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1、Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. 2009 Focused Update:ACC/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults1Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. 2009 Focused Update:ACC/AHA
2、 Guidelines for the Diagnosis and Management of Heart Failure in Adults2009 WRITING GROUP TO REVIEW NEW EVIDENCE AND UPDATE THE 2005 GUIDELINE FOR THE MANAGEMENT OF PATIENTS WITH CHRONIC HEART FAILURE WRITING ON BEHALF OF THE 2005 HEART FAILURE WRITING COMMITTEE Mariell Jessup, MD, FACC, FAHA, Chair
3、; William T. Abraham, MD, FACC, FAHA; Donald E. Casey, MD, MPH, MBA; Arthur M. Feldman, MD, PhD, FACC, FAHA; Gary S. Francis, MD, FACC, FAHA; Theodore G. Ganiats, MD; Marvin A. Konstam, MD, FACC; Donna M. Mancini, MD; Peter S. Rahko, MD, FACC, FAHA; Marc A. Silver, MD, FACC, FAHA; Lynne Warner Steve
4、nson, MD, FACC, FAHA; Clyde W. Yancy, MD, FACC, FAHA2Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. 3Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Stages in the Development of Heart Failure/Recommended Therapy by Stage.
5、 ACEI indicates angiotensin-converting enzymeInhibitors; ARB, angiotensin II receptor blocker: EF, ejection fraction; FHx CM, family history of cardiomyopathy, HF, heartFailure; LVH, left ventricular hypertrophy; and MI, myocardial infarction.4Jessup et al (2009) Circulation 2009, American Heart Ass
6、ociation. All rights reserved. Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IA thorough history and physical examination should be obtained/performed in patients presenting w
7、ith HF to identify cardiac and noncardiac disorders or behaviors that might cause or accelerate the development or progressionof HF. (Level of Evidence: C)1. A thorough history and physical examinationshould be obtained/performed in patients presenting with HF to identify cardiac andnoncardiac disor
8、ders or behaviors that might cause or accelerate the development orprogression of HF. (Level of Evidence: C)2005 recommendation remains current in the 2009 update.Recommendations for the Initial Clinical Assessment of Patients with Heart Failure5Jessup et al (2009) Circulation 2009, American Heart A
9、ssociation. All rights reserved. Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IA careful history of current and past use of alcohol, illicitdrugs, current or past standard or
10、 “alternative therapies,” and chemotherapy drugs should be obtained from patientspresenting with HF. (Level of Evidence: C)2. A careful history ofcurrent and past use ofalcohol, illicit drugs, current or past standard or “alternative therapies,” and chemotherapy drugs should be obtained from patient
11、s presenting with HF. (Level of Evidence: C)2005 recommendation remains current in the 2009 update.Recommendations for the Initial Clinical Assessment of Patients with Heart Failure6Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Updates to Initial and Serial C
12、linical Assessments of Patients Presenting with Heart Failure2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IIn patients presenting with HF, initial assessment should be made of the patients ability to perform routine and desiredactivities of daily living. (Level of E
13、vidence: C)3. In patients presenting with HF, initial assessmentshould be made of the patients ability to performroutine and desired activities of daily living. (Levelof Evidence: C)2005 recommendation remains current in the 2009 update.Recommendations for the Initial Clinical Assessment of Patients
14、 with Heart Failure7Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IInitial examination o
15、f patients presenting with HF should include assessment of the patients volume status, orthostatic blood pressure changes, measurement of weightand height, and calculation of body mass index. (Level of Evidence: C4. Initial examination of patients presenting with HFshould include assessment of the p
16、atients volumestatus, orthostatic blood pressure changes,measurement of weight and height, and calculationof body mass index. (Level of Evidence: C)2005 recommendation remains current in the 2009 update.Recommendations for the Initial Clinical Assessment of Patients with Heart Failure8Jessup et al (
17、2009) Circulation 2009, American Heart Association. All rights reserved. Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IInitial laboratory evaluation of patients presenting wi
18、th HF should include complete blood count, urinalysis, serum electrolytes (including calcium and magnesium), blood urea nitrogen, serum creatinine, fasting blood glucose (glycohemoglobin), lipid profile, liver function tests, and thyroid-stimulating hormone. (Level of Evidence: C)5. Initial laborato
19、ry evaluation ofpatients presenting with HF shouldinclude complete blood count,urinalysis, serum electrolytes (including calcium and magnesium), blood urea nitrogen,serum creatinine, fasting blood glucose (glycohemoglobin), lipid profile, liver function tests, and thyroid-stimulating hormone. (Level
20、 of Evidence: C)2005 recommendation remains current in the 2009 update.Recommendations for the Initial Clinical Assessment of Patients with Heart Failure9Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Updates to Initial and Serial Clinical Assessments of Patie
21、nts Presenting with Heart Failure2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass ITwelve-lead electro-cardiogram and chest radiograph (posterior toanterior PA and lateral) should be performed initially in all patients presenting with HF. (Level of Evidence: C)6. Twelve
22、-lead electro-cardiogram and chestradiograph (PA and lateral) should be performedinitially in all patients presenting with HF. (Level ofEvidence: C)2005 recommendation remains current in the 2009 update.Recommendations for the Initial Clinical Assessment of Patients with Heart Failure10Jessup et al
23、(2009) Circulation 2009, American Heart Association. All rights reserved. Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass ITwo-dimensional echo-cardiography with Doppler should
24、be performed during initial evaluation of patients presenting with HF to assess left ventricular ejection fraction (LVEF), LV size, wall thickness, and valve function. Radionuclideventriculography can be performed to assess LVEF and volumes. (Level of Evidence: C)7. Two-dimensional echo-cardiography
25、 with Doppler should beperformed during initial evaluation ofpatients presenting with HF toassess LVEF, left ventricular size,wall thickness, and valve function.Radionuclide ventriculography canbe performed to assess LVEF andvolumes. (Level of Evidence: C2005 recommendation remains current in the 20
26、09 update.Recommendations for the Initial Clinical Assessment of Patients with Heart Failure11Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure2005 Guideline Recommendati
27、ons2009 Focused Update RecommendationsCommentsClass ICoronary arteriography should be performed in patients presenting with HF who have angina or significant ischemiaunless the patient is not eligible for revascularization of any kind. (Level of Evidence: B)8. Coronary arteriography should be perfor
28、med in patients presenting with HF who have angina or significant ischemia unless the patient is noteligible for revascularization of any kind. (Level of Evidence: B2005 recommendation remains current in the 2009 update.Recommendations for the Initial Clinical Assessment of Patients with Heart Failu
29、re12Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IIaCoronary arteriography should be pe
30、rformed in patients presenting with HF who have angina or significant ischemia unless the patient is not eligible for revascularization of any kind. (Level o Evidence: B)1. Coronary arteriography should be performed in patients presenting with HF who have angina or significant ischemia unless the pa
31、tient is noteligible for revascularization of any kind. (Level of Evidence: B2005 recommendation remains current in the 2009 update.Recommendations for the Initial Clinical Assessment of Patients with Heart Failure13Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserve
32、d. Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IIaCoronary arteriography is reasonable for patients presenting with HF who have chest pain that may or may not be of cardiac
33、origin who have not had evaluation of their coronary anatomy and who have no contraindications to coronaryrevascularization. (Level of Evidence: C)2. Coronary arteriography is reasonable for patientspresenting with HF who have chest pain that mayor may not be of cardiac origin who have not hadevalua
34、tion of their coronary anatomy and who have no contraindications to coronaryrevascularization. (Level of Evidence: C)2005 recommendation remains current in the 2009 update.Recommendations for the Initial Clinical Assessment of Patients with Heart Failure14Jessup et al (2009) Circulation 2009, Americ
35、an Heart Association. All rights reserved. Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IIaNoninvasive imaging to detect myocardial ischemia and viability is reasonable in pa
36、tients presenting with HF who have known coronary artery disease and no angina unless the patient is not eligible for revascularization of any kind. (Level of Evidence: B)3. Noninvasive imaging to detect myocardial ischemiaand viability is reasonable in patients presenting withHF who have known coro
37、nary artery disease and No angina unless the patient is not eligible for revascularization of any kind. (Level of Evidence: B)2005 recommendation remains current in the 2009 update.Recommendations for the Initial Clinical Assessment of Patients with Heart Failure15Jessup et al (2009) Circulation 200
38、9, American Heart Association. All rights reserved. Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IIaMaximal exercise testing with or without measurement of respiratory gas ex
39、change and/or blood oxygen saturation is reasonable in patients presenting with HF to help determine whether HF is the cause of exercise limitation when thecontribution of HF is uncertain. (Level of Evidence: C)4. Maximal exercise testing with or without measurement of respiratorygas exchange and/or
40、 blood oxygen saturation is reasonable in patientspresenting with HF to help determinewhether HF is the cause of exercise limitation when the contribution of HFis uncertain. (Level of Evidence: C)2005 recommendation remains current in the 2009 update.Recommendations for the Initial Clinical Assessme
41、nt of Patients with Heart Failure16Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IIaMaxi
42、mal exercise testing with measurement of respiratory gas exchange is reasonable to identify high-risk patients presenting with HF who are candidates for cardiac transplantation or other advanced treatments. (Level of Evidence: B)5. Maximal exercise testing with measurement ofrespiratory gas exchange
43、 is reasonable to identifyhigh-risk patients presenting with HF who are candidates for cardiac transplantation or Other advanced treatments. (Level of Evidence: B)2005 recommendation remains current in the 2009 update.Recommendations for the Initial Clinical Assessment of Patients with Heart Failure
44、17Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IIaScreening for hemo-chromatosis, sleep
45、-disturbed breathing, or human immunodeficiency virus is reasonable in selectedpatients who present with HF. (Level of Evidence: C)6. Screening for hemo-chromatosis, sleep-disturbedbreathing, or human immunodeficiency virus isreasonable in selected patients who present withHF. (Level of Evidence: C)
46、2005 recommendation remains current in the 2009 update.Recommendations for the Initial Clinical Assessment of Patients with Heart Failure18Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Updates to Initial and Serial Clinical Assessments of Patients Presenting
47、with Heart Failure2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IIaDiagnostic tests for rheumatologic diseases, amyloidosis, orpheochromocytoma are reasonable in patients presenting with HF in whom there is a clinical suspicion of these diseases. (Level of Evidence:
48、C)7. Diagnostic tests for rheumatologic diseases,amyloidosis, or pheochromocytoma are Reasonable in patients presenting with HF in whom there is a clinical suspicion of these diseases. (Level ofEvidence: C)2005 recommendation remains current in the 2009 update.Recommendations for the Initial Clinica
49、l Assessment of Patients with Heart Failure19Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsCla
50、ss IIaEndomyocardial biopsy can be useful in patients presenting with HF when a specific diagnosis is suspected that wouldinfluence therapy. (Level of Evidence: C)8. Endomyocardial biopsycan be useful in patientspresenting with HF when a specific diagnosis issuspected that would influence therapy. (
51、Levelof Evidence: C)2005 recommendation remains current in the 2009 update.Recommendations for the Initial Clinical Assessment of Patients with Heart Failure20Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Updates to Initial and Serial Clinical Assessments of
52、Patients Presenting with Heart Failure2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IIaMeasurement of BNP can be useful in the evaluation ofpatients presenting in the urgent care setting in whom the clinical diagnosis of HF is uncertain. (Level of Evidence: A)9. Meas
53、urement of natriuretic peptides (BNP and NTproBNP) canbe useful in the evaluation ofpatients presenting in the urgentcare setting in whom the clinical diagnosis of HF is uncertain. Measurement of natriuretic peptides (BNP and NT-proBNP)can be useful in risk stratification. (Level of Evidence: A)Modi
54、fied recommendation(added a caveat onnatriuretic peptides and theirrole as part of totalevaluation, in both diastolicand systolic dysfunction).Recommendations for the Initial Clinical Assessment of Patients with Heart Failure21Jessup et al (2009) Circulation 2009, American Heart Association. All rig
55、hts reserved. Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IIbNoninvasive imaging may be considered to define thelikelihood of coronary artery disease in patients with HF and
56、 LV dysfunction. (Level of Evidence: C)1. Noninvasive imaging maybe considered to definethe likelihood of coronary artery disease in patients with HF and LV dysfunction. (Level of Evidence: C)2005 recommendation remains current in the 2009 update.Recommendations for the Initial Clinical Assessment o
57、f Patients with Heart Failure22Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IIbHolter m
58、onitoring might be considered in patients presenting with HF who have a history of myocardial infarction (MI) and are being considered for electrophysiologic study todocument ventricular tachycardia (VT) inducibility. (Level of Evidence: C)2. Holter monitoring might be considered in patientspresenti
59、ng with HF who have a history of MI andare being considered for electrophysiologic studyto document VT inducibility. (Level of Evidence: C)2005 recommendation remains current in the 2009 update.Recommendations for the Initial Clinical Assessment of Patients with Heart Failure23Jessup et al (2009) Ci
60、rculation 2009, American Heart Association. All rights reserved. Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IIIEndomyocardial biopsy should not be performed in the routine
61、evaluation of patients with HF. (Level of Evidence: C)1. Endomyocardial biopsy should not be performedin the routine evaluation of patients with HF.(Level of Evidence: C)2005 recommendation remains current in the 2009 update.Recommendations for the Initial Clinical Assessment of Patients with Heart
62、Failure24Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IIIRoutine use of signal-averaged
63、 electro-cardiography is notrecommended for the evaluation of patients presenting with HF. (Level of Evidence: C)2. Routine use of signal-averaged electrocardiography is not recommended for theevaluation of patients presenting with HF. (Levelof Evidence: C)2005 recommendation remains current in the
64、2009 update.Recommendations for the Initial Clinical Assessment of Patients with Heart Failure25Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure2005 Guideline Recommenda
65、tions2009 Focused Update RecommendationsCommentsClass IIIRoutine measurement of circulating levels of neurohormones(e.g., norepinephrine or endothelin) is not recommended forpatients presenting with HF. (Level of Evidence: C)3. Routine measurement of circulating levels ofneurohormones (e.g., norepin
66、ephrine orendothelin) is not recommended for patientspresenting with HF. (Level of Evidence: C)2005 recommendation remains current in the 2009 update.Recommendations for the Initial Clinical Assessment of Patients with Heart Failure26Jessup et al (2009) Circulation 2009, American Heart Association.
67、All rights reserved. Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IAssessment should be made at each visit of the ability of apatient with HF to perform routine and desired a
68、ctivities of daily living. (Level of Evidence: C)1. Assessment should bemade at each visit of theability of a patient with HF toperform routine and desiredactivities of daily living. (Levelof Evidence: C)2005 recommendation remains current in the 2009 update.Recommendations for Serial Clinical Asses
69、sment of Patients Present with Heart Failure27Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsCl
70、ass IAssessment should be made at each visit of the volumestatus and weight of a patient with HF. (Level of Evidence:C)2. Assessment should bemade at each visit of thevolume status and weight of apatient with HF. (Level ofEvidence: C)2005 recommendation remains current in the 2009 update.Recommendat
71、ions for Serial Clinical Assessment of Patients Present with Heart Failure28Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure2005 Guideline Recommendations2009 Focused Up
72、date RecommendationsCommentsClass ICareful history of current use of alcohol, tobacco, illicit drugs, “alternative therapies,” and chemotherapy drugs, as well as diet and sodium intake, should be obtained at each visit of a patient with HF. (Level of Evidence: C)3. Careful history of currentuse of a
73、lcohol, tobacco, illicit drugs, “alternative therapies,” And chemotherapy drugs, as well as diet and sodium intake, should be obtained at each visit of a patient with HF. (Level of Evidence: C)2005 recommendation remains current in the 2009 update.Recommendations for Serial Clinical Assessment of Pa
74、tients Present with Heart Failure29Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IIaRepe
75、at measurement of ejection fraction (EF) and the severity of structural remodeling can provide useful information in patients with HF who have had a change in clinical status or who have experienced or recovered from a clinical eventor received treatment that might have had a significanteffect on ca
76、rdiac function. (Level of Evidence: C)1. Repeat measurement of EF andthe severity of structural remodelingcan be useful to provide informationin patients with HF who have had achange in clinical status or who haveexperienced or recovered from aclinical event or received treatment that might have had
77、 a significanteffect on cardiac function. (Level ofEvidence: C)2005 recommendation remains current in the 2009 update.Recommendations for Serial Clinical Assessment of Patients Present with Heart Failure30Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Updates
78、to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IIbThe value of serial measurements of BNP to guide therapy for patients with HF is not well established. (Level of Evidence: C)1. The va
79、lue of serial measurements of BNP to guide therapy for patients with HF is not well established. (Level of Evidence: C)2005 recommendation remains current in the 2009 update.Recommendations for Serial Clinical Assessment of Patients Present with Heart Failure31Jessup et al (2009) Circulation 2009, A
80、merican Heart Association. All rights reserved. Updates to Patients with Reduced Left Ventricular Ejection Fraction2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IMeasures listed as Classrecommendations for patients in stages A and Bare also appropriate forpatients in
81、 Stage C. (Levelsof Evidence: A, B, and C asappropriate)1. Measures listed as Class I recommendations for patients in stages A and B are also appropriate for patients in Stage C. (Levels of Evidence: A, B, and Cas appropriate)2005 recommendationremains current in 2009update.Patients with Reduced Lef
82、t Ventricular Ejection Fraction32Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Diuretics and salt restrictionare indicated in patients withcurrent or prior symptoms ofHF and reduced LVEF whohave evidence of fluidretention (see Table 4).(Level of Evidence: C)2
83、. Diuretics and saltrestriction are indicated inpatients with current or prior symptoms of HF andreduced LVEF who haveevidence of fluid retention(Level of Evidence: C)2005 recommendationremains current in 2009update.Updates to Patients with Reduced Left Ventricular Ejection Fraction2005 Guideline Re
84、commendations2009 Focused Update RecommendationsCommentsClass IPatients with Reduced Left Ventricular Ejection Fraction33Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. 2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IAngiotensin
85、convertingenzyme inhibitors arerecommended for allpatients with current or priorsymptoms of HF and reduced LVEF, unlesscontraindicated (Level ofEvidence: A)3. Angiotensin-converting enzyme inhibitors are recommended for all patients with current or prior symptoms of HF and reduced LVEF, unless contr
86、aindicated (Level of Evidence: A)2005 recommendationremains current in 2009update.Updates to Patients with Reduced Left Ventrical Ejection FractionPatients with Reduced Left Ventircular Ejection Fraction34Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Beta blo
87、ckers (using of theproven to reduce mortality,i.e.bisoprolol, carvedilol, andsustained release metoprolol succinate) arerecommended for all stablepatients with current or priorsymptoms of HF and reduced LVEF, unlesscontraindicated (Level of Evidence: A)4. Beta blockers (using 1 of the 3proven to red
88、uce mortality, i.e., bisoprolol, carvedilol, and sustained release metoprololsuccinate) are recommended for all stable patients with current or prior symptoms of HF and reduced LVEF, unless contraindicated (Level ofEvidence: A)2005 recommendationremains current in 2009 update.Updates to Patients wit
89、h Reduced Left Ventricular Ejection Fraction2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IPatients with Reduced Left Ventricular Ejection Fraction35Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Angiotensin II receptor lockers
90、 approved for thetreatment of HF are recommended in patients with current or priorsymptoms of HF and reduced LVEF who are ACEinhibitor-intolerant.(Level of Evidence: A)5. Angiotensin II receptor blockers (see Table 3 inthe full-text guidelines)are recommended inpatients with current orprior symptoms
91、 of HF andreduced LVEF who areACE inhibitor-intolerant(Level of Evidence: A)2005 recommendationremains current but textmodified to eliminatespecific agents tested.Updates to Patients with Reduced Left Ventricular Ejection Fraction2005 Guideline Recommendations2009 Focused Update RecommendationsComme
92、ntsClass IPatients with Reduced Left Ventricular Ejection Fraction36Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Drugs known to adversely affect the clinical status ofpatients with current or priorsymptoms of HF and reduced LVEF should beavoided or withdrawn
93、 whenever possible (e.g.,nonsteroidal anti-inflammatory drugs, mostantiarrhythmic drugs, andmost calcium channelblocking drugs; (Level of Evidence: B)6. Drugs known to adversely affectthe clinical status of patients withcurrent or prior symptoms of HF andreduced LVEF should be avoided orwithdrawn wh
94、enever possible (e.g.,nonsteroidal anti-inflammatory drugs,most antiarrhythmic drugs, and most calcium channel blockingdrugs; (Level of Evidence: B)2005 recommendationremains current in 2009 update. Updates to Patients with Reduced Left Ventricular Ejection Fraction2005 Guideline Recommendations2009
95、 Focused Update RecommendationsCommentsClass IPatients with Reduced Left Ventricular Ejection Fraction37Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Exercise training is beneficial as an adjunctive approach to improve clinical status in ambulatory patients w
96、ith current or prior symptoms of HF and reduced LVEF.(Level of Evidence: B)Maximal exercise testingwith or withoutmeasurement of respiratorygas exchange is reasonableto facilitate prescription ofan appropriate exercise program for patients presenting with HF. (Level of Evidence: C)Modified recommend
97、ation(changed class ofrecommendation from I toIIa)Updates to Patients with Reduced Left Ventricular Ejection Fraction2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IPatients with Reduced Left Ventricular Ejection Fraction38Jessup et al (2009) Circulation 2009, America
98、n Heart Association. All rights reserved. Maximal exercise testing with or withoutmeasurement of respiratory gas exchange isrecommended to facilitate prescription of an appropriate exercise program for patients with HF. (Level of Evidence: C)7. Maximal exercise testingwith or without measurement ofr
99、espiratory gas exchange isrecommended to facilitateprescription of an appropriateExercise program for patients withHF. (Level of Evidence: C)2005 recommendation Remains current in 2009update.Updates to Patients with Reduced Left Ventricular Ejection Fraction2005 Guideline Recommendations2009 Focused
100、 Update RecommendationsCommentsClass IPatients with Reduced Left Ventricular Ejection Fraction39Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Exercise training is beneficial as an adjunctive approach to improve clinicalstatus in ambulatory patients with curre
101、nt or priorsymptoms of HF and reduced LVEF. (Level ofEvidence: B)8. Exercise training is beneficial as an adjunctiveapproach to improve clinicalstatus in ambulatorypatients with current or priorsymptoms of HF andreduced LVEF. (Level of Evidence: B)2005 recommendationremains current in 2009update.Upd
102、ates to Patients with Reduced Left Ventricular Ejection Fraction2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IPatients with Reduced Left Ventricular Ejection Fraction40Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. An implanta
103、ble cardioverter-defibrillator is recommendedas secondary prevention to prolong survival in patientswith current or prior symptoms of HF and reduced LVEF who have a history of cardiac arrest, ventricular fibrillation, or hemodynamicallydestabilizing ventriculartachycardia. (Level ofEvidence: A)9. An
104、 implantable cardioverter-defibrillator is recommendedas secondary prevention toprolong survival in patientswith current or prior symptoms ofHF and reduced LVEF who have ahistory of cardiac arrest,ventricular fibrillation, orhemodynamically destabilizingventricular tachycardia.(Level ofEvidence: A)2
105、005 recommendation remains current in 2009 update.Updates to Patients with Reduced Left Ventricular Ejection Fraction2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass I Patients with Reduced Left Ventricular Ejection Fraction41Jessup et al (2009) Circulation 2009, Americ
106、an Heart Association. All rights reserved. Implantable cardioverter-defibrillator therapy is recom-mended for primary prevention to reduce total mortality by a reduction in sudden cardiac death in patients with ischemic heart disease who are at least 40 days post-MI, have an LVEF less than or equal
107、to 30%, with NYHA functional class II or III symptoms while undergoing chronic optimal medical therapy, and have reasonable expectation of survival with a good functional status for more than 1 year. (Level of Evidence: A)10. Implantable cardioverter-defibrillator therapy is recommended for primaryp
108、revention of sudden cardiac death toreduce total mortality in patients withnonischemic dilated cardiomyopathy orIschemic heart disease at least 40 dayspost-MI, a LVEF less than or equal to35%, and NYHA functional class II or IIIsymptoms while receiving chronicoptimal medical therapy, and who haverea
109、sonable expectation of survival witha good functional status for more than1 year. (Level of Evidence: A)Modified recommendation to be consistent with the ACC/AHA/Heart Rhythm Society (HRS)2008 Device-Based Therapyguidelines.Updates to Patients with Reduced Left Ventricular Ejection Fraction2005 Guid
110、eline Recommendations2009 Focused Update RecommendationsCommentsClass IPatients with Reduced Left Ventricular Ejection Fraction42Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. An implantable cardioverter-defibrillator therapy isrecommended for primarypreventio
111、n to reduce total mortalityby a reduction in sudden cardiacdeath in patients with nonischemiccardiomyopathy who have anLVEF less than or equal to 30%,with NYHA functional class II or III symptoms while undergoing chronic optimal medical therapy,and who have reasonableexpectation of survival with a g
112、oodfunctional status for more than 1year. (Level of Evidence: B) An implantable cardioverter-defibrillator is recommended as secondary prevention to prolongsurvival in patients with current orprior symptoms of HF and reduced LVEF who have a historyof cardiac arrest, ventricularfibrillation, or hemod
113、ynamicallydestabilizing ventriculartachycardia. (Level ofEvidence: A)2005 recommendation nolonger current. See 2009 Class I No 9 recommendation above.Updates to Patients with Reduced Left Ventricular Ejection Fraction2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IPat
114、ients with Reduced Left Ventricular Ejection Fraction43Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Patients with LVEF less than or equal to 35%, sinusrhythm, and NYHA functional class III or ambulatory classIV symptoms despite recommended, optimal medicalth
115、erapy and who have cardiac dyssynchrony, which iscurrently defined as a QRS duration greater than 120 ms,should receive cardiac resynchronization therapy unlesscontraindicated. (Level of Evidence: A)11. Patients with LVEF of less than or equal to 35%, sinus rhythm, and NYHA functional class III or a
116、mbulatory class IV symptoms despite recommended, optimal medical therapy and who have cardiac dyssynchrony, which is currently defined as a QRS duration or equal to 0.12 seconds, should receive cardiac resynchronization therapy, with or without an ICD, unless contraindicated. (Level of Evidence: A)C
117、larified recommendation(includes therapy with orwithout an ICD).Updates to Patients with Reduced Left Ventricular Ejection Fraction2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IPatients with Reduced Left Ventricular Ejection Fraction44Jessup et al (2009) Circulation
118、 2009, American Heart Association. All rights reserved. Addition of an aldosterone antagonist is reasonable in selected patients with moderately severe to severesymptoms of HF and reduced LVEF who can be carefully monitored for preserved renal function and normalK+ concentration. Creatinine should b
119、e or equal to 2.5 mg/dL in men or or equal to 2.0 mg/dL in women & K+ should be 5.0 mEq/L. Under circumstances where monitoring forhyperkalemia or renal dysfunction is not anticipated to be feasible, the risks may outweigh the benefits ofaldosterone antagonists. (Level of Evidence: B)12. Addition of
120、 an aldosterone antagonist is recommendedin selected patients with moderately severe to severe symptoms ofHF and reduced LVEF who can becarefully monitored for preserved renal function and normal K+ concentration.Creatinine should be 2.5 mg/dL or less in men or 2.0 mg/dL or less in women and K+shoul
121、d be 5.0 mEq/L. Under circumstances where monitoring forhyperkalemia or renal dysfunction is not anticipated to be feasible, the risks may outweigh the benefits of aldosteroneantagonists.116118 (Level of Evidence: B)2005 recommendation remains current in 2009 update.Updates to Patients with Reduced
122、Left Ventricular Ejection Fraction2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IPatients with Reduced Left Ventricular Ejection Fraction45Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. 13. The combination of hydralazineand nit
123、rates is recommended toImprove outcomes for patients self-described as African- Americans,with moderate-severe symptoms onOptimal therapy with ACE inhibitors,beta blockers, and diuretics.(Level of Evidence: B)New recommendationUpdates to Patients with Reduced Left Ventricular Ejection Fraction2005 G
124、uideline Recommendations2009 Focused Update RecommendationsCommentsClass IPatients with Reduced Left Ventricular Ejection Fraction46Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. 1. It is reasonable to treat patients with atrial fibrillationand HF with a strat
125、egy tomaintain sinus rhythm orwith a strategy to controlventricular rate alone. (Level of Evidence: A)New recommendationUpdates to Patients with Reduced Left Ventricular Ejection Fraction2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IIaPatients with Reduced Left Vent
126、ricular Ejection Fraction47Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. 2. Maximal exercise testing with or without measurementof respiratory gas exchange isreasonable to facilitateprescription of an appropriate exercise program for patientspresenting with H
127、F. (Level of Evidence: C)Modified recommendation(changed class ofrecommendation from I toIIa)Updates to Patients with Reduced Left Ventricular Ejection Fraction2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IIaPatients with Reduced Left Ventricular Ejection Fraction48
128、Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Angiotensin II receptorblockers are reasonable touse as alternatives to ACEinhibitors as first-line therapy for ts with mild to moderate HF and reduced LVEF, especially for pts already taking ARBs for other indica
129、tions. (Level of Evidence: A)3. Angiotensin II receptor blockers are reasonable touse as alternatives toACEinhibitors as first-linetherapy for pts withmild to moderate HF andreduced LVEF, especiallyfor pts already takingARBs for other indications.(Level of Evidence: A)2005 recommendation remains cur
130、rent in 2009update.Updates to Patients with Reduced Left Ventricular Ejection Fraction2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IIaPatients with Reduced Left Ventricular Ejection Fraction49Jessup et al (2009) Circulation 2009, American Heart Association. All righ
131、ts reserved. Digitalis can be beneficial in patients with current or priorsymptoms of HF and reduced LVEF to decreasehospitalizations for HF. (Level of Evidence: B)4. Digitalis can be beneficial in patients with current orprior symptoms of HF and reduced LVEF to decreasehospitalizations for HF.(Leve
132、l of Evidence: B)2005 recommendation remains current in 2009 update.Updates to Patients with Reduced Left Ventricular Ejection Fraction2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IIaPatients with Reduced Left Ventricular Ejection Fraction50Jessup et al (2009) Circu
133、lation 2009, American Heart Association. All rights reserved. The addition of a combination of hydralazine and a nitrate is reasonablefor patients with reducedLVEF who are alreadytaking an ACE inhibitor andbeta-blocker for symptomatic HF and whohave persistent symptoms.(Level of Evidence: A)5. The a
134、ddition of a combination of hydralazine and a nitrate isreasonable for patients withreduced LVEF who are alreadytaking an ACE inhibitor andBeta blocker for symptomaticHF and who have persistentsymptoms. (Level of Evidence: A)2005 recommendation remains current in 2009 update.Updates to Patients with
135、 Reduced Left Ventricular Ejection Fraction2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IIaPatients with Reduced Left Ventricular Ejection Fraction51Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Placement of an ICD isreasonab
136、le in patients with LVEFof 30% to 35% of any origin withNYHA functional class II or IIIsymptoms who are taking chronicoptimal medical therapy and whohave reasonable expectation ofsurvival with good functionalstatus of more than 1 year. (Levelof Evidence: B)An ICD is recommended assecondary preventio
137、n to prolongsurvival in patients with current orprior symptoms of HF and reducedLVEF who have a history of cardiacarrest, ventricular fibrillation, orhemodynamically destabilizingventricular tachycardia. (Level ofEvidence: A)2005 recommendation nolonger current. See2009 Class I No. 9recommendation.U
138、pdates to Patients with Reduced Left Ventricular Ejection Fraction2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IIaPatients with Reduced Left Ventricular Ejection Fraction52Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. 6. For
139、patients who have LVEF lessthan or equal to 35%, a QRS durationof greater than or equal to 0.12seconds, and atrial fibrillation (AF),CRT with or without an ICD isreasonable for the treatment of NYHAFunctional class III or ambulatory classIV heart failure symptoms on optimalrecommended medical therap
140、y. (Level of Evidence: B)New recommendation added to be consistent with the ACC/AHA/HRS 2008Device-Based Therapyguidelines.Updates to Patients with Reduced Left Ventricular Ejection Fraction2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IIaPatients with Reduced Left V
141、entricular Ejection Fraction53Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. 7. For patients with LVEF of less than or equal to 35% with NYHAfunctional class III or ambulatoryclass IV symptoms who arereceiving optimal recommendedmedical therapy and who havefre
142、quent dependence onventricular pacing, CRT isreasonable. (Level of Evidence:C)New recommendation added to be consistent withthe ACC/AHA/HRS 2008Device-Based Therapyguidelines.Updates to Patients with Reduced Left Ventricular Ejection Fraction2005 Guideline Recommendations2009 Focused Update Recommen
143、dationsCommentsClass IIaPatients with Reduced Left Ventricular Ejection Fraction54Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Class IIbA combination of hydralazine and a nitrate might bereasonable in patients withcurrent or prior symptoms ofHF and reduced L
144、VEF whocannot be given an ACEinhibitor or ARB because ofdrug intolerance, hypotension,or renal insufficiency. (Level ofEvidence: C)1. A combination of hydralazine and a nitrate might be reasonablein patients with current or priorsymptoms of HF and reducedLVEF who cannot be given anACE inhibitor or A
145、RB because ofdrug intolerance, hypotension, orrenal insufficiency. (Level of Evidence: C)2005 recommendationremains current in2009 update.Updates to Patients with Reduced Left Ventricular Ejection Fraction2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsPatients with Reduced
146、Left Ventricular Ejection Fraction55Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. The addition of an ARB maybe considered in persistently symptomatic patients withreduced LVEF who arealready being treated withconventional therapy. (LevelOf Evidence: B)2. The
147、addition of an ARB maybe considered in persistentlysymptomatic patients withreduced LVEF who are alreadybeing treated with conventionaltherapy. (Level of Evidence: B)2005 recommendationremains current in 2009 update.Class IIbUpdates to Patients with Reduced Left Ventricular Ejection Fraction2005 Gui
148、deline Recommendations2009 Focused Update RecommendationsCommentsPatients with Reduced Left Ventricular Ejection Fraction56Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Class IIIRoutine combined use of anACE inhibitor, ARB, andaldosterone antagonist isnot rec
149、ommended forpatients with current or priorsymptoms of HF andreduced LVEF. (Level ofEvidence: C)1. Routine combined use ofan ACE inhibitor, ARB, andaldosterone antagonist isnot recommended forpatients with current or priorsymptoms of HF andreduced LVEF. (Level ofEvidence: C)2005 recommendationremains
150、 current in 2009update.Updates to Patients with Reduced Left Ventricular Ejection Fraction2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsPatients with Reduced Left Ventricular Ejection Fraction57Jessup et al (2009) Circulation 2009, American Heart Association. All rights re
151、served. Calcium channel blocking drugs are not indicated asroutine treatment for HFinpatients with current orprior symptoms of HF andreduced LVEF. (Level ofEvidence:2. Calcium channel blocking drugs are not indicated asroutine treatment for HF inpatients with current orprior symptoms of HF and reduc
152、ed LVEF.(Level of Evidence: A)2005 recommendation remains current in 2009update.Class IIIUpdates to Patients with Reduced Left Ventricular Ejection Fraction2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsPatients with Reduced Left Ventricular Ejection Fraction58Jessup et al
153、(2009) Circulation 2009, American Heart Association. All rights reserved. Long-term use of an infusionof a positive inotropic drugmay be harmful & is not recommended for pts with current or prior symptoms of HF and reduced LVEF, except as palliation for pts with end-stage disease who cannot be stabi
154、lized with standard medical treatment (see recommendations for Stage D). (Level of Evidence: C)3. Long-term use of an infusionof a positive inotropic drug may be harmful & is not recommended for pts with currentor prior symptoms of HF & reducedLVEF, except as palliation for ptswith end-stage disease
155、 who cannotbe stabilized with standard medical treatment (see recommendations forStage D). (Level of Evidence: C)2005 recommendation remains current in 2009 update.Class IIIUpdates to Patients with Reduced Left Ventricular Ejection Fraction2005 Guideline Recommendations2009 Focused Update Recommenda
156、tionsCommentsPatients with Reduced Left Ventricular Ejection Fraction59Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Use of nutritional supplements as treatment for HF is not indicated in patients with current or prior symptoms of HF andreduced LVEF. (Level o
157、f Evidence: C)4. Use of nutritionalsupplements as treatment for HF is not indicated in patients with current or priorsymptoms of HF and reduced LVEF. (Level ofEvidence: C)2005 recommendation remains current in 2009 update.Class IIIUpdates to Patients with Reduced Left Ventricular Ejection Fraction20
158、05 Guideline Recommendations2009 Focused Update RecommendationsCommentsPatients with Reduced Left Ventricular Ejection Fraction60Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Hormonal therapies otherthan to replete deficiencies are not recommended and may be
159、harmful to patients with current or prior symptoms of HF and reduced LVEF. (Level of Evidence: C)5. Hormonal therapies other than to replete deficienciesare not recommended and may be harmful to patientswith current or prior symptoms of HF and reduced LVEF. (Level of Evidence: C)2005 recommendation
160、remains current in 2009 update.Class IIIUpdates to Patients with Reduced Left Ventricular Ejection Fraction2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsPatients with Reduced Left Ventricular Ejection Fraction61Jessup et al (2009) Circulation 2009, American Heart Associati
161、on. All rights reserved. Meticulous identification andcontrol of fluid retention isrecommended in patients with refractory end-stageHF. (Level of Evidence: B)1. Meticulous identification and control of fluid retention isrecommended in patients with refractory end-stage HF (Level of Evidence: B)2005
162、recommendation remains current in 2009 update.2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IUpdates to Patients with Refractory End-Stage Heart Failure (Stage D)Patients with Refractory End-Stage Heart Failure (Stage D)62Jessup et al (2009) Circulation 2009, America
163、n Heart Association. All rights reserved. Referral for cardiactransplantation in potentially eligible patients is recommended for patients with refractory end-stage HF. (Level of Evidence: B)2. Referral for cardiac transplantation in potentially eligible patients is recommended for patients with ref
164、ractory end-stage HF. (Level of Evidence: C)2005 recommendation remains current in 2009 update.2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IUpdate to Patients with Refractory End-Stage Heart Failure (Stage D)Patients with Refractory End-Stage Heart Failure (Stage D
165、)63Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. 2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IReferral of patients with refractory end-stage HF to An HF program with expertise in the management of refractory HF is useful. (L
166、evel of Evidence: A)3. Referral of patients with refractory end-stage HF to aHF program with expertise in the management ofrefractory HF is useful.(Level of Evidence: A)2005 recommendation remains current in 2009 update.Update to Patients with Refractory End-Stage Heart Failure (Stage D)Patients wit
167、h Refractory End-Stage Heart Failure (Stage D)64Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Options for end-of-life care should be discussed withthe patient and family when severe symptoms inpatients with refractory end-stage HF persist despiteapplication o
168、f all recommended therapies. (Level ofEvidence: C4. Options for end-of-life care should be discussed with the patient and family when severe symptoms inpatients with refractory end-stage HF persist despiteapplication of all recommended therapies. (Level of Evidence: C2005 recommendation remains curr
169、ent in 2009 update.2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IUpdate to Patients with Refractory End-Stage Heart Failure (Stage D)Patients with Refractory End-Stage Heart Failure (Stage D)65Jessup et al (2009) Circulation 2009, American Heart Association. All rig
170、hts reserved. Patients with refractory end-stage HF and implantable defibrillators should receiveinformation about the option to inactivate defibrillation. (Level of Evidence: C)5. Patients with refractory end-stage HF and implantabledefibrillators should receive information about the option toinact
171、ivate the defibrillator. (Level of Evidence: C)2005 recommendation remains current in 2009 update.2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IUpdate to Patients with Refractory End-Stage Heart Failure (Stage D)Patients with Refractory End-Stage Heart Failure (Stag
172、e D)66Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Consideration of an LV assist device as permanent or “destination” therapy is reasonable in highly selected patients with refractory end-stage HF and an estimated 1-year mortality over 50% with medical thera
173、py. (Level of Evidence: B)1. Consideration of an LV assist device as permanentor “destination” therapy is reasonable in highly Selected patients with refractory end-stage HF and an estimated 1-year mortality over 50% with medical therapy. (Level of Evidence: B)2005 recommendation remains current in
174、2009 update.2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass I!aUpdate Patients with Refractory End-Stage Heart Failure (Stage D)Patients with Refractory End-Stage Heart Failure (Stage D)67Jessup et al (2009) Circulation 2009, American Heart Association. All rights rese
175、rved. Pulmonary artery catheter placement may be reasonable to guide therapy in patients with refractory end-stage HF and persistently severesymptoms. (Level of Evidence: C)1. Pulmonary artery catheter placement may bereasonable to guide therapy in patients with refractoryend-stage HF and persistent
176、ly severe symptoms. (Level of Evidence: C)2005 recommendation remains current in 2009 update.2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IIbUpdate to Patients with Refractory End-Stage Heart Failure (Stage D)Patients with Refractory End-Stage Heart Failure (Stage D
177、)68Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. The effectiveness of mitral valve repair or replacementis not established for severe secondary mitralregurgitation in refractory end-stage HF. (Level ofEvidence: C)2. The effectiveness of mitral valve repair or
178、 replacementis not well established for severe secondary mitralregurgitation in refractory end-stage HF. (Level ofEvidence: C)2005 recommendation remains current in 2009 update.2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IIbUpdate to Patients with Refractory End-St
179、age Heart Failure (Stage D)Patients with Refractory End-Stage Heart Failure (Stage D)69Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Continuous intravenous infusion of a positive inotropic agent may be considered for palliation of symptoms in patients with re
180、fractory end-stage HF. (Level of Evidence: C)3. Continuous intravenous infusion of a positive Inotropic agent may be considered for palliation of symptoms in patients with refractory end-stage HF. (Level ofEvidence: C)2005 recommendation remains current in 2009 update.2005 Guideline Recommendations2
181、009 Focused Update RecommendationsCommentsClass IIbUpdate to Patients with Refractory End-Stage Heart Failure (Stage D)Patients with Refractory End-Stage Heart Failure (Stage D)70Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Partial left ventriculectomy is no
182、t recommended inpatients with nonischemic cardiomyopathy andrefractory end-stage HF. (Level of Evidence: C)1.Partial left ventriculectomyis not recommended inpatients with nonischemic cardiomyopathy andrefractory end-stage HF. (Level of Evidence: C)2005 recommendation remains current in 2009 update.
183、2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IIIUpdate to Patients with Refractory End-Stage Heart Failure (Stage D)Patients with Refractory End-Stage Heart Failure (Stage D)71Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Rou
184、tine intermittent infusions of positive inotropic agents are not recommended for patients with refractory end-stage HF. (Level of Evidence: B)2. Routine intermittent infusions of vasoactive and Positive inotropic agents are not recommended for patients with refractory end-stage HF. (Level of Evidenc
185、e: A)Modified recommendation(changed Level of Evidencefrom B to A).2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IIIUpdate to Patients with Refractory End-Stage Heart Failure (Stage D)Patients with Refractory End-Stage Heart Failure (Stage D)72Jessup et al (2009) Cir
186、culation 2009, American Heart Association. All rights reserved. Recommendations for the Hospitalized Patient New Recommendations2009 Focused Update RecommendationsClass I1. The diagnosis of HF is primarily based on signs and symptoms derived from a thorough history and physical examination. Clinicia
187、ns should determine the following:a. adequacy of systemic perfusion;b. volume status;c. the contribution of precipitating factors and/or comorbidities;d. if the HF is new onset or an exacerbation of chronic disease; &e. whether it is associated with preserved EF.Chest radiographs, electrocardiogram,
188、 and echocardiography are key tests in this assessment. (Level of Evidence: C)73Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Recommendations for the Hospitalized Patient New Recommendations2009 Focused Update RecommendationsClass I2. Concentrations of B-type
189、 natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) should be measured in pts being evaluated for dyspnea in which the contribution of HF is not known. Final diagnosis requires interpreting these results in the context of all available clinical data and ought not to b
190、e considered a stand alone test. (Level of Evidence: A)74Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Recommendations for the Hospitalized Patient New Recommendations2009 Focused Update RecommendationsClass I 3. Acute coronary syndrome precipitating HF hospi
191、talization should be promptly identified by ECG & cardiac troponin testing, and treated, as appropriate to the overall condition and prognosis of the pt.(Level of Evidence: C)75Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Recommendations for the Hospitalized
192、 Patient New Recommendations2009 Focused Update RecommendationsClass I4. It is recommended that the following common potential precipitating factors for acute HF be identified as recognition of these comorbidities is critical to guide therapy: acute coronary syndromes/coronary ischemia severe hypert
193、ension atrial and ventricular arrhythmias infections pulmonary emboli renal failure medical or dietary noncompliance. (Level of Evidence: C)76Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Recommendations for the Hospitalized Patient New Recommendations2009 Fo
194、cused Update RecommendationsClass I5. Oxygen therapy should be administered to relieve symptoms related to hypoxemia. (Level of Evidence: C)77Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Recommendations for the Hospitalized Patient New Recommendations2009 Fo
195、cused Update RecommendationsClass I6. Whether the diagnosis of HF is new or chronic, patients who present with rapid decompensation and hypoperfusion associated with decreasing urine output and other manifestations of shock are critically ill and rapid intervention should be used to improve systemic
196、 perfusion. (Level of Evidence: C)78Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Recommendations for the Hospitalized Patient New Recommendations2009 Focused Update RecommendationsClass I7. Patients admitted with HF and with evidence of significant fluid ove
197、rload should be treated with IV loop diuretics. Therapy should begin in the ED or outpatient clinic without delay, as early intervention may be associated with better outcomes for patientshospitalized with decompensated HF. (Level of Evidence: B) If patients are already receiving loop diuretic thera
198、py, the initial IV dose should equal or exceed their chronic oral daily dose. Urine output and signs and symptoms of congestion should be serially assessed, and diuretic dose should be titrated accordingly to relieve symptoms and to reduce extracellular fluid volume excess. (Level of Evidence: C)79J
199、essup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Recommendations for the Hospitalized Patient New Recommendations2009 Focused Update RecommendationsClass I8. Effect of HF treatment should be monitored with careful measurement of fluid intake and output; vital sig
200、ns; body weight, determined at the same time each day; Clinical signs (supine and standing) and symptoms of systemic perfusion and congestion. Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of HF medication
201、s. (Level of Evidence: C80Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Recommendations for the Hospitalized Patient New Recommendations2009 Focused Update RecommendationsClass I9. When diuresis is inadequate to relieve congestion, as evidenced by clinical ev
202、aluation, the diuretic regimen should be intensified using either:a. higher doses of loop diuretics;b. addition of a second diuretic (such as metolazone, spironolactone or intravenous chlorothiazide); orc. continuous infusion of a loop diuretic. (Level of Evidence: C)81Jessup et al (2009) Circulatio
203、n 2009, American Heart Association. All rights reserved. Recommendations for the Hospitalized Patient New Recommendations2009 Focused Update RecommendationsClass I10. In patients with clinical evidence of hypotension associated with hypoperfusion and obvious evidence of elevated cardiac filling pres
204、sures (e.g., elevated jugularvenous pressure; elevated PAWP), IV inotropic or vasopressor drugs should be administered to maintain systemic perfusion and preserve end-organ performancewhile more definitive therapy is considered. (Level of Evidence: C)82Jessup et al (2009) Circulation 2009, American
205、Heart Association. All rights reserved. Recommendations for the Hospitalized Patient New Recommendations2009 Focused Update RecommendationsClass I11. Invasive hemodynamic monitoring should be performed to guide therapy in pts who are in respiratory distress or with clinical evidence ofimpaired perfu
206、sion in whom the adequacy or excess of intracardiac filling pressures cannot be determined from clinical assessment. (Level of Evidence: C)83Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Recommendations for the Hospitalized Patient New Recommendations2009 Foc
207、used Update RecommendationsClass I12. Medications should be reconciled in every patient and adjusted as appropriate on admission to and discharge from the hospital. (Level of Evidence: C)84Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Recommendations for the
208、Hospitalized Patient New Recommendations2009 Focused Update RecommendationsClass I13. In patients with reduced ejection fraction experiencing a symptomatic exacerbation of HF requiring hospitalization during chronic maintenancetreatment with oral therapies known to improve outcomes, particularly ACE
209、inhibitors or ARBs and beta-blocker therapy, it is recommended that thesetherapies be continued in most patients in the absence of hemodynamicinstability or contraindications. (Level of Evidence: C)85Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Recommendatio
210、ns for the Hospitalized Patient New Recommendations2009 Focused Update RecommendationsClass I14. In patients hospitalized with HF with reduced EF not treated with oral therapies known to improve outcomes, particularly ACE inhibitorsor ARBs and BB therapy, initiation of these therapies is recommended
211、in stable patients prior to hospital discharge. (Level of Evidence: B)86Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Recommendations for the Hospitalized Patient New Recommendations2009 Focused Update RecommendationsClass I15. Initiation of BBs is recommende
212、d after optimization ofvolume status and successful discontinuation of IV diuretics,vasodilators, and inotropic agents. BB should be initiated at a low dose and only in stable patients. Particular caution should be used when initiating BB in patients who have required inotropes during their hospital
213、 course. (Level of Evidence: B)87Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Recommendations for the Hospitalized Patient New Recommendations2009 Focused Update RecommendationsClass I16. In all patients hospitalized with HF, both with preserved and low EF,
214、transition should be made from IV to PO diuretic therapy with careful attention to PO diuretic dosing and monitoring of lytes. With all med changes, the patient should be monitored for supine and upright hypotension, worsening renalfunction and HF signs/symptoms. (Level of Evidence: C)88Jessup et al
215、 (2009) Circulation 2009, American Heart Association. All rights reserved. Recommendations for the Hospitalized Patient New Recommendations2009 Focused Update RecommendationsClass I17. Comprehensive written discharge instructions for all patients with a hospitalization for HF and their caregivers is
216、 strongly recommended, with special emphasis on the following6 aspects of care: - diet discharge medications, with a special focus on adherence, persistence, and - uptitration to recommended doses of ACE inhibitor/ARB and BB medication, - activity level, - follow-up appointments, - daily weight moni
217、toring, and - what to do if HF symptoms worsen. (Level of Evidence: C)89Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Recommendations for the Hospitalized Patient New Recommendations2009 Focused Update RecommendationsClass I18. Post discharge systems of care,
218、 if available, should be used to facilitate the transition to effective outpatient care for patients hospitalized with HF. (Level of Evidence: B)90Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Recommendations for the Hospitalized Patient New Recommendations20
219、09 Focused Update RecommendationsClass IIa1. When patients present with acute HF and known or suspected AMI due to occlusive coronary disease, especially when there are signs and symptoms of inadequate systemicperfusion, urgent cardiac catheterization andrevascularization is reasonable where it is l
220、ikely to prolong meaningful survival.(Level of Evidence: C)2. In patients with evidence of severely symptomatic fluid overload in the absence of systemic hypotension, vasodilators such as intravenous nitroglycerin, nitroprusside or nesiritide can be beneficial when added to diuretics and/or in those
221、 who do not respond to diuretics alone. (Level of Evidence: C)91Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Recommendations for the Hospitalized Patient New Recommendations2009 Focused Update RecommendationsClass IIa3. Invasive hemodynamic monitoring can be
222、 useful for carefully selected patients with acute HF Who have persistent symptoms despite empiric adjustment of standard therapies, and:a. whose fluid status, perfusion, or SVR or PVR are uncertain.b. whose systolic pressure remains low, or is associated with symptoms, despite initial therapy,c. wh
223、ose renal function is worsening with therapyd. who require parenteral vasoactive agents ore. who may need consideration for advanced device therapy or transplantation. (Level of Evidence: C)4. Ultrafiltration is reasonable for patients with refractory congestion not responding to medical therapy. (L
224、evel of Evidence: B)92Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Recommendations for the Hospitalized Patient New Recommendations2009 Focused Update RecommendationsClass IIb1. Intravenous inotropic drugs such as dopamine, dobutamine or milrinone might be r
225、easonable for those patients presenting withdocumented severe systolic dysfunction, low blood pressure and evidence of low cardiac output, with or without congestion, to maintain systemic perfusion and preserve end-organ performance. (Level of Evidence: C)93Jessup et al (2009) Circulation 2009, Amer
226、ican Heart Association. All rights reserved. Recommendations for the Hospitalized Patient New Recommendations2009 Focused Update RecommendationsClass III1. Use of parenteral inotropes in normotensive patients with acute decompensated HF without evidence of decreased organ perfusion is not recommende
227、d. (Level of Evidence: B)2. Routine use of invasive hemodynamic monitoring in normotensive patients with acute decompensated HF and congestion with symptomatic response to diuretics and vasodilators is not recommended.(Level of Evidence: B)94Jessup et al (2009) Circulation 2009, American Heart Assoc
228、iation. All rights reserved. Updates to Treatment of Special Populations2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass I1. The combination of a fixed-dose of isosorbide dinitrate and hydralazine to a standard medicalregimen for HF, including ACE inhibitors and beta bl
229、ockers, is recommended in order to improve outcomes for pts self-described as African Americans, with NYHA functional class III or IV HF. Othersmay benefit similarly, but this has not yet been tested. (Level ofEvidence: A)Modified recommendation (Class of recommendation elevated from IIa to I) based
230、 on A-HeFT (AfricanAmerican Heart Failure Trial) and robust secondary analyses of the original database and in anextended access study all confirm a substantial benefit realized from the addition of isosorbidedinitrate and hydralazine to evidence-based medical and device therapy for African American
231、s with HF.Treatment of Special Populations95Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. Groups of patients including a. high-risk ethnic minority groups (e.g., blacks), b. groups underrepresented in clinical trials, andc. any groups believed to be underserv
232、ed should, in the absence of specific evidence to direct otherwise, have clinical screening and therapy In a manner identical to that applied to the broader population. (Level of Evidence: B)2. Groups of patients including: a) high-risk ethnic minority groups (e.g., blacks), b) groups underrepresent
233、ed in clinical trials, and c) any groups believed to be underserved should, in the absence of specific evidence to direct otherwise, have clinical screening and therapy in a manner identical to that applied to the broader population. (Level of Evidence: B)2005 recommendation remains current in 2009
234、update.Updates to Treatment of Special Populations2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass ITreatment of Special Populations96Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. It is recommended that evidence-based therapyfor
235、HF be used in the elderly patient, with individualized consideration of the elderlypatients altered ability to metabolize or tolerate standard medications. (Level of Evidence: C)3. It is recommended that evidence-based therapy for HF be used in the elderly patient, with individualized consideration
236、of the elderlypatients altered ability to metabolize or tolerate standard medications. (Level of Evidence: C)2005 recommendation remains current in 2009update.Updates to Treatment of Special Populations2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass ITreatment of Speci
237、al Populatinos97Jessup et al (2009) Circulation 2009, American Heart Association. All rights reserved. The addition of isosorbide dinitrate and hydralazine to a standard medical regimen forHF, including ACE inhibitors and beta blockers, is reasonable and can be effective in blacks with NYHA function
238、al class III or IV HF. Others may benefit similarly, but this has not yet beentested. (Level of Evidence: A)Modified recommendation (Class of recommendationelevated from IIa to I) (see Class I, No. 1 above).Updates to Treatment of Special Populations2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IIaTreatment of Special Populatinos98
