2009 ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice GuidelinesDeveloped in Collaboration With:International Society for Heart and Lung Transplantation1第1页，共52页。Initial Clinical Assessment of Patients Presenting With Heart Failure2第2页，共52页。Recommendations for the Initial Clinical Assessment of Patients Presenting With Heart FailureIdentifying and Evaluating Noncardiac Disorders or BehaviorsA thorough history and physical examination should be obtained/performed in patients presenting with heart failure (HF) to identify cardiac and noncardiac disorders or behaviors that might cause or accelerate the development or progression of HF. A careful history of current and past use of alcohol, illicit drugs, current or past standard or “alternative therapies,” and chemotherapy drugs should be obtained from patients presenting with HF. NO CHANGENO CHANGE3第3页，共52页。Initial Assessment and Examination of Patients With HFIn patients presenting with HF, initial assessment should be made of the patients ability to perform routine and desired activities of daily living. Initial examination of patients presenting with HF should include assessment of the patients volume status, orthostatic blood pressure changes, measurement of weight and height, and calculation of body mass index. NO CHANGENO CHANGERecommendations for the Initial Clinical Assessment of Patients Presenting With Heart Failure 4第4页，共52页。Initial Laboratory EvaluationInitial laboratory evaluation of patients presenting with 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. Twelve-lead electrocardiogram and chest radiograph (posterior-anterior and lateral) should be performed initially in all patients presenting with HF. NO CHANGENO CHANGERecommendations for the Initial Clinical Assessment of Patients Presenting With Heart Failure 5第5页，共52页。Two-Dimensional EchocardiographyRecommendations for the Initial Clinical Assessment of Patients Presenting With Heart Failure Two-dimensional echocardiography with Doppler should be performed during initial evaluation of patients presenting with HF to assess LVEF, left ventricle size, wall thickness, and valve function. Radionuclide ventriculography can be performed to assess LVEF and volumes. Coronary arteriography should be performed in patients presenting with HF who have angina or significant ischemia unless the patient is not eligible for revascularization of any kind. NO CHANGENO CHANGECoronary Revascularization6第6页，共52页。Coronary RevascularizationRecommendations for the Initial Clinical Assessment of Patients Presenting With Heart Failure Coronary arteriography is reasonable for patients presenting with HF who have known or suspected coronary artery disease but who do not have angina unless the patient is not eligible for revascularization of any kind.I IIa IIb IIINO CHANGECoronary arteriography is reasonable for patients presenting with HF who have chest pain that may or may not be of cardiac origin who have not had evaluation of their coronary anatomy and who have no contraindications to coronary revascularizations. I IIa IIb IIINO CHANGE7第7页，共52页。Noninvasive Imaging and Exercise TestingNoninvasive imaging to detect myocardial ischemia and viability is reasonable in patients presenting with HF who have known coronary artery disease and no angina unless the patient is not eligible for revascularization of any kind.I I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIIIMaximal exercise testing with or without measurement of respiratory gas 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 the contribution of HF is uncertain.I IIa IIb IIIDetecting Myocardial IschemiaMaximal Exercise TestingNO CHANGENO CHANGERecommendations for the Initial Clinical Assessment of Patients Presenting With Heart Failure 8第8页，共52页。Initial Clinical Assessment of Patients Presenting With Heart FailureEndomyocardial BiopsyEndomyocardial biopsy can be useful in patients presenting with HF when a specific diagnosis is suspected that would influence therapy.I IIa IIb IIINO CHANGENO CHANGEEndomyocardial biopsy should not be performed in the routine evaluation of patients with HF.9第9页，共52页。Initial Clinical Assessment of Patients Presenting With Heart Failure Measurement of BNP and Noninvasive ImagingMeasurement of natriuretic peptides (B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proNBP) can be useful in the evaluation of patients presenting in the urgent care setting in whom the clinical diagnosis of HF is uncertain. Measurement of natriuretic peptides (BMP and NT-proBNP) can be helpful in risk stratification.Noninvasive imaging may be considered to define the likelihood of coronary artery disease in patients with HF and LV dysfunction. I I IIIaIIaIIaIIbIIbIIbIIIIIIIIII I IIIaIIaIIaIIbIIbIIbIIIIIIIIII I IIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIINO CHANGEModified10第10页，共52页。Documenting Ventricular Tachycardia InducibilityInitial Clinical Assessment of Patients Presenting With Heart Failure Holter monitoring might be considered in patients presenting with HF who have a history of MI and are being considered for electrophysiologic study to document ventricular tachycardia inducibility.NO CHANGERoutine use of signal-averaged electrocardiography is not recommended for the evaluation of patients presenting with HF.NO CHANGE11第11页，共52页。Measuring Circulating Levels of NeurohormonesRoutine measurement of circulating levels of neurohormones (e.g., norepinephrine or endothelin) is not recommended for patients presenting with HF. NO CHANGEInitial Clinical Assessment of Patients Presenting With Heart Failure 12第12页，共52页。 Patients With Reduced Left Ventricular Ejection Fraction13第13页，共52页。Patients With Reduced Left Ventricular Ejection FractionMeasures listed as Class I recommendations for patients in Stages A and B are also appropriate for patients in Stage C. NO CHANGEDiuretics and salt restriction are indicated in patients with current or prior symptoms of HF and reduced LVEF who have evidence of fluid retention.NO CHANGEMeasuring LVEF14第14页，共52页。Patients With Reduced Left Ventricular Ejection Fraction Angiotensin-converting enzyme (ACE) inhibitors are recommended for all patients with current or prior symptoms of HF and reduced LVEF, unless contraindicated .NO CHANGEUse of 1 of the 3 beta blockers proven to reduce mortality (i.e., bisoprolol, carvedilol, and sustained release metoprolol succinate) is recommended for all stable patients with current or prior symptoms of HF and reduced LVEF, unless contraindicated. ModifiedMeasuring LVEF15第15页，共52页。Patients With Reduced Left Ventricular Ejection FractionNO CHANGEAngiotensin II receptor blockers are recommended in-patient with current or prior symptoms of HF and reduced LVEF who are ACE-inhibitor intolerantNO CHANGEDrugs known to adversely affect the clinical status of patients with current or prior symptoms of HF and reduced LVEF should be avoided or withdrawn whenever possible (e.g., nonsteroidal anti-inflammatory drugs, most antiarrhythmic drugs, and most calcium channel blocking drugs).Angiotensin ll Receptor Blockers16第16页，共52页。Patients With Reduced Left Ventricular Ejection Fraction A cardioverter-defibrillator (ICD) is recommended as secondary prevention to prolong survival in patients with current or prior symptoms of HF and reduced LVEF who have a history of cardiac arrest, ventricular fibrillation, or hemodynamically destabilizing ventricular tachycardia.NO CHANGESecondary Prevention: Implantable Cardioverter-Defibrillator17第17页，共52页。Patients With Reduced Left Ventricular Ejection Fraction ICD therapy is recommended for primary prevention of sudden cardiac death to reduce total mortality in patients with nonischemic dilated cardiomyopathy or ischemic heart disease at least 40 days post-myocardial infarction, have an LVEF less than or equal to 35%, with NYHA functional class II or III symptoms while receiving chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 year.ModifiedPrimary Prevention: Implantable Cardioverter-Defibrillator18第18页，共52页。Patients With Reduced Left Ventricular Ejection Fraction Patients with LVEF less than or equal to 35%, sinus rhythm, and NYHA functional class III or ambulatory class IV symptoms despite recommended, optimal medical therapy and who have cardiac dyssynchrony, which is currently defined as a QRS duration greater than or equal to 0.12 seconds, should receive cardiac resynchronization therapy, with or without an ICD, unless contraindicated.Clarified RecResynchronization Therapy19第19页，共52页。Patients With Reduced Left Ventricular Ejection FractionAddition of an aldosterone antagonist is recommended in selected patients with moderately severe to severe symptoms of HF and reduced LVEF who can be carefully monitored for preserved renal function and normal potassium concentration. Creatinine 2.5 mg/dL or less in men or 2.0 mg/dL or less in women and potassium should be less than 5.0 mEq/L. Under circumstances where monitoring for hyperkalemia or renal dysfunction is not feasible, the risks may outweigh the benefits of aldosterone antagonists.NO CHANGEThe Risks of Aldosterone Antagonists20第20页，共52页。Patients With Reduced Left Ventricular Ejection FractionRecommendations for Hydralazine and NitratesThe combination of hydralazine and nitrates is recommended to improve outcomes for patients self-described as African-Americans, with moderate-severe symptoms on optimal therapy with ACE inhibitors, beta blockers, and diuretics.NewThe addition of a combination of hydralazine and a nitrate is reasonable for patients with reduced LVEF who are already taking an ACE inhibitor and beta blocker for symptomatic HF and who have persistent symptoms.I I I IIaIIaIIa IIbIIbIIb IIIIIIIIII I I IIaIIaIIa IIbIIbIIb IIIIIIIIII I I IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIIINO CHANGE21第21页，共52页。Patients With Reduced Left Ventricular Ejection FractionRecommendations for Atrial Fibrillation and Heart FailureIt is reasonable to treat patients with atrial fibrillation and HF with a strategy to maintain sinus rhythm or with a strategy to control ventricular rate alone.I I IIIaIIaIIaIIbIIbIIbIIIIIIIIII I IIIaIIaIIaIIbIIbIIbIIIIIIIIII I IIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIINew22第22页，共52页。Patients With Reduced Left Ventricular Ejection Fraction Measurement of Respiratory Gas Exchange Maximal exercise testing with or without measurement of respiratory gas exchange is reasonable to facilitate prescription of an appropriate exercise program for patients presenting with HF.Angiotensin II receptor blockers are reasonable to use as alternatives to ACE inhibitors as first-line therapy for patients with mild to moderate HF and reduced LVEF, especially for patients already taking ARBs for other indications.NO CHANGEI IIa IIb IIII I IIIaIIaIIaIIbIIbIIbIIIIIIIIII I IIIaIIaIIaIIbIIbIIbIIIIIIIIII I IIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIModifiedAngiotensin II receptor blockers23第23页，共52页。Patients With Reduced Left Ventricular Ejection Fraction Digitalis can be beneficial in patients with current or prior symptoms of HF and reduced LVEF to decrease hospitalizations for HF.NO CHANGEI I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIIIThe Benefits of Digitalis24第24页，共52页。Patients With Reduced Left Ventricular Ejection FractionImplantable Cardioverter-Defibrillator in Pts With Low LVEF For patients who have LVEF less than or equal to 35%, a QRS duration of greater than or equal to 0.12 seconds, and atrial fibrillation, cardiac resynchronization therapy with or without an ICD is reasonable for the treatment of NYHA functional class III or ambulatory class IV heart failure symptoms on optimal recommended medical therapy.NewI I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIIIFor patients with LVEF of less than or equal to 35% with NYHA functional class III or ambulatory class IV symptoms who are receiving optimal recommended medical therapy and who have frequent dependence on ventricular pacing, cardiac resynchronization therapy is reasonable.NewI IIa IIb III25第25页，共52页。Patients With Reduced Left Ventricular Ejection FractionARB and Conventional TherapyThe addition of an ARB may be considered in persistently symptomatic patients with reduced LVEF who are already being treated with conventional therapy.NO CHANGERoutine combined use of an ACE inhibitor, ARB, and aldosterone antagonist is not recommended for patients with current or prior symptoms of HF and reduced LVEF.NO CHANGEI I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIIICalcium channel blocking drugs are not indicated as routine treatment for HF in patients with current or prior symptoms of HF and reduced LVEF.NO CHANGEI I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIIICalcium Channel Blocking Drugs26第26页，共52页。Patients With Reduced Left Ventricular Ejection FractionLong-term use of an infusion of a positive inotropic drug may be harmful and is not recommended for patients with current or prior symptoms of HF and reduced LVEF, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment.NO CHANGEInfusion of Positive Inotropic Drugs 27第27页，共52页。Patients With Reduced Left Ventricular Ejection FractionHormonal Therapies Hormonal therapies other than to replete deficiencies are not recommended and may be harmful to patients with current or prior symptoms of HF and reduced LVEF. NO CHANGENutritional Supplements Use of nutritional supplements as treatment for HF is not indicated in patients with current or prior symptoms of HF and reduced LVEF.NO CHANGE28第28页，共52页。Patients With Heart Failure and Normal Left Ventricular Ejection Fraction29第29页，共52页。Patients With Heart Failure and Normal Left Ventricular Ejection FractionNormal Left Ventricular Ejection Fraction Physicians should control systolic and diastolic hypertension in patients with HF and normal LVEF, in accordance with published guidelines.NO CHANGEPhysicians should control ventricular rate in patients with HF and normal LVEF and atrial fibrillation.NO CHANGEPhysicians should use diuretics to control pulmonary congestion and peripheral edema in patients with HF and normal LVEF.NO CHANGE30第30页，共52页。Patients With Heart Failure and Normal Left Ventricular Ejection FractionNormal Left Ventricular Ejection Fraction Coronary revascularization is reasonable in patients with HF and normal LVEF and coronary artery disease in whom symptomatic or demonstrable myocardial ischemia is judged to be having an adverse effect on cardiac function.NO CHANGEI IIa IIb III31第31页，共52页。Patients With Heart Failure and Normal Left Ventricular Ejection FractionNormal Left Ventricular Ejection Fraction Restoration and maintenance of sinus rhythm in patients with atrial fibrillation and HF and normal LVEF might be useful to improve symptoms.NO CHANGEThe use of beta-adrenergic blocking agents, ACEIs, ARBs, or calcium antagonists in patients with HF and normal LVEF and controlled hypertension might be effective to minimize symptoms of HF.NO CHANGEThe usefulness of digitalis to minimize symptoms of HF in patients with HF and normal LVEF is not well established.NO CHANGE32第32页，共52页。Recommendations for the Hospitalized PatientNew Recommendations33第33页，共52页。The diagnosis of heart failure is primarily based on signs and symptoms derived from a thorough history and physical exam. Clinicians should determine the following:a. adequacy of systemic perfusion;b. volume status;c. the contribution of precipitating factors and/or co-morbidities d. if the heart failure is new onset or an exacerbation of chronic disease; ande. whether it is associated with preserved normal or reduced ejection fraction.Chest radiographs, electrocardiogram and echocardiography are key tests in this assessment.The Hospitalized PatientNewDiagnosis of HFNew34第34页，共52页。The Hospitalized Patient Concentrations of BNP or NT-proBNP should be measured in patients 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 be considered a stand-alone test.NewAcute coronary syndrome precipitating HF hospitalization should be promptly identified by electrocardiogram and cardiac troponin testing, and treated, as appropriate to the overall condition and prognosis of the patient.NewPatients Being Evaluated for Dyspnea35第35页，共52页。The Hospitalized Patient 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 hypertension atrial and ventricular arrhythmias infections pulmonary emboli renal failure medical or dietary noncomplianceNewPrecipitating Factors for Acute HF 36第36页，共52页。The Hospitalized Patient Oxygen Therapy and Rapid Intervention Oxygen therapy should be administered to relieve symptoms related to hypoxemia. 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 perfusion.NewNew37第37页，共52页。The Hospitalized Patient Treatment With Intravenous Loop DiureticsPatients admitted with HF and with evidence of significant fluid overload should be treated with intravenous loop diuretics. Therapy should begin in the emergency department or outpatient clinic without delay, as early intervention may be associated with better outcomes for patients hospitalized with decompensated HFIf patients are already receiving loop diuretic therapy, the initial intravenous 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. NewNew38第38页，共52页。The Hospitalized Patient Monitoring and Measuring Fluid Intake and OutputEffect of HF treatment should be monitored with careful measurement of fluid intake and output; vital signs; 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 intravenous diuretics or active titration of HF medications.New39第39页，共52页。The Hospitalized PatientIntensifying the Diuretic Regimen NewWhen diuresis is inadequate to relieve congestion, as evidenced by clinical evaluation, the diuretic regimen should be intensified :a. higher doses of loop diuretics;b. addition of a second diuretic (such as metolazone, spironolactone or intravenous chlorthiazide) orc. continuous infusion of a loop diuretic.40第40页，共52页。Invasive hemodynamic monitoring should be performed to guide therapy in patients who are in respiratory distress or with clinical evidence of impaired perfusion in whom the adequacy or excess of intracardiac filling pressures cannot be determined from clinical assessment. In patients with clinical evidence of hypotension associated with hypoperfusion and obvious evidence of elevated cardiac filling pressures (e.g., elevated jugular venous pressure; elevated pulmonary artery wedge pressure), intravenous inotropic or vasopressor drugs should be administered to maintain systemic perfusion and preserve end-organ performance while more definitive therapy is considered. The Hospitalized Patient Preserving End-Organ Performance NewNew41第41页，共52页。The Hospitalized Patient Reconciling and Adjusting MedicationsMedications should be reconciled in every patient and adjusted as appropriate on admission to and discharge from the hospital. In patients with reduced ejection fraction experiencing a symptomatic exacerbation of HF requiring hospitalization during chronic maintenance treatment with oral therapies known to improve outcomes, particularly ACE inhibitors or ARBs and beta-blocker therapy, it is recommended that these therapies be continued in most patients in the absence of hemodynamic instability or contraindications.NewNew42第42页，共52页。The Hospitalized PatientIn patients hospitalized with HF with reduced ejection fraction not treated with oral therapies known to improve outcomes, particularly ACE inhibitors or ARBs and beta-blocker therapy, initiation of these therapies is recommended in stable patients prior to hospital discharge. Initiation of beta-blocker therapy is recommended after optimization of volume status and successful discontinuation of intravenous diuretics, vasodilators, and inotropic agents. Beta-blocker therapy should be initiated at a low dose and only in stable patients. Particular caution should be used when initiating beta-blockers in patients who have required inotropes during their hospital course. NewNew43第43页，共52页。The Hospitalized PatientIn all patients hospitalized with HF, both with preserved and low ejection fraction, transition should be made from intravenous to oral diuretic therapy with careful attention to oral diuretic dosing and monitoring of electrolytes. With all medication changes, the patient should be monitored for supine and upright hypotension and worsening renal function and HF signs/symptoms.New44第44页，共52页。The Hospitalized PatientUrgent Cardiac Catheterization and RevascularizationWhen patients present with acute HF and known or suspected acute myocardial ischemia due to occlusive coronary disease, especially when there are signs and symptoms of inadequate systemic perfusion, urgent cardiac catheterization and revascularization is reasonable where it is likely to prolong meaningful survival. I IIa IIb IIINew45第45页，共52页。The Hospitalized Patient Severe Symptomatic Fluid OverloadIn patients with evidence of severely symptomatic fluid overload in the absence of systemic hypotension, vasodilators such as intravenous nitroglycerin, nitroprusside or neseritide can be beneficial when added to diuretics and/or in those who do not respond to diuretics alone.NewI IIa IIb III46第46页，共52页。Invasive hemodynamic monitoring can be 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 systemic orpulmonary vascular resistances are uncertain;b. whose systolic pressure remains low, pr is associated with symptoms, despite initialtherapy;c. whose renal function is worsening with therapy;d. who require parenteral vasoactive agents; ore. who may need consideration for advanced device therapy or transplantation. The Hospitalized Patient Invasive Hemodynamic Monitoring I IIa IIb IIINew47第47页，共52页。Ultrafiltration is reasonable for patients with refractory congestion not responding to medical therapy.The Hospitalized Patient Intravenous inotropic drugs such as dopamine, dobutamine or milrinone might be reasonable for those patients presenting with documented 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. Ultrafiltration and Intravenous Inoptropic DrugsNewNewI I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII48第48页，共52页。The Hospitalized Patient I I I IIaIIaIIa IIbIIbIIb IIIIIIIIII I I IIaIIaIIa IIbIIbIIb IIIIIIIIII I I IIaIIaIIa IIbIIbIIb IIIIIIIIII I I IIaIIaIIa IIbIIbIIb IIIIIIIIII I I IIaIIaIIa IIbIIbIIb IIIIIIIIII I I IIaIIaIIa IIbIIbIIb IIIIIIIIIParenteral Inotropes 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.Use of parenteral inotropes in normotensive patients with acute decompensated HF without evidence of decreased organ perfusion is not recommended.NewNew49第49页，共52页。 Thank you for your attention50第50页，共52页。第51页，共52页。第52页，共52页。