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周京敏教授：2022 AHA/ACC/HFSA 心衰管理指南解读 | OCC 2022

放大字体  缩小字体 发布日期：2022-06-01  来源：丁香园  浏览次数：18484
核心提示：《2022 AHA/ACC/HFSA 心衰管理指南》发布以来得到国内很多专家的好评，该指南反映了近段时间心衰管理的综合进展，从预防到治疗进行了全面更新。新版指南重新定义

portant; overflow-wrap: break-word !important;">《2022 AHA/ACC/HFSA 心衰管理指南》发布以来得到国内很多专家的好评，该指南反映了近段时间心衰管理的综合进展，从预防到治疗进行了全面更新。新版指南重新定义了心力衰竭的分期和分类，全面更新了管理策略及治疗方案，更加强调心衰预防以及心衰专业团队的管理协调。
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portant; overflow-wrap: break-word !important;">在第十六届东方心脏病学会议，上海心血管病年会分会场，来自复旦大学附属中山医院的周京敏教授就「2022 AHA/ACC/HFSA 心衰管理指南」相关内容进行解读，现梳理重点内容如下。
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portant; overflow-wrap: break-word !important;">01. 心力衰竭的分期、A、B 期的建议
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portant; overflow-wrap: break-word !important;">对于有心衰风险（A 期）或心衰前期（B 期）的人来说，一级预防很重要。新版指南对 HF 分期进行了修订，并提出了两个新的术语来分别强调 A 期（「有心衰风险」）和 B 期（「心衰前期」）患者的风险预防。
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portant; overflow-wrap: break-word !important;">心衰风险期（Stage A）和心衰前期（Stage B）的推荐
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portant; overflow-wrap: break-word !important;">02. 心衰 C、D 期基于射血分数的分类及建议
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portant; overflow-wrap: break-word !important;">心衰 C 期的动态演变的过程
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portant; overflow-wrap: break-word !important;">疑似心衰患者的诊断流程
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portant; overflow-wrap: break-word !important;">更新心力衰竭的分类与再分类：结合 EF 动态演变过程后新增 HFimpEF
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background-color: rgb(238, 237, 235) !important; background-size: 22px !important; background-position: center center !important; background-repeat: no-repeat !important; vertical-align: bottom; height: 171.511px !important; width: 364px !important;" />
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portant; overflow-wrap: break-word !important;">* HFimpEF：射血分数改善的心衰
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portant; overflow-wrap: break-word !important;">* 定义：既往 LVEF ≤ 40%，当前一次随访测定 LVEF > 40%；
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portant; overflow-wrap: break-word !important;">* HFrEF 患者 EF 值改善至超过 40%，即使后续的 EF 值超过了 50%，也不代表其射血分数恢复或转变为 HFpEF，其仍然只是 HFrEF 的一种亚型；
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portant; overflow-wrap: break-word !important;">* 心力衰竭患者 EF 即使改善，并不代表整个心肌完全恢复或左室功能恢复正常，在大多数患者中心脏结构异常仍然持续存在。
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portant; overflow-wrap: break-word !important;">初始及后续评估相关建议
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portant; overflow-wrap: break-word !important;">C 期治疗：HFrEF 的 GDMT 增加 SGLT2i
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portant; overflow-wrap: break-word !important;">图片
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portant; overflow-wrap: break-word !important;">HFrEF C、D 期治疗流程图
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portant; overflow-wrap: break-word !important;">图片
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portant; overflow-wrap: break-word !important;">C 期 HFrEF 患者的其他药物治疗
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portant; overflow-wrap: break-word !important;">HFimpEF 的治疗建议
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portant; overflow-wrap: break-word !important;">LVEF 改变不是单向的，既可以增加，也可以减少。其增减依赖于潜在病因、疾病持续时间，是否坚持 GDMT 以及其它造成心肌毒性的因素等。重要的是，对于许多使用 GDMT 将 EF 改善至正常范围的患者，停用药物治疗后 EF 会降低。
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portant; overflow-wrap: break-word !important;">ICD 和 CRT
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portant; overflow-wrap: break-word !important;">图片
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portant; overflow-wrap: break-word !important;">心肌病或 HFrEF 患者选择 CRT 流程建议
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portant; overflow-wrap: break-word !important;">图片
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portant; overflow-wrap: break-word !important;">GDMT 优化后可考虑的其他非药物治疗
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portant; overflow-wrap: break-word !important;">图片
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portant; overflow-wrap: break-word !important;">HFmrEF 的治疗建议
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portant; overflow-wrap: break-word !important;">图片
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portant; overflow-wrap: break-word !important;">HFpEF 的治疗建议
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portant; overflow-wrap: break-word !important;">心脏淀粉样变的诊断和治疗
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portant; overflow-wrap: break-word !important;">心衰 D 期的相关治疗建议
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portant; overflow-wrap: break-word !important;">机械循环支持和心脏移植
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portant; overflow-wrap: break-word !important;">03. 急性失代偿心衰住院患者的建议
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portant; overflow-wrap: break-word !important;">急性失代偿性心衰住院患者的评估
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portant; overflow-wrap: break-word !important;">图片
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portant; overflow-wrap: break-word !important;">住院期间 GDMT 的目标，维持和优化
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portant; overflow-wrap: break-word !important;">图片
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portant; overflow-wrap: break-word !important;">利尿剂和血管舒张药物的应用
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portant; overflow-wrap: break-word !important;">VTE 的预防、心源性休克的评估和管理
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portant; overflow-wrap: break-word !important;">04. 合并症的管理
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portant; overflow-wrap: break-word !important;">有特定心衰合并症的患者的治疗建议
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portant; overflow-wrap: break-word !important;">图片
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portant; overflow-wrap: break-word !important;">心衰患者合并症的管理
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portant; overflow-wrap: break-word !important;">合并房颤的管理建议
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portant; overflow-wrap: break-word !important;">肿瘤心脏病学建议
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portant; overflow-wrap: break-word !important;">总 结
portant; overflow-wrap: break-word !important;">
portant; overflow-wrap: break-word !important;">最后，周教授总结了《2022 AHA/ACC/HFSA 心衰指南》10 条更新要点：
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portant; overflow-wrap: break-word !important;">① 对于射血分数降低型心力衰竭（HFrEF），指南指导的药物治疗（GDMT）目前包括 4 种药物类别，其中新增钠-葡萄糖共转运蛋白-2 抑制剂（SGLT2i）。
portant; overflow-wrap: break-word !important;">
portant; overflow-wrap: break-word !important;">② 对于射血分数轻度降低型心力衰竭（HFmrEF），SGLT2i 作为新治疗药物推荐（2a 推荐），而 ARNi、ACEi、ARB、MRA 和 β 受体阻滞剂的推荐级别较低（2b 推荐）。
portant; overflow-wrap: break-word !important;">
portant; overflow-wrap: break-word !important;">③ 对于射血分数保留型心力衰竭（HFpEF），新增推荐 SGLT2i（2a）、MRAs（2b）和 ARNi（2b）。之前的几项建议推荐级别也进行了更新：包括高血压治疗（1）、心房颤动治疗（2a）、ARB 使用（2b），以及避免常规使用硝酸盐或磷酸二酯酶-5 抑制剂（3-无益处）。
portant; overflow-wrap: break-word !important;">
portant; overflow-wrap: break-word !important;">④ LVEF 改善的心力衰竭（HFimpEF）指的是既往诊断 HFrEF 而现在 LVEF > 40% 的患者。这些患者应继续进行 HFrEF 治疗。
portant; overflow-wrap: break-word !important;">
portant; overflow-wrap: break-word !important;">⑤ 对已发表的干预措施进行高质量的成本效益研究，为治疗建议的选择提供价值声明。
portant; overflow-wrap: break-word !important;">
portant; overflow-wrap: break-word !important;">⑥ 心肌淀粉样变的治疗建议更新，包括血清和尿液单克隆轻链筛查、骨扫描、基因测序、四聚体稳定剂治疗和抗凝治疗。
portant; overflow-wrap: break-word !important;">
portant; overflow-wrap: break-word !important;">⑦ 对于 LVEF > 40% 的患者，支持充盈压增加的临床证据对于 HF 的诊断很重要，充盈压增加的证据可以从无创（如利钠肽、舒张功能的影像学）或有创检查（如血流动力学检测）中获得。
portant; overflow-wrap: break-word !important;">
portant; overflow-wrap: break-word !important;">⑧ 希望延长生存期的晚期心衰患者应转诊至心衰专业团队。心衰专业团队审查心衰管理方案，评估终末期心衰治疗手段，并在符合患者护理目标的情况下使用姑息治疗，包括姑息性正性肌力治疗。
portant; overflow-wrap: break-word !important;">
portant; overflow-wrap: break-word !important;">⑨ 对于有心衰风险（A 期）或心衰前期（B 期）的人来说，一级预防很重要。新版指南对 HF 分期进行了修订，并提出了两个新的术语来分别强调 A 期（「at-risk」for HF）和 B 期（pre-HF）患者的风险预防。
portant; overflow-wrap: break-word !important;">
portant; overflow-wrap: break-word !important;">⑩ 对心力衰竭合并症如铁缺乏、贫血、高血压、睡眠障碍、2 型糖尿病、心房颤动、冠状动脉疾病和恶性肿瘤患者做出了指南推荐。
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