有证据和／或共识证实采取的措施／治疗无实用性／无效并且在某些病例可能有害。 证据等级： A级：资料来自多项随机临床试验或荟萃分析； B级：资料来自单个随机临床试验或大的非随机研究； C级：专家共识的意见和／或小规模的研究。 本指南的建议尽可能采用循证医学作为证据，相关的医学术语应用英语的表达方式经过一系列计算机检索（包括Medline和EMBASE）并人工检索了一部分文章，所列出的参考文献具有代表性但并非全部。对于某类药物的建议也是指具体有循证医学证据证实有效的药物，除非公认这类药物有广泛的类效应。 委员会把本指南的重点锁定为心力衰竭的预防及成人LVEF正常或减低的慢性心力衰竭患者的诊断与治疗。本指南没有涉及急性心力衰竭，后者需要制定专门的指南，并且在ACC/AHA急性ST段抬高心肌梗死指南[8]及ACC/AHA不稳定心绞痛和非ST段抬高心肌梗死指南2003[9]中有部分论述。本指南还排除了儿童的心力衰竭，因为儿童心力衰竭的基础疾病与成人不同，并且尚没有包括儿童的治疗心力衰竭的对照研究。本指南也不包括主要由瓣膜病（见ACC/AHA心脏瓣膜病治疗指南[7]）或先天性心脏病引起的心力衰竭，不包括对心脏特异性疾病（例如血色素沉着症、结节病或淀粉样变性）的治疗建议。 本指南的目的是帮助医务工作者在心力衰竭的预防、诊断和治疗方面提供可选用的方法，为的是在多数情况下满足多数患者的需求，但对于特定患者的最终决定还需医务人员根据情况加以确定。本指南并未从社会学观点上分析费效学，也不能帮助建立合理利用医疗资源的政策，事实上本指南并未考虑资源不足的问题，没有给政策制定者提供资源分配的信息。本指南描述的治疗策略是对每个患者可采纳的治疗方法的罗列，每个患者都是独特的，不仅是因为其心力衰竭的病因与过程不同，还包括其个人和社会对这种疾病的观念。指南只能罗列出有证据依据的决定或建议，这也是本指南的目的。
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评论列表：（评论 63 ）以下网友评论只代表网友个人观点，不代表本站观点。 2007-12-12 15:19:00 by: doctor2
建议
I类
1．继续进行有关心功能和生存预后的教育。(证据：C)
2．进行关于提前制定治疗的指导原则及其实施事宜的教育，进行关于姑息性和修养性治疗作用的教育。(证据：C)
3．讨论取消ICD活性。(证据：C)
4．确保住院时治疗和出院后治疗的连续性。(证据：C)
5．适于减轻痛苦的疗养性治疗，包括阿片制剂，不排除使用正性肌力药物和静脉应用利尿剂以缓解症状。(证据：C)
6．所有心衰工作人员应审核目前的终末期程序并努力改善姑息治疗和终末期治疗的方法。(证据：C)
III类
在生命的最后几天内实施积极措施（包括在NYHA IV级、预期现有治疗不能使其获得临床改善的患者中插管和植入心脏除颤器）。（证据：C）
尽管在所有慢性终末期疾病中终末期治疗问题都是值得重视的，在慢性心衰中存在几个需要特别讨论的一般原则。在患者病情过于严重而不能参与决定之前，应对患者及家属进行有关疾病预期的病程、最后可选择的治疗以及治疗计划的教育。讨论优选治疗、生存意愿和预先的指导原则时应包括各种可能的偶然事件，包括对可能为可逆性心衰加重的反应、心脏骤停、突变事件如严重脑血管意外以及主要并存非心血管疾病的恶化。在与家属共同考虑这些问题时，应区分开短期干预（预期能快速恢复）和持久生命支持（不能恢复良好功能）。多数因严重心衰住院的患者愿意选择在心肺骤停事件时实施复苏。在一项大型研究中，仅23%表示不愿进行复苏，但其中40%在住院后又改变想法[664]。此频率高于在其它慢性疾病中所见到的[665],也许由于心衰患者更可能在住院强化治疗后获得延长的生活质量良好的稳定时期。“病人自我决定权法案”[666]要求美国的医院查询和记录入院时的预先指导原则的信息。然而，当未被提前考虑时，入院时强加的复苏问题可能增高了患者及家属的焦虑，不能反应真实的优先选择[667]。多数未在住院时讨论复苏问题的心衰患者表示他们不希望发生这种情况 [664]。另外，在一项研究中，复苏选择对住院期间预后影响甚微，即使对于重症监护的心衰患者，他们中仅4％经历意外心脏骤停，而其它慢性疾病的重症监护患者心脏骤停大于25％[668]。
当心衰单独或与其它严重疾病一起给病人带来的痛苦变得不能忍受时，病人不再希望进行复苏。此时，应确定病人希望先得到哪些方面的进一步治疗。在某些情况下，病人可能想得到清醒时的全面支持治疗，而不是复苏；在另一些情况下，病人不再需要任何住院治疗。选择任何先于复苏的决定时可能需去除植入性除颤设备的生命救护功能；对任何病人而言，极差的功能状况也应影响首先植入这种设备的决定[669]。为了观察病人和家属的意愿和指导原则，最好由同一医疗组负责门诊、住院以及抢救期的治疗，以减少这一时期治疗不连贯性的危险。应鼓励病人提前选择当自己不能参与决定时法定处理医疗事宜的人员（即律师或医疗代理人）。该人员负责与医疗组联系。迅速与医疗组取得联系可减少患者急诊时由于医生不熟悉病情而产生的矛盾和不确定性。可能参与患者治疗的所有人员需迅速明确所定治疗方案。治疗晚期心衰患者的人员应客观判断生存预后并准确告知患者及家属。同样，医护人员应为生命最后阶段的治疗过程提供实际建议。最后，对于如何为生命最后阶段提供舒适包括减少疼痛和呼吸困难仍需更多关注和研究。
直到最近才开始为心衰濒死患者提供临终关怀，临终关怀最初用于癌症病人。此时临终关怀的重点扩展为缓解症状而不仅是疼痛[670]。这是合理的，因为心衰患者以呼吸困难为特征，同情性治疗需频繁静脉使用利尿剂、在某些情况下需持续输注正性肌力药物，而不仅是强效镇痛剂。
然而，很多濒死心衰患者的确在生命最后数天内主诉疼痛[671, 672]。治疗这些患者的医生应熟悉抗焦虑剂、催眠药物及麻醉药的使用以缓解病人痛苦。传统地，应用临床关怀需要医生预测6个月内的死亡，但这在实施中可能有困难，因为医疗人员通常不能精确预测心衰患者的死亡。美国一个大型研究显示，在因终末阶段疾病收入重症监护病房的患者中，大多数经宽标准确认为需进行临终关怀的患者存活超过6个月，尽管预测结果不是这样[673]。这种预测生存和实际生存之间的偏差在心衰患者中尤其明显，较其它慢性疾病更常见，特点是尽管接近生命终点，生活治疗良好；以及尽管近期症状缓解可能因猝死而结束生命。目前的指南和策略[674]正在修订以使心衰患者能够受益于临终关怀提供的治疗。最后，何时是生命终点的推断反应了客观信息和主观信息、情感、以及病人和家属准备状态之间复杂的相互作用。理想地，应与治疗晚期心衰最有经验的医生或医疗组一起或与这样的专家合作或咨询这样的专家以作出这些决定。但事实上并不常这样做。写作委员会建议所有参与心衰治疗者首先提高对终末期疾病的认识并为接近该期的患者和家庭提供治疗。这个时代随着我们更熟悉进展至终末期心衰的过程,目前由积极干预向姑息治疗的突然转变将转变为逐渐的和进行性的强调缓解痛苦直到它主导了最后阶段的治疗[672]。
2007-12-12 15:22:42 by: doctor2
建议
I类
1．学术性解读或教育性外出参观有益于推进指南的实施。(证据：A)
2．对入院或临床恶化危险性高的患者实行多原则疾病治疗计划以推进指南的实施、突破习惯改变的障碍，并减少随后因心衰住院的危险。(证据：A)
IIa类
1．图表审查和结果反馈可有效推进指南的实施。(证据：A)
2．催询系统可有效推进指南的实施。(证据：A)
3．以临床指南为基础的工作实绩检测可能提高医疗质量。(证据：B)
4．地方学术领导人的声明和支持有利于推进指南的实施。(证据：A)
IIb类
可考虑对低入院或临床恶化危险的患者实行多原则疾病治疗计划以推进指南的实施 (证据：B)
III类
1．仅传播指南而不努力改变行为不利于指南实施。 (证据：A)
2．仅教育基础医疗人员不利于指南实施。(证据：A)
尽管出版了基于证据的指南[147,675], 目前心衰患者的治疗仍不理想。大量研究表明治疗关键步骤未得到充分使用，例如ACEIs在收缩功能和LVEF减低患者中的使用[513,676,677]。由外在和固有标准判断的心衰总体住院治疗质量差异较大，较低质量表现为较高再住院率和死亡率[491,678,679]。良好的门诊治疗可防止很多心衰的住院 [680]。 有关指南实施的文献可分为3个部分：单独医疗人员个人的治疗干预，疾病治疗系统，和工作实绩检测的使用。
8.1. 医疗人员个人的治疗干预
最近一项对照研究显示单纯发布心衰指南后对所建议的做法进行书面和口头催询不能改变重症监护病房心衰的治疗 [681]。确实，大范围文献资料证实适当改变医生的行为相当困难[682-684]。 单纯进行基础医师教育和被动传播指南通常不足以维持质量的提高。图表审查和结果反馈、考虑特殊药物或试验使用的催询系统、以及利用地方学术领导所产生的结果差异较大。同时突破不同障碍的多因素干预趋向于较单方面努力更成功。例如，学术性解读，包括结合了交流和行为改变技巧的外出参观教育比较有效，通常被医药公司采用[685]。因此，指南的传播必须伴随更加强化的教育和行为干预以最大程度改善医生的实践模式。
8.2. 疾病治疗系统
疾病治疗方法将心衰看作是跨越家庭、门诊和医院的慢性疾病。多数患者具有多重医疗、社会和行为的难题，有效治疗需要多原则系统的方法以处理这些困难。心衰疾病治疗计划内容各不相同，但通常包括深入的病人教育、鼓励患者更积极加入他们的治疗、通过电话随访或家庭护理密切监视患者、仔细讨论治疗方案以严格遵循以证据为基础的指南、以及由医生指导下的多准则治疗。
观察研究和随机对照试验表明，疾病治疗计划可减少住院频率、改善生活质量和功能状况[146,686]。临床恶化或住院危险性高的患者很可能受益于疾病治疗计划，代表了这种干预治疗产生最佳花费-效益比的患者[687]。疾病治疗规模最大的成功的随机对照试验研究目标是因心衰住院、曾有心衰病史、5年内住院4次或以上、或因急性心梗或未控制的高血压而加重心衰的老年患者[143]。与对照组相比，随机分入疾病治疗计划的患者住院显著减少、治疗费用降低。然而
，尚不清楚疾病治疗计划中的哪个成分是成功的关键。另外，尚不明确这种干预治疗在资源和人员受限时以及在不同病人群体中是否可行。
8.3. 工作实绩检测
工作实绩检测是特殊疾病或状况的治疗标准，为评估和继之改善医疗质量而设计。选择每一工作实绩检测条目的基础是该条目与改善病人预后相关。在心衰领域，这种检测可能包括左室功能水平记录、使用的药疗法、或病人教育的检测。这些检测可在机构内部使用或公开使用以比较医疗人员、医院和医疗组织的工作实绩。理论上，通过以下方面，工作实绩检测可提高医疗质量：鼓励医疗人员在质量而不是花费的基础上竞争、使消费者在市场内作出明智的选择、鼓励医疗人员把精力集中在某些疾病或治疗过程、以及提供信息以帮助内部质量的提高，工作实绩检测可提高医疗质量。证据是混杂的，但某些研究提示工作实绩检测可改善健康状况预后。
ACC和AHA与多个组织一起致力于发展和实施工作实绩检测。ACC/AHA 执行指南是工作实绩检测的有益出发点，但需考虑以下几点：1)ACC/AHA执行指南是为提高单个患者的治疗而制定。工作实绩检测通常用于改善群体患者的治疗。虽然目的上有很多相同之处，工作实绩检测需要考虑其它因素,例如易化资料收集、简化标准、实施检测的患者足够数据的计算、以及具有在不同临床情形下的机动性。2)通常，多数工作实绩检测应从执行指南的I类和III类建议中选择；但是，鉴于改善病人群体治疗中包含其它因素，在某些情况下也可选择IIa建议。3)应让临床医生了解某一具体工作实绩检测不适用于某个患者的原因。
8.4. 全科医生和心脏专科医生的作用
尚无足够证据用于提出有关全科医生和心脏专科医生在心衰治疗中的确切作用的建议。一些研究提示与心脏专科医生相比，初级医疗医生群体心衰知识较少、对指南的执行较差[689-691]。一些研究发现由专科医师治疗的患者较由全科医师治疗者预后好[692,693]，而其它研究表明心脏专科医师实施花费更多的治疗，有改善生存的趋势[694]。尽管存在这些观察结果，有心衰知识和经验的初级医疗医师应能够治疗大多数简单的心衰患者。相反，经基本治疗后仍有症状的患者可从由具有心衰治疗专门知识和经验的会诊医师指导的治疗中受益。
对于常出现在心衰患者中的非心脏合并症，治疗的问题是：全科医师和心脏专科医师治疗水平是否相似？何时是咨询专业医师的最佳时间？全科医师和心脏专业医师共同治疗患者的最有效系统是什么？疾病治疗计划最佳花费效益比的入口点是什么？无论这些问题的最终答案是什么，所有医生和其它医疗人员必须提倡和遵循已证实改善患者预后的治疗实践。如果医生在遵循某一特殊建议时感到力不从心（例如β-受体阻滞剂的使用）应将病人转诊至有心衰专门知识的医生。全科医师和心脏专业医师一起工作，建立以最优化心衰患者治疗的共同协作模式可能是最富有成效的。
2007-12-12 15:38:25 by: doctor2
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