重症心力衰竭的风险评估与处.ppt

关于诊断 ECG: all patients with HF is recommended assess cardiac rhythm and conduction detect LV hypertrophy evaluate QRS duration, especially when ejection fraction (EF) 35% detect evidence of myocardial infarction or ischemia Strength of Evidence=B chest X-ray examination: all patients with HF is recommended 快速反映心脏结构,肺淤血情况以及治疗效果 胸部X线检查:左心衰竭与感染性肺病的鉴别; 肺部CT(平扫或增强)和同位素检查:明确病变性质和诊断大面积肺栓塞; CT或经食道超声和MRI检查:主动脉夹层的诊断 Strength of Evidence=B 关于诊断 实验室检测 动脉血气分析: 判断氧合(PO2)、肺通气(PCO2)、酸碱平衡，在全部严重AHF患者水平均有一定下降； 无创性脉搏血氧和etCO2检测通常可替代动脉血气分析，但低心输出量和血管收缩性休克状态时不适用 证据水平C级 血浆B型尿钠肽(BNP) ： 急诊AHF的快速诊断方法，可对呼吸困难进行鉴别诊断 推荐诊断基线是NT-PROBNP 300pg/ml，BNP 100pg/ml以上具有诊断CHF意义 关于诊断 超声心动图 评价和检测心房、心室、瓣膜结构和功能; 诊断AMI的机械性并发症及心包疾病; 测定主动脉和肺动脉血流速率评价心功能； 评价肺动脉压和检测左心室前负荷; 超声心动图对AHF右心植入导管者测量不准确 超声心动图对评价AHF和ACS患者心脏结构和功能是必需的 　　I类推荐，证据水平C级 关于诊断 其他检查： 冠心病(不稳定心绞痛或心肌梗死)患者，冠脉造影很重要，在此基础上的介入治疗能够改善预后 I类推荐，证据水平B级 冠脉造影也推荐用于长期发作而其他检查无法解释病因的AHF患者 肺动脉漂浮导管有助于AHF的诊断与随访 AHF患者的一般监测 AHF推荐定期监测的项目 Frequency Value Specifics At least daily Weight Determine after voiding in the morning Account for possible increased food intake due to improved appetite At least daily Fluid intake and output More than daily Vital signs Including orthostatic blood pressure At least daily Signs Edema Ascites Pulmonary rales Hepatomegaly Increased jugular venous pressure Hepatojugular reflux Liver tenderness At least daily Symptoms Orthopnea Paroxysmal nocturnal dyspnea Nocturnal cough Dyspnea Fatigue At least daily Electrolytes Potassium Sodium At least daily Renal function BUN Serum creatinine Strength of Evidence = C AHF的治疗目标 ★Immediate(ED/ICU/CCU) 　Improve symptoms 　Restore oxygenation 　Improve organ perfusion and haemodynamics 　Limit cardiac/renal damage 　Minimize ICU length of stay ★Intermediate (in hospital) 　Stabilize patient and optimize treatment stratege 　Initiate appropriate (life-saving) pharmacological therapy 　Consider device therapy in appropriate patients 　Minimize hospital length of