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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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2007-12-12 15:09:19  by:  doctor2
<b>建议</b> I类 1．包括(a) 高危种族 (例如黑人)、(b)临床试验中未充分代表的人群、和(c)任何未被充分研究的人群在内的病人群体,由于缺乏指导治疗的特殊证据，应采用与更大范围人群相同的方式进行临床筛选和治疗。(证据：B) 2．建议将心衰的循证治疗用于老年患者，应用时需单独考虑老年患者代谢和耐受标准药物治疗的能力。(证据：C) IIa类 包括应用ACEIs和β-受体阻滞剂在内的心衰标准治疗方案中增加硝酸异山梨酯和肼苯哒嗪对于NYHA心功能III或IV级的黑人是合理的并可能有效。其它人也可能同样受益，但还未经临床试验证实。(证据：A) 一些亚群存在加速心衰进展或使心衰治疗复杂化的独特因素，很多心衰患者属于这些亚群。 　　5.1. 女性和男性 　　很多医生认为心衰主要是男性疾病，因为冠心病危险因素通常发生于男性并且心衰治疗的临床试验中也主要入选男性；然而，总体人群中心衰患者的大部分却是女性（尤其老年女性），她们常发生LVEF正常的心衰[27]。即使LVEF减低的心衰在女性也可能不同于男性。但是，大多数大型、多中心试验未包括足够数量的女性以获得关于安全、有效治疗的结论。一些研究表明女性心衰患者应使用低于男性患者的ACEIs剂量[511]，有研究显示女性在心梗后应给予少于男性的心血管药物[510,512,513]。这些结果可解释女性患者住院治疗质量的改善慢于男性患者，以及女性患者心衰发作过后身体健康状况的改善劣于男性患者[510]。一些研究提示女性心衰患者，尤其无症状LVEF减低患者可能未从ACEI治疗获得生存益处[514,515]。女性还可能有与男性不同的安全特征，例如ACEI更易使她们发生咳嗽 [516]。地高辛在女性患者中的疗效资料彼此矛盾，提示如果处方该药，应特别注意剂量和肾功能[314]。目前正在尽很大的努力(而且强制性的)将更多女性患者纳入政府发起的研究。 　　由于心衰常伴有勃起障碍，男性患者可能选择使用5型磷酸二酯酶抑制剂（例如西地那非）作为加强性能力的方法。对照试验中几乎不入选使用西地那非的心衰患者，因此，该药对心衰患者的效果和安全性是未知的。不过，最近的研究提示西地那非可能对冠心病患者产生血流动力学益处，以及可能改善心衰患者的某些外周血管异常[517]。虽然心衰患者似乎能毫无困难地耐受该药的短期使用，但服用硝酸盐的患者不应使用西地那非，它能加强增加细胞内cGMP水平的药物的全身血管扩张作用，而引起持久的低血压[518]。 　　5.2. 种族问题 　　种族在很大程度上是一个社会性和政治性的不精确的概念[519]。“少数”种族的概念，尤其那些在临床试验中使用、但很明确不可用于很多人口统计领域和临床实践中的这个概念可能对应于大量人口。然而，回顾流行病学和临床试验证据获得的相关领域的认识对指导社会经济和临床治疗仍是有益的。对于心衰评估尤其合适，因为心衰影响黑人，现有的及新的治疗对西班牙人口的效果也需更多信息来评价。心衰是黑人中主要的公共健康问题。在黑人中心衰发生更为常见，影响到大约3％的成年黑人。这反应出黑人心衰发病率较总体人群高50％。 　　与非黑人相比，黑人患者发生心衰症状的平均年龄更早，可能由于黑人更易发生高血压和糖尿病以及他们更常表现钠潴留、心室肥厚和血管损伤。一旦确定诊断，黑人患者心衰进展较白人迅速，表现为开始住院和再次住院的危险性更高[520-522]。这种危险不能用心外膜冠状动脉疾病或有证据的心肌梗死来解释，两者在黑人心衰患者中均较白人中少见。尚无明确数据表明是否存在死亡危险的增加[520-522]。关于黑人心衰患者是否常常未接受最佳住院治疗的文献尚不统一[523, 524]。然而，心血管危险评估和疾病检测及治疗以及门诊病人治疗质量的缺陷可能确是黑人心衰发病率增加的原因之一[525-527]。在大多数心衰的临床试验中黑人和其它少数种族患者缺少，使大多数临床试验的结果不能有效外推至种族亚群。至今，无资料表明在任何特殊群体中是否应采取与标准治疗有明显不同的治疗。临床经验提示亚洲患者在ACEI治疗期间发生咳嗽的危险高于平均水平。亚组资料的回顾性分析显示在高血压的治疗中，黑人心衰患者对ACEIs的反应较白人差[528]。最近一项队列匹配设计的大型ACEI心衰试验证实，与匹配的白人患者相比黑人患者因心衰住院更多[529]。然而，在该试验中黑人和非黑人心衰患者的死亡率相似[529]。有趣的是，两个在黑人患者中评价不同β-受体阻滞剂疗效的试验的结果不一致: 布新洛尔导致黑人患者严重临床事件危险的非显著性增加，但它减少非黑人患者的死亡和住院[530]。因此，布新洛尔可能是与那些在心衰治疗中证实了的β-受体阻滞剂完全不同的β-受体阻滞剂。相反地，卡维地洛的益处是明显的并且在黑人和非黑人患者中程度相似[531]。心脏移植的预后也可能存在种族差异[532]。尚需进一步研究来澄清这些问题。 　　基因药物领域的出现提示种族之间某些高危单核苷酸多态性表达可能存在明显变异，可能是心衰自然史和药物反应不同的生理基础 [533-536] 。来自这些早期研究的资料尚不确定，种族分型必然是异基因的，需谨慎理解这些数据。 一项在NYHAIII/IV级黑人心衰患者中进行的前瞻性、双盲随机试验已经完成[356]。病人群体的特征是非缺血性心衰和高血压及肥胖病史的比例较高。该研究在标准心衰治疗方案基础上辅助使用硝酸异山梨酯和肼苯哒嗪使总死亡减低43％,因此试验提前终止；并且距第一次住院的时间和生活质量也均得到改善。该方案产生益处的机制可能与NO生物活性的改善相关，但该方案降低血压的效果小（但有显著意义）。硝酸异山梨酯和肼苯哒嗪在其它接受标准治疗的心衰患者中的效果不明，因为该研究群体仅限于黑人，但没有理由相信这种益处仅限于黑人[356]。 　　5.3. 老年患者 　　心衰在老年患者中尤其常见，其发生率从65岁的2-3%升高至80岁以上的>80% [537]。心衰是老年患者住院的最常见原因[538-541]。心衰在老年人中的高发病率可能与心室功能（尤其舒张功能）年龄相关的改变和高血压及其它慢性危险因素的累积效应有关[542-546]。另外,心衰危险因素（例如高血压、糖尿病、和高血脂）通常在老年患者中未被积 极治疗，而且老年患者常常服用可能加重心衰症状的药物(例如非甾体类抗炎药物)[132]。 　　在老年患者中心衰未被充分认识和治疗[547]。医生和病人都常常将心衰症状归于衰老，并且使用非侵入性心脏影像检查常不能发现收缩功能受损，因为老年人常发生LVEF代偿的心衰。另外，一些研究显示与较年轻的患者相比，老年患者对利尿剂、ACEIs、和正性肌力药物的反应减弱并且因治疗产生的不良反应发生率高[513,551-555]。除了这些危险与受益比相关的不确定性，对老年心衰治疗不利的因素还包括在评价心衰最新治疗的大型临床试验中，这些非常老的个体代表性很差。 　　一些多元心衰治疗方案成功地减少了老年患者的再住院率和发病率[143,556]。医疗组织一直在努力寻找执行这些方法的有效途径[557,558]。
2007-12-12 15:16:53  by:  doctor2
建议 I类 1．如无特殊情况，本指南中的其他建议适用于有伴随疾病的心衰患者。(证据：C) 2．根据相应指南控制收缩压/舒张压以及糖尿病。(证据：C) 3．使用硝酸酯和β-受体阻滞剂治疗心绞痛。(证据：B) 4．合并心绞痛时应根据相应指南选择冠脉血运重建。(证据：A) 5．患有阵发或持续房颤或曾经有血栓栓塞事件者行抗凝治疗。(证据：A) 6．应用β-受体阻滞剂（禁用或不耐受时应用胺碘酮）控制房颤患者的心室率。(证据：A) 7．根据相应指南治疗慢性稳定性心绞痛。(证据：C) 8．有基础冠状动脉疾病者，应开具抗血小板药物处方以预防心肌梗死和死亡。(证据：B) IIa类 1．房颤患者使用地高辛控制心室率。(证据：A) 2．使用胺碘酮减少房性心律失常复发和减少ICD因室性心律失常放电。(证据：C) IIb类 1．在伴有房颤的心衰患者中，应用现有措施恢复和维持窦性心律。(证据：C) 2．未患房颤或无血栓栓塞史的心衰病人使用抗凝药物。(证据：B) 3．在患有贫血的心衰患者中加强红细胞生成的益处尚未完全明确。(证据：C) III类 1．应用I或III类抗心律失常药物以防止室性心律失常。(证据：A) 2．为改善心衰患者的生存而使用抗心律失常药物治疗无症状室性心律失常。 (证据：A) LVEF减少的患者常伴有心血管和非心血管疾病，其疾病过程或治疗可能加重心衰症状。对于很多患者而言，适当治疗这些伴随疾病可带来与心衰本身的治疗同等重要的对症状和预后的益处。 　　6.1. 心血管疾病 　　6.1.1. 高血压、高血脂和糖尿病 　　大约2/3心衰患者既往或目前有高血压病史，约1/3有糖尿病病史[559]。两种疾病都是收缩或舒张功能异常的原因[560,561]，或直接或通过（与高血脂一起）加速冠状动脉疾病的进展促进心功能异常[562,563]。长期治疗高血压和高血脂减少心衰发生的危险[55,56,564,565]。在一个大型临床试验中，用降脂药物治疗有心肌梗死病史的高胆固醇血症患者减少全因死亡和发生心衰的危险[564]。在两个大型多中心研究中，治疗高血压减少死亡和心衰的危险，不管血压的升高是以收缩压或舒张压为主[55,56,565]。对于患有糖尿病的患者血压降低的益处尤其显著[63,66,566]。 　　心衰使高血压和糖尿病的治疗复杂化。一些抗高血压药物应避免在心衰患者中使用，因为它们抑制心功能或导致水钠潴留。另外，心衰本身对胰岛素的作用产生抵抗[567, 568]， 所产生的高胰岛素血症可能促进心脏和血管肥厚[569-571]并因而加速心衰的进展。这些机制与加速的动脉硬化及能量代谢的改变一起都将对心功能产生不良影响，这可解释为什么患有糖尿病的患者预后较非糖尿病患者差。 　　在有基础危险因素或已患心血管疾病的患者中，噻唑烷二酮类药物与外周水肿增加和症状性心衰相关。噻唑烷二酮类药物发生水肿的危险呈剂量相关，并且在同时使用胰岛素治疗的糖尿病患者中危险性更高。然而，由于NYHA I－II级患者噻唑烷二酮相关的液体潴留发生率低，如仔细监测液体潴留可安全使用该类药物。而在NYHAIII-IV级心衰患者中不建议使用这类药物。临床经验显示，噻唑烷二酮类药物的新型口服制剂的一个副作用是体重增加，部分是由于液体潴留。这在心脏储备减低的心衰患者中可能促成或加重心衰，故应谨慎应用[572,573]。 　　关于治疗的建议 　　对于LVEF已减少并伴心衰症状的患者，治疗高血压、高胆固醇血症或糖尿病的益处知之甚少。此类资料的缺乏是令人瞩目的,这是由于心衰的进展常伴随血压的降低（由于心功能的恶化）和血脂的降低（由于心脏恶病质的发生）[564] ，还由于降压或降脂药物的益处只有在较长时期治疗后才能显现,即超出了很多心衰患者预期寿命[55,56,564,565]。尽管如此，就象没有心衰的患者一样治疗心衰患者的高血压、高胆固醇和糖尿病是明智的，尤其是对那些对降压治疗反应特别好的LVEF代偿的患者[574,575]。合并高血压的心衰患者应考虑肾动脉狭窄的可能，因为肾动脉支架在两种情况下均有治疗作用。在患有两种疾病的患者中应优选既能控制血压又能治疗心衰的药物：包括利尿剂、ACEIs、和β-受体阻滞剂。相反，应避免使用具有心脏抑制作用的大多数钙通道阻滞剂或具有钠潴留作用的强效直接血管扩张剂（如米诺地尔）。 　　非糖尿病心衰患者常规使用的药物也应用于糖尿病心衰患者。ACEI和β-受体阻滞剂在糖尿病和非糖尿病患者中均可阻止心衰的进展[193,260,576]，因此也应用于糖尿病患者，除非担心其掩盖低血糖症状或加重葡萄糖耐受不良或胰岛素抵抗。 　　6.1.2. 冠状动脉疾病 　　大约2/3心衰患者具有基础的冠状动脉疾病，可因为引起心绞痛而限制运动耐量，也可因为发生心肌梗死而导致进一步的心肌损伤。因此，医生应根据现代的指南治疗基础冠状动脉疾病、改善其预后。通常，合并心绞痛的心衰患者应给予缓解心绞痛的药物和合适的治疗心衰的药物[577]。硝酸酯和β-受体阻滞剂可改善心绞痛症状并给LVEF减低的患者带来血流动力学和临床益处，因而是优选的，这些病况并存时优选它们[255,260,262,578,579]。然而，在使用利尿剂充分控制液体潴留之前，上述两药的联合使用可能对心绞痛改善不明显；因此，使用利尿剂减低心室容量和压力，具有独立的抗心绞痛作用[580]。 　　有人提出钙通道拮抗剂的全身和冠状血管舒张作用可能改善心功能和缓解心肌缺血。但这些理论上的优势在心衰的对照临床试验中并未转化为临床益处[581-583]。这些药物未能改善心衰症状或提高运动耐量[580-584],短期和长期使用这些药物治疗（即使使用持续释放或血管选择性制剂）增加心衰恶化的危险和左室功能异常患者的死亡[114,585-593]。因此，大多数钙通道阻滞剂应避免用于心衰患者，即使用于心绞痛或高血压的治疗。现有制剂仅氨氯地平显示未对生存产生不利影响，尽管关于该药的经验大多来自未服用β-受体阻滞剂的患者[594]。 　　对既有心衰又有心绞痛症状的患者，应重点考虑冠脉血运重建。冠脉血运重建可缓解心肌缺血症状[595,596]，已证实冠状动脉旁路移植术缓解心绞痛并降低多支病变、低LVEF、和稳定心绞痛患者的死亡危险[597]（见ACC/AHA/ACPASIM慢性稳定性心绞痛治疗指南[598]或冠状动脉旁路移植手术ACC/AHA 2004指南更新[29]）。 　　<b>关于无心绞痛的患者的治疗 </b> 　　对于有心肌梗死病史但无心衰或心绞痛的患者，4类干预已被用于减少再梗死和死亡危险：神经内分泌拮抗剂（例如ACEIs和β-受体阻滞剂）[66,103,104,109]；处理血脂异常的药物（例如他汀）；抗血小板药物（例如阿司匹林和氯吡格雷）[209,211]；以及冠脉血运重建[595]。对于有心梗病史并有心衰但无心绞痛的患者，ACEIs和β-受体阻滞剂的使用同样减少再梗死和死亡的危险[106-108,599,600],但这类病人是否受益于阿司匹林和冠脉血运重建尚不十分明确。 　　已证实阿司匹林减少无心衰患者主要缺血事件发生的危险，但阿司匹林在心衰患者中的作用尚未证实[595], 有研究提出其有可能减弱ACEIs对血流动力学和生存的益处[202, 205, 206]。因而，阿司匹林在慢性心衰患者中防止缺血事件的作用是有争议的（见第4.3.1.2.2.1部分）。其它抗血小板药物 (例如氯吡格雷) 可能不与ACEIs产生不利的相互作用[204]，更好预防临床事件[211]。但它们对心衰预后的有益作用尚需证实（见第4.3.1.2.2.1部分）。 　　在其它指南中建议某些亚群的患者进行外科血运重建[29]。一些医生建议对无心绞痛症状的心衰和冠心病患者进行冠脉血运重建。对该方法的提倡提示对于那些具有无收缩功能的存活心肌的患者而言，外科再灌注能改善心脏功能和缓解心衰症状[601-603]，并可减少多支病变患者致命性冠脉阻塞的危险[602]。然而尽管存在理论上的可行性，在无心绞痛的心衰患者中，冠脉血运重建尚未被证实改善心脏功能/症状或防止再梗死/死亡[21,604]。 　　6.1.3. 室上性心律失常 　　心衰患者的病程中常并发室上性快速心律失常，它在心肌病变累及心房或由于左/右室压力或容量过负荷导致心房扩张时发生。最常见的可治疗的房性心律失常是房颤，波及10％－30％的慢性心衰患者并与运动能力的下降和长期预后的恶化相关[605-607]。室上性快速心律失常可通过4种不同机制产生不利作用：1)丧失心房在心室充盈中的作用可减少心输出量；2)快速心率增加氧耗并减少冠状动脉灌注（通过缩短心室充盈时间）；3)快速心室率可减弱心脏收缩（通过加重力-频关系的异常）[608,609]及舒张[610,611]；4)颤动心房内血液的淤滞使患者易于发生肺或全身的栓塞。对于大多数缺血或非缺血性扩张性心肌病患者，心室率过快比丧失心房支持更为重要，因为转复为窦性心律未产生预期的临床益处[612]。快速室上性心律失常可引起心肌病（即使在没有基础性收缩异常的患者中）或加重其它疾病导致的心肌病[115,116]。因此，在有基础室上性心律失常的患者中，控制心室率和防止血栓栓塞事件是心衰治疗的首要内容[613,614]。在心衰失代偿患者中使用β-受体阻滞剂控制心室率时应给予特殊护理和起始低剂量。 　　临床实践中最常应用地高辛减慢伴房颤心衰患者的心室率，但强心甙减慢静息心率更有效[299,615]，而不能减慢运动引起的过快室率[297-299,615]。β-受体阻滞剂较地高辛更有效减慢活动引起的过快心率[297,299]，并且由于它们对心衰进程的有益作用而被优先选用[255,260,262]。用于控制心室率时联合应用地高辛和β-受体阻滞剂较单用β-受体阻滞剂更有效。虽然维拉帕米和地尔硫卓也可抑制运动时心室率，但它们抑制心肌功能、增加心衰危险，应避免使用[588, 590]。如果β-受体阻滞剂无效或有禁忌证，胺碘酮可作为有效代替[616]。如果药物治疗后快速心律失常仍持续存在，可能需要进行房室结消融[325]。在无结构性心脏疾病的患者中，导管介入隔离肺静脉是最有效的；但对于已有心衰的患者益处不明。无论采用何种干预，均应将心室率降至休息时低于80－90次/分、中度运动时低于110－130次/分。所有有房颤病史的心衰患者无论是否获得窦性心律均应维持抗凝治疗，因为不被感知的房颤复发率高并伴随栓塞危险[614]。 　　房颤的心衰患者是否应转复并维持窦性心律？虽然房颤增加栓塞危险，但恢复窦性心律的益处仍不明确[614]，而且这样做的困难和危险也不容忽视。大多数电转复为窦性心律的患者在短期内恢复为房颤，除非采用I 或 III类抗心律失常药物治疗[605]。但I类药物对心衰患者可能效果不佳并且其心脏抑制和致心律失常作用更加明显，可能增加死亡危险[323, 324, 327]。III类抗心律失常药物 （例如索他洛尔、多非利特、胺碘酮）在某些患者可维持窦性心律，但是这些药物有器官毒性（胺碘酮）[617, 618]或致心律失常作用（多非利特）[619]。最近四项临床试验在5032例患者中评价了恢复和维持窦性心律的疗效和安全性[620]。这些试验均表明积极控制心律并未改善死亡率和发病率。试验未入选具有房颤相关心衰症状的患者。研究表明控制室率可减少住院和药物相关副作用。无论选择何种治疗，多数发生血栓栓塞事件的患者在事件发生时为房颤心律，这些患者未进行抗凝治疗或抗凝不充分。亚组分析表明，能够维持窦性心律者预后更好。另一项研究正在进行中[621]。在获得更确切资料之前，治疗必须个体化。 　　6.1.4.血栓栓塞事件的预防 　　由于血液在扩张且运动减低的心脏腔室内及外周血管内淤滞[622,623]，也可能由于促凝因子活性增强[624]，慢性心衰患者发生血栓栓塞事件的危险性增高。然而，在大型研究中，临床状况稳定的患者血栓栓塞危险性低（1%-3%/年），即使是射血分数非常低和心脏超声提示心内血栓的患者[625-629]。如此低的发生率使抗凝治疗在这些患者中的益处不易被观察到。几个回顾性分析发现，服用华法令的心衰患者血栓栓塞的危险并不低于未用抗凝治疗的患者 [625, 627, 628] 。一项回顾性研究显示华法令减少心衰患者的主要心血管事件和死亡，但另一项研究并未得出同样结果 [630-632] 。一项评价阿司匹林、华法令或氯吡格雷对低射血分数心衰患者预后影响的研究已于近期完成。遗憾的是，由于入选人数少未能得出有关疗效的确定性结论，似乎任一种治疗都不优于其它。另一项对比阿司匹林和华法令在LVEF减低心衰患者中的疗效的临床试验正在进行，可能会提供较确定的资料。 　　<b>有关治疗的建议 </b> 　　由于缺乏确定性的临床试验，尚不明确如何在心衰患者中使用抗凝药物。一些医生在所有射血分数显著减低并且心脏扩张的患者中应用抗凝剂[622]。另一些医生提倡在已知有心脏血栓的患者中使用华法令[623],尽管很多超声可检测到的血栓并不发生栓塞，而很多血栓事件又可能与未检测到的血栓有关[179,633]。在曾有血栓事件或患有阵发或持续性房颤的心衰患者中应用华法令抗凝证据是最充分的[614]。患有可能增加血栓栓塞危险的基础疾病（例如淀粉样变性病或左室致密化不全）的患者和患有家族性扩张性心肌病、及一级亲属有血栓栓塞史的患者也应考虑抗凝治疗。 　　6.2. 非心血管疾病 　　6.2.1. 肾功能不全 　　心衰患者由于肾灌注不良、肾脏本身疾病或心衰治疗药物等原因常伴有肾功能受损。存在肾脏低灌注或肾脏本身疾病时患者对利尿剂和ACEI[161,634]反应较差，在使用地高辛治疗的过程中发生不良反应的危险也增加[304]。在使用利尿剂或ACEIs[160,488]治疗的过程中肾功能虽有可能恶化，但常是短期、无症状和可恢复的。持续或进展性肾功能不全常因基础肾脏疾病恶化所致，预后不良[19,635]。贫血[636]和为行透析治疗而行的动静脉瘘增加心脏负荷，加重终末期肾脏疾病患者的心衰症状。另外，慢性肾功能不全时产生的毒性代谢产物和磷酸盐、甲状腺、甲状旁腺的代谢异常可抑制心脏功能。尽管可能存在这些不利的相互作用，多数心衰患者还是较易耐受轻至中度肾功能不全。这些患者血尿素氮和血肌酐的改变通常无临床意义，不需停用改善心衰进展的药物。然而，如果血肌酐增至3mg/dL以上，现有治疗的效果将受到严重影响并且其毒性增加[161,304,634]。血肌酐大于5mg/dL时,可能需要血液过滤或透析以控制液体潴留、最小化尿毒症危险并使患者能够对心衰的常规治疗药物有反应和耐受这些药物[490,637]。 　　6.2.2. 肺部疾病 　　由于心衰和肺部疾病均以呼吸困难为主要症状，鉴别这两种疾病以及当二者并存时判断心源性和肺源性成分的比例非常重要。在运动试验的同时进行气体交换检测或血气分析可能对此有帮助，尤其当与右心导管一起使用时[638]。一些用于治疗心衰的药物可引起或加重肺部症状。ACEIs可引起持续干咳，可能与呼吸道感染相混淆，相反地，常不适当地因肺部原因停用ACEIs。因此，医生对所有主诉咳嗽的心衰患者应寻找肺部原因，无论是否服用ACEI。只有当呼吸道疾病被排除并且咳嗽在停药后消失、重新用药后再次出现时才能认为ACEI 是咳嗽的原因。因为ACEI-相关的咳嗽不代表任何严重病理改变，可鼓励很多患者去耐受该药。β-受体阻滞剂可加重哮喘患者的支气管痉挛症状；但是很多无症状或轻微气道反应疾病患者可很好耐受β-受体阻滞剂。同样，大多数慢阻肺患者无支气管哮喘，选用β-受体阻滞剂仍是合理的[639]。值得注意的是,当使用改善心衰生存的大剂量时，酒石酸美多洛尔和比索洛尔均丧失其β1选择性。 　　6.2.3. 癌症 　　由于很多化疗药物特别是蒽环类抗生素[640]、大剂量环磷酰胺[641-645]、和曲妥单抗[646] 具有心脏毒性，癌症患者尤其易于发生心衰。曲妥单抗是最近批准的用于治疗转移性乳腺癌的单克隆抗体[647]，引起心衰的可能性较大，特别是当与蒽环类抗生素合用时。纵隔放疗也可引起心包、心肌、心脏瓣膜和冠状动脉的急性或慢性损伤，尤其与心脏毒性化疗一起使用时[648]。接受强效心脏毒性药物治疗的癌症患者应密切监测心功能不全的发展。心衰可能在接触蒽环类抗生素很多年后才出现，尤其当出现其它负荷如心动过速时。尽管一些研究者提倡非侵入性左室功能评估和心内膜活检[649],仍有很多病例不能被早期发现。右雷佐生可能对以蒽环类抗生素为基础的化疗患者带来一些心脏保护作用，允许使用更大剂量化疗药物[650,651]。化疗药物引起的心衰治疗类似于其它原因的心衰，但尚不清楚癌症患者是否与其它原因患者反应相似。由于大多数蒽环类抗生素所致的心肌病具有显著心动过速，很多专家认为β-受体阻滞剂在这些患者的治疗中起着重要作用。化疗相关的心衰曾被认为是不可逆进展的，但仍然可因治疗而改善，即使接触后很晚才发生者。 　　6.2.4. 甲状腺疾病 　　甲亢和甲减患者均易发展为心衰。对服用胺碘酮的患者应特别注意，他们可能发展为甲亢或甲减。新发房颤或室性心律失常加重时应重新评价甲状腺功能。 　　6.2.5. 丙型肝炎与艾滋病（HIV） 　　 　　丙型肝炎病毒感染可引起心肌病和心肌炎。这种病毒似乎既可引起扩张性也可引起肥厚性心肌病[474, 475]。这种病毒在日本人口中较北美和欧洲人口发病率高，提示对该型病毒性心肌炎存在基因易感性[476, 652]。一项小型研究显示丙型肝炎病毒心肌炎可能对使用强的松和硫唑嘌呤的免疫抑制治疗反应良好[653, 654]。初步资料也提示该型心肌炎可能对干扰素反应良好[475]，尽管人们担心干扰素可能抑制心脏功能。人类免疫缺陷病毒可能是扩张性心肌病的偶然病因，HIV患者如出现LVEF降低可能影响生存[655]。LVEF的减少常与CD4计数的显著减少相关，虽然心肌病的进展似乎与CD4水平下降无关[656]。使用叠氮胸苷治疗HIV也可能是心肌病的病因之一，可能通过影响心肌细胞线粒体[657]。HIV感染者的心衰也可因心包积液或肺动脉高压而引起或加重。使用干扰素-α治疗HIV-相关卡勃氏肉瘤也可引起可逆性LVEF减低。由于复杂机会性感染的出现、对这些病毒感染的自身免疫反应以及药物的心脏毒性，在HIV患者中很难确定治疗对心肌病发展和控制的影响[658]。 　　6.2.6. 贫血 　　在无基础心脏疾病时贫血很少引起心衰。当贫血作为高输出量心衰的唯一病因时，其程度肯定十分严重（例如,血红蛋白少于5 g/dl）。另一方面，心衰患者由于各种原因常存在贫血。可能促使心衰严重程度的增加。一项研究表明贫血的心衰患者预后较差[659,660]。尚不清楚贫血是生存减低的原因还是疾病更为严重的结果。一些小型研究提示应用促红素和铁剂对轻度贫血的心衰患者有益[661-663]。但也有人担心会增加血栓栓塞事件，尚需进一步研究。
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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Does digoxin provide additional hemodynamic and autonomic ben
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