1、jessup et al (2009) circulation 2009, american heart association. all rights reserved. 12009 focused update:acc/aha guidelines for the diagnosis and management of heart failure in adultsjessup et al (2009) circulation 2009, american heart association. all rights reserved. 22009 focused update:acc/ah

2、a 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, chai

3、r; 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 stev

4、enson, md, facc, faha; clyde w. yancy, md, facc, fahajessup et al (2009) circulation 2009, american heart association. all rights reserved. 3jessup et al (2009) circulation 2009, american heart association. all rights reserved. 4stages 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.jessup et al (2009) circulation 2009, american heart ass

6、ociation. all rights reserved. 5updates 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

7、with 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 diso

8、rders 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 failurejessup et al (2009) circulation 2009, american heart a

9、ssociation. all rights reserved. 6updates 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 o

10、r “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 patien

11、ts 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 failurejessup et al (2009) circulation 2009, american heart association. all rights reserved. 7updates to initial and serial

12、clinical 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

13、evidence: 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 patient

14、s with heart failurejessup et al (2009) circulation 2009, american heart association. all rights reserved. 8updates to initial and serial clinical assessments of patients presenting with heart failure2005 guideline recommendations2009 focused update recommendationscommentsclass iinitial examination

15、of 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

16、patients 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 failurejessup et al (

17、2009) circulation 2009, american heart association. all rights reserved. 9updates to initial and serial clinical assessments of patients presenting with heart failure2005 guideline recommendations2009 focused update recommendationscommentsclass iinitial laboratory evaluation of patients presenting w

18、ith 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 laborat

19、ory 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. (leve

20、l of evidence: c)2005 recommendation remains current in the 2009 update.recommendations for the initial clinical assessment of patients with heart failurejessup et al (2009) circulation 2009, american heart association. all rights reserved. 10updates to initial and serial clinical assessments of pat

21、ients 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. twel

22、ve-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 failurejessup et al

23、(2009) circulation 2009, american heart association. all rights reserved. 11updates to initial and serial clinical assessments of patients presenting with heart failure2005 guideline recommendations2009 focused update recommendationscommentsclass itwo-dimensional echo-cardiography with doppler shoul

24、d 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-cardiograp

25、hy 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

26、2009 update.recommendations for the initial clinical assessment of patients with heart failurejessup et al (2009) circulation 2009, american heart association. all rights reserved. 12updates to initial and serial clinical assessments of patients presenting with heart failure2005 guideline recommenda

27、tions2009 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 perf

28、ormed 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 fai

29、lurejessup et al (2009) circulation 2009, american heart association. all rights reserved. 13updates to initial and serial clinical assessments of patients presenting with heart failure2005 guideline recommendations2009 focused update recommendationscommentsclass iiacoronary arteriography should be

30、performed 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

31、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 failurejessup et al (2009) circulation 2009, american heart association. all rights reserve

32、d. 14updates 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 cardia

33、c 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 hadeval

34、uation 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 failurejessup et al (2009) circulation 2009, americ

35、an heart association. all rights reserved. 15updates 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

36、patients 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 co

37、ronary 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 failurejessup et al (2009) circulation 200

38、9, american heart association. all rights reserved. 16updates 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

39、exchange 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/

40、or 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 assess

41、ment of patients with heart failurejessup et al (2009) circulation 2009, american heart association. all rights reserved. 17updates to initial and serial clinical assessments of patients presenting with heart failure2005 guideline recommendations2009 focused update recommendationscommentsclass iiama

42、ximal 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 exchan

43、ge 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 failu

44、rejessup et al (2009) circulation 2009, american heart association. all rights reserved. 18updates to initial and serial clinical assessments of patients presenting with heart failure2005 guideline recommendations2009 focused update recommendationscommentsclass iiascreening for hemo-chromatosis, sle

45、ep-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:

46、c)2005 recommendation remains current in the 2009 update.recommendations for the initial clinical assessment of patients with heart failurejessup et al (2009) circulation 2009, american heart association. all rights reserved. 19updates to initial and serial clinical assessments of patients presentin

47、g 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 clini

49、cal assessment of patients with heart failurejessup et al (2009) circulation 2009, american heart association. all rights reserved. 20updates to initial and serial clinical assessments of patients presenting with heart failure2005 guideline recommendations2009 focused update recommendationscommentsc

50、lass 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 failurejessup et al (2009) circulation 2009, american heart association. all rights reserved. 21updates to initial and serial clinical assessments o

52、f 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. me

53、asurement 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)mo

54、dified 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 failurejessup et al (2009) circulation 2009, american heart association. all rig

55、hts reserved. 22updates 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 a

56、nd 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

57、 of patients with heart failurejessup et al (2009) circulation 2009, american heart association. all rights reserved. 23updates to initial and serial clinical assessments of patients presenting with heart failure2005 guideline recommendations2009 focused update recommendationscommentsclass iibholter

58、 monitoring 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 patientspresen

59、ting 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 failurejessup et al (2009) ci

60、rculation 2009, american heart association. all rights reserved. 24updates 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 routin