急性心力衰竭 (AHF)的規(guī)范治療

急性心力衰竭

(AFH)的規(guī)范治療一

、概

述·

>65歲，首要的住院病因·

高死亡率：住院4%～10%,出院后1年25~30%·高再住院率：出院后1年45%再住院或死亡·新發(fā)(更高院內(nèi)死亡率、較低出院后病死率和再

住院率),慢性心力衰竭急性失代償(約占70%)CharacteristicADHEREOPTIMIZE-HFMeanage

(yr)72.473.1Male(%)48.448.4Caucasian(%)74.474.1Historyof

HF(%)75.6a88°Reduced

LVEF(%)5448.8°CAD(%)57.5a50fAtrialfibrillation(%)30.930.8Renalinsufficiency(%)30.119.6°Diabetes(%)4442fMeansystolic

BPC(mm

Hg)143.9a142.6°Systolic

BP>140

mm

Hg50650Systolic

BP<90

mm

Hg3NA人口特征Patient

Characteristics

in

2

Large

HF

Registries心衰類型HFrEFHFmrETHFpEF1癥狀±體征癥狀±體征癥狀±體征2LVEF<40%LVEF<40%~49%LVEF>50%3--1.利鈉肽水平升高b1.利鈉肽水平升高b2.至少符合以下一條附加標

準

：2.至少符合以下一條附加標

準

：a.相關的結(jié)構性心臟病(LVH

和/或LAE)a.相關的結(jié)構性心臟病(LVH

和/或LAE)b.舒張功能不全b.舒張功能不全LVEF=左室射血分數(shù)；LAE=左心房擴大；LVH=左心室肥厚a.心衰早期(尤其是HFpEF)

和用利尿治療的患者可能沒有體征；b.BNP>35pg/ml和/或NT-proBNP>125pg/ml.臨床分型：左心室射血分數(shù)Congestion

+Dry

andWarmWet

andWarmDry

andColdWet

andCold個：inceased;+:positine;sngurive;DOE:dyspneaonexertion;HJRebepatojugularneflux:JVD:jugwlarrenousdistention;PND:parexysmal

nocturnal

dyspnea;S;renriculr

flling

marmaur;SOA:shortnes

of

ain.Soune:Referencs

10,11.·

簡潔，便于快速應用FigureSIGNSOF

LOWPERFUSIONCoolextremities

Low

urineoutput

Alteredmental

statusInadequate

response

to

IVdiureticPrerenalazotemia臨床分型：血流動力學分類FailureSIGNSOFCONGESTION↑JVD+HJRPeripheraledema

S?DOE/SOAOrthopnea/PNDRalesRecentweightgain1.Hemodynamic/Clinical

State

in

Acute

HeartPerfusion+ApracticalapproachtodifferentiatingAHFS:-relies

on

systolic

BP

at

the

time

of

presentation1.Hypertensivegroup:-femalenormal

LVEF-inhospital

mortality

rate-2%(with5%mortalityand30%readmissionrateswithin60-90

days

ofdischarge)2.Normotensivegroup:-low

LVEFsignsandsymptomsofpulmonary/systemiccongestion(oedema)beforeandatthetimeofadmission(with7%mortalityand30%readmissionrateswithin60-90daysofdischarge)3.Hypotensive

group:-lowSBPlevels(≤120mm

Hg)atthetimeofpresentation-low

LVEF

history

of

HF(mortalityrate7%duringhospitalization&with

14%mortaliyand

30%

readmissionrateswithin60-90daysofdischarge)臨床分型：收縮壓·

90mmHg?-in-hospitalmortalityrate-3%臨床分級：癥狀嚴重度·NYHA

心功能分級：癥狀、運動耐力·

ACCF/AHA

分級：結(jié)構改變、癥狀·

Killip分級：心梗后急性狀態(tài)分級表現(xiàn)近期病

死率(%)I級無明顯心功能損害，肺部無啰音

6Ⅱ級輕～中度心衰，肺部啰音和S3奔馬律，及X線肺17

淤血Ⅲ級重度心衰，肺啰音超過兩肺野的50%,X線肺水腫38IV級心源性休克，伴或不伴肺水腫

81術語定義充血的癥狀/體征(左側(cè))端坐呼吸、陣發(fā)性夜間呼吸困難、肺部啰音(雙側(cè))、

外周水腫(雙側(cè))充血的癥狀/體征(右側(cè))頸靜脈擴張、外周水腫(雙側(cè))、充血性肝大、肝頸靜

脈回流征、腹水、腸道充血的癥狀低灌注的癥狀/體征臨床：四肢濕冷、尿少、神志模糊、頭暈、脈壓窄實驗室檢測：代謝性酸中毒、血乳酸增高、血肌酐增高

低灌注并不等同于低血壓，但低灌注通常伴有低血壓低血壓收縮壓90mmHg心動過緩心率<40bpm心動過速心率>120bpm異常用力呼吸呼吸頻率-25次/分，動用了輔助呼吸肌，或盡管呼吸困難呼吸頻率-8次/分低氧飽和度指脈氧02飽和度(SaO2)-90%正常的氧飽和度即不能排除低氧血癥也不能排除組織

缺氧低氧血癥動脈血液中氧分壓(PaO2)-80mmHg(<10,67kPa)(血氣

分析)低氧血癥型呼吸衰竭(1型)PaO2-60mmHg(8kPa)高碳酸血癥動脈血二氧化碳分壓(PaCO2)=45mmHg(=6kPa)(血氣

分析)高碳酸血癥型呼衰(型)PaCO2-50mmHg(≥6.65kPa)酸中毒pH<7.35血乳酸增高≥2mmol/L少尿尿量-0.5mLkgh常用術語的定義VolumeOverload·Dyspneaon

exertion·Orthopnea·Paroxysmal

nocturnaldyspnea(PND)·Early

satiety·Nausea

and

vomiting·Rales·Peripheral

edema

·↑Jugular

venouspressure

(JVP)·(+)Hepatojugularreflex

(HJR)·Hepato-/splenomegaly·AscitesHypoperfusion·Fatigue·Altered

mental

status·Narrow

pulse

pressure·Hypotension·Cool

extremities·Worsening

renal

function二、臨床表現(xiàn)：無特異性粉紅色泡沫痰Acute

decompensated

heartfailureAcute

pulmonaryoedemaIsolated

rightventricular

failureCardiogenic

shockMain

mechanismsLV

dysfunctionSodiumandwater

renal

retentionIncreasedafterloadandlor

predominantLV

diastolicdysfunctionValvularheart

diseaseRVdysfunction

and/orpre-capillaypulmonaryhypertensionSeverecardiac

dysfunctionMain

cause

ofsymptomsFluidaccumulation,increased

intraventricularpressureFluidredistributionto

thelungsand

acute

respira-tory

failureIncreasedcentral

venous

pressureand

often

sys-

temichypoperfusionSystemichypoperfusionOnsetGradual

(days)Rapid(hours)Gradualor

rapidGradualor

rapidMain

haemodynamic

abnormalitiesIncreasedLVEDPandPCWPLowornormal

cardiac

output

Normal

to

lowSBPIncreasedLVEDP

andPCWP3Normalcardiac

output

Normal

tohigh

SBPIncreasedRVEDPLowcardiac

outputLow

SBPIncreasedLVEDP

andPCWP3Lowcardiac

outputLow

SBPMain

clinicalpresentations1,46Wetandwarm

OR

Dry

and

coldWet

and

warm?Dryand

cold

ORWet

and

coldWet

and

coldMain

treatmentDiureticsInotropicagents/vasopressors(if

peripheral

hypoperfu-

sion/hypotension)Short-termMCSor

RRT

if

neededDiureticsVasodilatorsDiureticsforperipheral

congestionInotropicagents/vasopressors(ifperipheralhypo-

perfusion/hypotension)Short-termMCSorRRT

if

neededlnotropicagents/vasopressorsShort-termMCSRRTLV=leftventicula;LVEDP=leftventricularend-diastolicpresure:MCS=mechanicalcirculatorysupport;PCWP=pulmonarycapilarywedgepresureRV=nightvenuricular;

RVEDP=rightventricularend-diastolicpressure,;RRT=renalreplacementtherapy:SBP=systolicbloodpressure.Maybenormal

withlow

cardiacoutput.Wet

and

cold

profile

with

need

of

inotropes

and/or

vasopressors

may

rarely

occur.診斷流程：新發(fā)AHFPatienthistory,signs

and/orsymptoms

suspected

ofacuteHF·Eectrocardiogram·Pulse

oximetry·Echocardiography·lnitial

laboratory

investigations'·Chest

X-ray·Lungultrasound·Ocher

speific

evaluationsbNatriureticpeptidetestingAcute

heart

failure

ruled

out

Acute

heart

failure

confirmedComprehensiveechocardiography·BNP≥100

pg/mL·NT-proBNP≥300pg/mL·MR-proANP≥120

pg/mL·BNP<100

pg/mL·NT-proBNP<300pg/mL·MR-proANP<120pg/mL心臟心力衰竭急性冠脈綜合征肺栓塞心肌炎左室肥厚肥厚性或限制性心肌病

瓣膜性心臟病先天性心臟病房性和室性快速型心律失常

心臟挫傷心臟復律、ICD電擊累及心臟的外科手術肺動脈高壓非心臟高齡缺血性卒中珠網(wǎng)膜下腔出血腎功能不全肝功能不全(主要是肝硬化伴腹水)副腫瘤綜合征慢性阻塞性肺疾病嚴重感染(包括肺炎和敗血癥)重度燒傷貧血嚴重代謝和激素異常(如甲狀腺功能亢進、DM酮癥酸中毒)利鈉肽升高原因ECG:

主要是排除心衰異?！ぬ岣咝乃ピ\斷概率，特異性低·病因信息·

治療適應證正常·

心衰可能性小，敏感性89%超聲心動圖廣泛用于心衰檢查·明確診斷·提示病因·

確定適宜治療Goals·Decermineaotiology·Aleviate

symptoms·Improve

congestion

and

organperfusion·Restore

oxygenation·Limitorgandamage(cardac,

renal,hepatic,gut)·Prevengthromboembolism·Determineaetlology·Improvesignsand

symptoms·Limitorgan

damage·PreventthromboembolismIntermediate)symptoms

and

qulicyfulcongestionreliefeary

reodmisionsurvivaland

long-termProcedures.Closemonicoringof

vitalsigns

andgradingseverityofsymptoms/signs·Disposicion

decislons:ICUIcCU

ward·Inicial

treatment

to

support

drcuhtoryand

respiratory

functions(vasodlaors.vasopressors,inotropesdiuretics,supplemertalO)·Identify

aetiology

and

relevntco-morbidtiesandscart

targeted

treatment·Ttratetherapy

to

controlsymptomsandtorelievecongestion,managehypoperfusionandoptimizebloodpressure·Iriciate

andup-ticrate

disasemodfjingpharmacologicalcherapy·Considerdevicetherapy

inappropriatepatients·Iitisteandup-itratedisease

modfyirgpharmacologicaland

devicetherapy·Develop

a

care

plan

with

theidentification

of

caregivers,ascheduleforup-titrationandmonitoringofpharmacological

therapyraviewof

devicetherapy·Enrolment

in

a

diseasemanagementprogramme·

院前·

住院

·出

院三、治療·Improve

of

life·Achieve·Provent·ImprovePre-dischargeImmediatePhases疑

似AHF是有無心源性休克?否是有無呼吸衰竭?否識別與處理急性病(誘)因C急性冠脈綜合征H

高血壓急班A

嚴重心律失常M

急性機械性損傷P

急性肺栓塞I

急性感染T

心包壓塞快速穩(wěn)定病情轉(zhuǎn)運至監(jiān)護病房是立即開始針對性治療循環(huán)支持(茲物、機械)呼吸支持●常規(guī)氧療●無創(chuàng)通氣、或經(jīng)鼻高

流量濕化氧療●有創(chuàng)機械通氣初始處理否確診AHF,全面評估病情根據(jù)不同臨床類型個體化選擇治療方案快速評估與處理(起病60-120

min

)初始評估與搶救

(

含

院

前

)進

一

步綜合評估

與診斷、治療·最常見的形式，

約50%~70%·

起病緩慢，主要

是進行性液體潴

留，導致全身淤

血

。Loopdureter(Chassr)

and

consilderInotropes(Class

lb)HypopertslionandcongestonrelefConsidervasopre1ors(.e.norepinephrine)(Cas

Ib)Persisterxhypoperuslon

OrgndamiageMCS(Chass

la)ANDVORReralreoplacermenttherzpy(Chasla)ORConsiderpallatvecareADHFCongestlon/FundoverlbadHypoperfuslonLoop

durece(Clas

)Congettonreladlnecrezedluretkdoses(Clas

I)and/orcombneduretics

(Cas

ila)Dluretke

resistanceorend-stagerenalfllureRenalrepbcermenttherapy(Classlha)ORConsiserpaliathvecareMedcaltherapyoptimzation(Ciss

)急性肺水腫Oxygen

(Classl)orvenilatory

support(ClasIlLa)SBPz110mmHgSignsof

fypoperfusionLoop

duretics

(Class)and

inotropes/vasopres5or5(Clas

Ib)Loopdiuretics(Class

)andlor

vasodilators(Class

Ib)Medical

therapy

opimization(Class)ORConsiderpalliatirecareConsiderRRT.MCS.otherdevices(Cassla)Loopdiuretics(Class)Congestion

reliefEmergency

PClor

surgicaltreatment2Consider

oxygen(Class

I)or

ventiatorysupport(Cas

la)Weaning

frominotropes/vasopressorsand/or

MCSContinue

aetiologicaltreatment

ifneeded

andmedical

therapy

optimization(Class

I)IdentifyandtreatotherspecificcausesbConsidershort-term

MCS(Class

lla)MCS(Clasla)AND/ORRenalreplacement

therapy(Claslla)ORConsiderpalliative

care心源性休克ACSand/ormechanicalcomplicationsConsider

inotropes/vasopressors(ClassIlb)Improvement

of

hypoperfusionandorgandysfunctionANDANDConsdercarefulud

admnktrationParipherallypoperfuslonlpersustenttypetensianVasopressorsand/or

notropas(Cas

Ib)Relbaf

ofsgnsandsymptomsFollow-upRVADANDVORRenalraplacemer

therapyORConslderpallatvecare單純性右室衰竭ACS

with

RVIwolement

oracutepumonary

ambolsmOpumtzefluldstaus

SpecmetreatmentsMarked

congerctonLoopdurecies(Class

)3.1氧療和呼吸支持·

呼吸困難明顯伴低氧血癥(Sa02<90%

或

Pa02<60mmHg)·

常規(guī)氧療效果不滿意、或呼吸頻率>25次/min

、Sp02<90%的患者，

盡早使用NIPPV;

二氧化碳潴留者，應首先考慮BiPAP

模式·

有NIPPV

適應證而又不能良好耐受的輕~中度低氧型呼吸衰竭患者可應用

HFNC·

積極治療后病情仍繼續(xù)惡化(意識障礙，呼吸節(jié)律異常，呼吸頻率>35~40

次/min

或<6~8次/min,

自主呼吸微弱或消失，

PaC02

進行性升高或

pH

動態(tài)性下降者),應氣管插管，行有創(chuàng)機械通氣(IPPV

)·

不常規(guī)氧療：血管收縮、心輸出量下降Onoral

loop

diurotke220-40mg

Lv.furosemldeafter

2h

≥50-70

mEqLafter

6h

≥100-150mLhDoubledose

Lv.untilmaxcimumLv.dose2250-70mEqLat2-6h2100-150mLnCheck

sorumcreatinineandelectrolytes

at

leastevery

24h·T

he

maximal

daily

dose

for

i.v.loop

diuretics

is

generally

considered

furosemide

400600

mgthough

upto

1000mgmay

beconsidered

in

patientswithseverelyimpairedkidney

function.·Combination

therapy

is

the

addition

to

the

loop

diuretic

ofa

diureticwith

a

different

site

of

action,e.g.thiazidesormetolazoneoracetazolamide.3.2利尿劑：基石·Urnary

spot

sodlum·Urne

output·Urnaryspot

sodlum·Urne

outputContinue

untilcompletedecongostionRopeat

simlar

dose.v.every

12hCombinationdiuretictherapies1-2

timesdaly

oral

dose

Lv.血管加壓素受體拮抗劑·

選擇性阻斷腎小管上的精氨酸血管加壓素受體·

排水不排鈉·

EVEREST研究：

ADHF

患者短期應用托伐普坦，容量負荷加重的患者呼吸困難和水腫明顯減輕，臨床狀況明顯好轉(zhuǎn)，并使低鈉血癥患者

的血鈉正?；婚L期治療未見病死率的降低，心血管死亡及住院的復

合終點差異無統(tǒng)計學意義，但在低鈉亞組(Na+<130mEq/L),

托伐

普坦治療組的心血管病死率和心衰再住院率均低于常規(guī)治療組，且對

腎功能無不良影響?！?/p>

更適用于心衰合并低鈉血癥的患者3.3血管擴張劑·

降低靜脈張力(優(yōu)化前負荷》和動脈張力

(降低后負荷),是治療AHF

的重要部分·SBP>110mmHg,可安全使用；SBP90~110mmHg,

酌

情謹慎使用，臨床嚴密觀察；SBP<90mmHg或有癥狀性低血

壓，避免使用?！じ鶕?jù)其變化及時調(diào)整劑量，直至心衰的癥狀緩解或收縮壓降至

110

mmHg

左右。硝酸甘油與硝酸異山梨酯·擴張靜脈容量血管、降低心臟前負荷，較大劑量時可同時降低心臟后負荷，

在不減少每搏輸出量和不增加心肌耗氧的情況下減輕肺淤血。·

尤其是適用于ACS

伴心衰·

硝酸甘油從10~20

μg/min

開始，以后每5

min

遞增5~10

μg/min;硝

酸異山梨酯靜脈滴注劑量1

mg/h,根據(jù)癥狀體征可以增加到不超過10

mg/h?！げ∏榉€(wěn)定后逐步減量至停用，突然終止用藥可能會出現(xiàn)反跳現(xiàn)象。·

長期應用均可能產(chǎn)生耐藥，可采用偏心給藥?！?/p>

嚴重心動過緩(<40次/min)

或心動過速(>120次/min)

患者不宜使用

硝酸酯類藥物。硝普鈉·

均衡擴張動脈和靜脈，降低心臟前、后負荷·

適用于急性左心衰特別是伴有高血壓的患者。·通常以0.5

μg/(kg·min)開始，根據(jù)治療反應以0.5μg/(kg·min)遞增，逐漸調(diào)整，直至癥狀緩解、收縮壓由原水平下降30

mmHg

或血

壓降至110mmHg

左右為止。·

停藥應逐漸減量，以免反跳?！?/p>

療程不超過72

h,

長期用藥可引起氰化物和硫氰酸鹽中毒，合并腎功能

不全患者尤其謹慎?！?/p>

靜脈輸注時需避光。烏拉地爾·阻斷突觸后α1

受體，使外周阻力降低，激活中樞5-羥色

胺1A

受體，降低延髓心血管中樞的交感反饋調(diào)節(jié)，外周交

感張力下降。·

降低心臟負荷和肺動脈壓，改善心功能，對心率無明顯影響。·靜脈注射12.5~25

mg,

如血壓無明顯降低可重復注射，

然后以0.4~2

mg/min靜脈滴注維持，并根據(jù)血壓調(diào)整。·

作為血管擴張劑單獨使用，也可與其他血管擴張劑(如硝酸酯類)合用，還可與正性

肌力藥合用。·1.5~2μg/kg

負荷劑量緩慢靜脈注射，繼以0.0075~0.01

μg/(kg·min)持續(xù)靜脈滴注，最大可調(diào)整至0.015~0.02

μg/(kg·min);·

對于血壓較低患者，可直接以維持量靜脈滴注。重組人腦利鈉肽(rh-BNP)Hemodynamic(Balanced

vasodilation)·

Veins1·Arteries1·Coronaryarteries2Neurohumoral↓Aldosterone3Endothelin2↓Norepinephrine3

Renal1↑

DiuresisNatriuresisCardiac·Lusitropic?·Antifibrotic?·

Antiremodeling?Treatment

of

HF48VariablesClinicalstudies

in

HFDose

titration

neededHemodynamic

effectToleranceCoronary

bloodflowMyocardialischemiaUrine

outputNeurohormonesVascularresistanceSymptomaticimprovementNitroprusside++++++=↓↑N/ANesiritide+++

+++

個N/A+/-↓+Nitroglycerin+十

+

+十

+

+++個↑N/AHF=heartfailure;↓=decreased;個=increased;N/A=notavailable;+/-=resultsvanied.Comparison

Between

Clinical

Effects

of

Intravenous

Vasodilators

inT

十個

+十3.4正性肌力藥·兒茶酚胺類：正在應用β-受體阻滯劑的患者不宜應用多巴酚丁胺·磷酸二酯酶抑制劑：不受β-受體阻滯劑影響·鈣增敏劑(左西孟旦):對于缺血性心肌病、尤其是ACS

伴HFrEF

患

者有一定優(yōu)勢；在低心排血量或組織低灌注時盡早使用·洋地黃類藥：唯一既有正性肌力作用又有負性傳導作用的藥物，對于

HFrEF、

特別是伴房顫快速心室率(>110次/min)

多是首選藥物劑量劑量調(diào)整與療程β腎上腺素能激動劑

多巴胺多巴酚丁胺3型磷酸二酯酶抑制劑

米力農(nóng)奧普力農(nóng)鈣離子增敏劑左西孟旦血管收縮藥去甲腎上腺素腎上腺素<3μg·kg?1min1:激動多巴胺受體，擴張腎動脈小

劑

量

起

始

，

根

據(jù)

病

情

逐

漸

調(diào)

節(jié)

，

最

大

劑

量

為3~5

μg·kg?1·min?1:激動心臟β,受體，發(fā)揮正性肌力作用

20μg·kg?1min?1,>10μg·kg?1min?1外周血管收縮

>5μg

·kg1min1:激動心臟β,受體、外周血管α受體明顯，增加臟器缺血風險2~20μg·

kg?1min?1維持：激動β,受體一般持續(xù)用藥時間不超過3~7d負荷量25~75

μg/kg靜脈注射(>10

min),繼以0

.

375~

一

般用藥時間為3~5d0.75

μg·

kg?1·min?1靜脈點滴維持負荷量10

μg/kg靜脈注射(>5min),繼以0.1~0.3

μgkg?1min?1一般用藥時間不超過3h靜脈點滴維持，必要時可以增加至0.4

μg-kg?1min?1負荷量6~12μg/kg靜脈注射(>10min),繼以0.05~0.2

μg·kg1min1靜脈點滴維持24h0.2~1.0

μg·

kg?1min?1靜脈點滴維持

0.05~0.5μg·

kg?1min?1靜脈點滴維持低血壓時不推薦予以負荷劑量-No

response:rcconsider

mechanistic

therapyInotropicagentsGood

responseOraltherapyfuroscmide,ACEIAcuteheartfailurewithsystolicdysfunctionOxygen/CPAPFurosemide±vasodilatorClinicalevaluation(leading

to

mechanistic

therapy)Vasodilator

Vasodilator

and

/or

inotropic(NTG,nitroprusside,BNP)

(dobutamine,PDEI

or

levosimendan)Volumeloading?inotropeand/ordopamine>5μg/kg/minand/ornorepinephrinemmHgSBP<85mmHgmmHg

SBP85-100SBP>1003.5阿片類·不推薦常規(guī)使用：AHF

應用嗎啡者其機械通氣比例增多、在

ICU

時間和住院時間延長、以及病死率可能更高?！┰瓴话灿殖獬掷m(xù)低血壓、意識障礙、嚴重COPD的患

者，可小劑量(3~5

mg)嗎啡緩慢靜脈注射，注意個體化?！MI

合并不伴有低血壓的AHF,

應用阿片藥物，具有鎮(zhèn)痛、

鎮(zhèn)靜和減輕心臟負荷的多重效應，獲益明確。3.6茶堿類·

不能在AHF

中常規(guī)使用：嚴重不良反應包括低血壓與休克、

室性心律失常而猝死?！ぜ痹\難以鑒別的心源性及肺源性呼吸困難，應用茶堿也是有

益的?！?/p>

增加心肌耗氧量，ACS

患者不宜使用·

老年人與肝腎功能不全者用量酌減。3.7超濾·不建議超濾代替袢利尿劑作為AHF

患者的一線治療，而

是應用于難治性淤血、對利尿劑反應不佳的患者?！と艉喜KI、

液體復蘇無效的少尿，以及出現(xiàn)嚴重高鉀血

癥(K+≥6.5

mmol/L)、嚴重酸中毒(pH

7.1)的患

者需要使用腎臟替代治療。3.8預防血栓栓塞·住院心衰患者發(fā)生有癥狀的肺動脈栓塞和深靜脈血栓栓塞的

風險分別為非心衰患者的2.15倍和1.21倍。依諾肝素40

mg(1

次/d),

深靜脈血栓風險從14

.5%降低到4%。·伴發(fā)房顫、CHA2DS2-VASc

評分男性≥2分或女性≥3分

的心衰患者，應接受維生素K

拮抗劑(華法林)或新型口服

抗凝藥

(NOAC)

治療疑似心衰患者評估血流動力學特征存在充血癥狀?是(占急性心衰的95%)“濕”患者適當?shù)耐庵芄嘧?是“干冷”患者

翟注不足，低血容量“濕暖”悲者SBP升高或正常“濕冷”患者，BSP是否90

mllg心面性體液諧面充血表現(xiàn)為主導正性肌力藥扳抗時考慮升壓藥·利尿劑血管擴張劑··A

Proposed

ModelforInitialAssessmentand

ManagementofAcute

Heart

FailureSyndromesMihaiChaorzhiad,MD二DagenBranmvald,MDClinical

severityDenovo

orchronic

BloodpressureheartfailureComorbidites

Heart

rateandrhythmPrecipitantsGheoytadheandtbraumaold.JMMA2011:306:17023.4治療選擇血管內(nèi)體液再分布，

高血壓表現(xiàn)為主導·血管擴張劑·和尿劑·血管擴張劑·利尿劑·抵抗時考慮使用

正性肌力藥利尿劑(灌注校正后)

看對藥物無應善?？墒褂枚Y械苗環(huán)支持·擴容·若仍灌注不足，考

慮便用正性肌力藥是“千暖”磨者

適當蓮注否(占急性心衰的5%)超濾(如利屎抵航)是

否調(diào)節(jié)口服

泊療“干”患者·

···否否Initial

EDcontact02

4

681224Time(hours)frominitialED

physician

evaluationReassessresponse

totherapyAddadditionaltherapyas

neededTransfer

outof

EDor

Observation

UnitInitiate

IVADHFtherapyDiuretic(mild-modvolumeoverload)Diuretic+IVvasodilators(mod-sevvolumeoverload)Inotrope

(iflowCO

state)5急診管理：Determine

patientdispositionAdmit(ICUvs.observationunitvs.floor)ordischarge

homeAssessresponseto

initialtherapyAddadditionaltherapyas

neededEstablisADHFdiagnosis33,046

Hospitaization

Episodes

in

Derivation

CohortBUN<43mgdBUN243mg/d8.98%CrudeMortality(647/7202)24,933

Hospitalization

Episodes