ACCAHA成人心力衰竭診斷與治療指南修訂版幻燈英文

ACCAHA成人心力衰竭診斷與治療指南修訂版幻燈英文第1頁/共98頁2第2頁/共98頁3StagesintheDevelopmentofHeartFailure/RecommendedTherapybyStage.ACEIindicatesangiotensin-convertingenzymeInhibitors;ARB,angiotensinIIreceptorblocker:EF,ejectionfraction;FHxCM,familyhistoryofcardiomyopathy,HF,heartFailure;LVH,leftventricularhypertrophy;andMI,myocardialinfarction.第3頁/共98頁4UpdatestoInitialandSerialClinicalAssessmentsofPatientsPresentingwithHeartFailure2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassIAthoroughhistoryandphysicalexaminationshouldbeobtained/performedinpatientspresentingwithHFtoidentifycardiacandnoncardiacdisordersorbehaviorsthatmightcauseoracceleratethedevelopmentorprogressionofHF.(LevelofEvidence:C)1.Athoroughhistoryandphysicalexaminationshouldbeobtained/performedinpatientspresentingwithHFtoidentifycardiacandnoncardiacdisordersorbehaviorsthatmightcauseoracceleratethedevelopmentorprogressionofHF.(LevelofEvidence:C)2005recommendationremainscurrentinthe2009update.RecommendationsfortheInitialClinicalAssessmentofPatientswithHeartFailure第4頁/共98頁5UpdatestoInitialandSerialClinicalAssessmentsofPatientsPresentingwithHeartFailure2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassIAcarefulhistoryofcurrentandpastuseofalcohol,illicitdrugs,currentorpaststandardor“alternativetherapies,”andchemotherapydrugsshouldbeobtainedfrompatientspresentingwithHF.(LevelofEvidence:C)2.Acarefulhistoryofcurrentandpastuseofalcohol,illicitdrugs,currentorpaststandardor“alternativetherapies,”andchemotherapydrugsshouldbeobtainedfrompatientspresentingwithHF.(LevelofEvidence:C)2005recommendationremainscurrentinthe2009update.RecommendationsfortheInitialClinicalAssessmentofPatientswithHeartFailure第5頁/共98頁6UpdatestoInitialandSerialClinicalAssessmentsofPatientsPresentingwithHeartFailure2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassIInpatientspresentingwithHF,initialassessmentshouldbemadeofthepatient’sabilitytoperformroutineanddesiredactivitiesofdailyliving.(LevelofEvidence:C)3.InpatientspresentingwithHF,initialassessmentshouldbemadeofthepatient’sabilitytoperformroutineanddesiredactivitiesofdailyliving.(LevelofEvidence:C)2005recommendationremainscurrentinthe2009update.RecommendationsfortheInitialClinicalAssessmentofPatientswithHeartFailure第6頁/共98頁7UpdatestoInitialandSerialClinicalAssessmentsofPatientsPresentingwithHeartFailure2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassIInitialexaminationofpatientspresentingwithHFshouldincludeassessmentofthepatient’svolumestatus,orthostaticbloodpressurechanges,measurementofweightandheight,andcalculationofbodymassindex.(LevelofEvidence:C4.InitialexaminationofpatientspresentingwithHFshouldincludeassessmentofthepatient’svolumestatus,orthostaticbloodpressurechanges,measurementofweightandheight,andcalculationofbodymassindex.(LevelofEvidence:C)2005recommendationremainscurrentinthe2009update.RecommendationsfortheInitialClinicalAssessmentofPatientswithHeartFailure第7頁/共98頁8UpdatestoInitialandSerialClinicalAssessmentsofPatientsPresentingwithHeartFailure2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassIInitiallaboratoryevaluationofpatientspresentingwithHFshouldincludecompletebloodcount,urinalysis,serumelectrolytes(includingcalciumandmagnesium),bloodureanitrogen,serumcreatinine,fastingbloodglucose(glycohemoglobin),lipidprofile,liverfunctiontests,andthyroid-stimulatinghormone.(LevelofEvidence:C)5.InitiallaboratoryevaluationofpatientspresentingwithHFshouldincludecompletebloodcount,urinalysis,serumelectrolytes(includingcalciumandmagnesium),bloodureanitrogen,serumcreatinine,fastingbloodglucose(glycohemoglobin),lipidprofile,liverfunctiontests,andthyroid-stimulatinghormone.(LevelofEvidence:C)2005recommendationremainscurrentinthe2009update.RecommendationsfortheInitialClinicalAssessmentofPatientswithHeartFailure第8頁/共98頁9UpdatestoInitialandSerialClinicalAssessmentsofPatientsPresentingwithHeartFailure2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassITwelve-leadelectro-cardiogramandchestradiograph(posteriortoanterior[PA]andlateral)shouldbeperformedinitiallyinallpatientspresentingwithHF.(LevelofEvidence:C)6.Twelve-leadelectro-cardiogramandchestradiograph(PAandlateral)shouldbeperformedinitiallyinallpatientspresentingwithHF.(LevelofEvidence:C)2005recommendationremainscurrentinthe2009update.RecommendationsfortheInitialClinicalAssessmentofPatientswithHeartFailure第9頁/共98頁10UpdatestoInitialandSerialClinicalAssessmentsofPatientsPresentingwithHeartFailure2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassITwo-dimensionalecho-cardiographywithDopplershouldbeperformedduringinitialevaluationofpatientspresentingwithHFtoassessleftventricularejectionfraction(LVEF),LVsize,wallthickness,andvalvefunction.RadionuclideventriculographycanbeperformedtoassessLVEFandvolumes.(LevelofEvidence:C)7.Two-dimensionalecho-cardiographywithDopplershouldbeperformedduringinitialevaluationofpatientspresentingwithHFtoassessLVEF,leftventricularsize,wallthickness,andvalvefunction.RadionuclideventriculographycanbeperformedtoassessLVEFandvolumes.(LevelofEvidence:C2005recommendationremainscurrentinthe2009update.RecommendationsfortheInitialClinicalAssessmentofPatientswithHeartFailure第10頁/共98頁11UpdatestoInitialandSerialClinicalAssessmentsofPatientsPresentingwithHeartFailure2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassICoronaryarteriographyshouldbeperformedinpatientspresentingwithHFwhohaveanginaorsignificantischemiaunlessthepatientisnoteligibleforrevascularizationofanykind.(LevelofEvidence:B)8.CoronaryarteriographyshouldbeperformedinpatientspresentingwithHFwhohaveanginaorsignificantischemiaunlessthepatientisnoteligibleforrevascularizationofanykind.(LevelofEvidence:B2005recommendationremainscurrentinthe2009update.RecommendationsfortheInitialClinicalAssessmentofPatientswithHeartFailure第11頁/共98頁12UpdatestoInitialandSerialClinicalAssessmentsofPatientsPresentingwithHeartFailure2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassIIaCoronaryarteriographyshouldbeperformedinpatientspresentingwithHFwhohaveanginaorsignificantischemiaunlessthepatientisnoteligibleforrevascularizationofanykind.(LeveloEvidence:B)1.CoronaryarteriographyshouldbeperformedinpatientspresentingwithHFwhohaveanginaorsignificantischemiaunlessthepatientisnoteligibleforrevascularizationofanykind.(LevelofEvidence:B2005recommendationremainscurrentinthe2009update.RecommendationsfortheInitialClinicalAssessmentofPatientswithHeartFailure第12頁/共98頁13UpdatestoInitialandSerialClinicalAssessmentsofPatientsPresentingwithHeartFailure2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassIIaCoronaryarteriographyisreasonableforpatientspresentingwithHFwhohavechestpainthatmayormaynotbeofcardiacoriginwhohavenothadevaluationoftheircoronaryanatomyandwhohavenocontraindicationstocoronaryrevascularization.(LevelofEvidence:C)2.CoronaryarteriographyisreasonableforpatientspresentingwithHFwhohavechestpainthatmayormaynotbeofcardiacoriginwhohavenothadevaluationoftheircoronaryanatomyandwhohavenocontraindicationstocoronaryrevascularization.(LevelofEvidence:C)2005recommendationremainscurrentinthe2009update.RecommendationsfortheInitialClinicalAssessmentofPatientswithHeartFailure第13頁/共98頁14UpdatestoInitialandSerialClinicalAssessmentsofPatientsPresentingwithHeartFailure2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassIIaNoninvasiveimagingtodetectmyocardialischemiaandviabilityisreasonableinpatientspresentingwithHFwhohaveknowncoronaryarterydiseaseandnoanginaunlessthepatientisnoteligibleforrevascularizationofanykind.(LevelofEvidence:B)3.NoninvasiveimagingtodetectmyocardialischemiaandviabilityisreasonableinpatientspresentingwithHFwhohaveknowncoronaryarterydiseaseandNoanginaunlessthepatientisnoteligibleforrevascularizationofanykind.(LevelofEvidence:B)2005recommendationremainscurrentinthe2009update.RecommendationsfortheInitialClinicalAssessmentofPatientswithHeartFailure第14頁/共98頁15UpdatestoInitialandSerialClinicalAssessmentsofPatientsPresentingwithHeartFailure2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassIIaMaximalexercisetestingwithorwithoutmeasurementofrespiratorygasexchangeand/orbloodoxygensaturationisreasonableinpatientspresentingwithHFtohelpdeterminewhetherHFisthecauseofexerciselimitationwhenthecontributionofHFisuncertain.(LevelofEvidence:C)4.Maximalexercisetestingwithorwithoutmeasurementofrespiratorygasexchangeand/orbloodoxygensaturationisreasonableinpatientspresentingwithHFtohelpdeterminewhetherHFisthecauseofexerciselimitationwhenthecontributionofHFisuncertain.(LevelofEvidence:C)2005recommendationremainscurrentinthe2009update.RecommendationsfortheInitialClinicalAssessmentofPatientswithHeartFailure第15頁/共98頁16UpdatestoInitialandSerialClinicalAssessmentsofPatientsPresentingwithHeartFailure2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassIIaMaximalexercisetestingwithmeasurementofrespiratorygasexchangeisreasonabletoidentifyhigh-riskpatientspresentingwithHFwhoarecandidatesforcardiactransplantationorotheradvancedtreatments.(LevelofEvidence:B)5.Maximalexercisetestingwithmeasurementofrespiratorygasexchangeisreasonabletoidentifyhigh-riskpatientspresentingwithHFwhoarecandidatesforcardiactransplantationorOtheradvancedtreatments.(LevelofEvidence:B)2005recommendationremainscurrentinthe2009update.RecommendationsfortheInitialClinicalAssessmentofPatientswithHeartFailure第16頁/共98頁17UpdatestoInitialandSerialClinicalAssessmentsofPatientsPresentingwithHeartFailure2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassIIaScreeningforhemo-chromatosis,sleep-disturbedbreathing,orhumanimmunodeficiencyvirusisreasonableinselectedpatientswhopresentwithHF.(LevelofEvidence:C)6.Screeningforhemo-chromatosis,sleep-disturbedbreathing,orhumanimmunodeficiencyvirusisreasonableinselectedpatientswhopresentwithHF.(LevelofEvidence:C)2005recommendationremainscurrentinthe2009update.RecommendationsfortheInitialClinicalAssessmentofPatientswithHeartFailure第17頁/共98頁18UpdatestoInitialandSerialClinicalAssessmentsofPatientsPresentingwithHeartFailure2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassIIaDiagnostictestsforrheumatologicdiseases,amyloidosis,orpheochromocytomaarereasonableinpatientspresentingwithHFinwhomthereisaclinicalsuspicionofthesediseases.(LevelofEvidence:C)7.Diagnostictestsforrheumatologicdiseases,amyloidosis,orpheochromocytomaareReasonableinpatientspresentingwithHFinwhomthereisaclinicalsuspicionofthesediseases.(LevelofEvidence:C)2005recommendationremainscurrentinthe2009update.RecommendationsfortheInitialClinicalAssessmentofPatientswithHeartFailure第18頁/共98頁19UpdatestoInitialandSerialClinicalAssessmentsofPatientsPresentingwithHeartFailure2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassIIaEndomyocardialbiopsycanbeusefulinpatientspresentingwithHFwhenaspecificdiagnosisissuspectedthatwouldinfluencetherapy.(LevelofEvidence:C)8.EndomyocardialbiopsycanbeusefulinpatientspresentingwithHFwhenaspecificdiagnosisissuspectedthatwouldinfluencetherapy.(LevelofEvidence:C)2005recommendationremainscurrentinthe2009update.RecommendationsfortheInitialClinicalAssessmentofPatientswithHeartFailure第19頁/共98頁20UpdatestoInitialandSerialClinicalAssessmentsofPatientsPresentingwithHeartFailure2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassIIaMeasurementofBNPcanbeusefulintheevaluationofpatientspresentingintheurgentcaresettinginwhomtheclinicaldiagnosisofHFisuncertain.(LevelofEvidence:A)9.Measurementofnatriureticpeptides(BNPandNTproBNP)canbeusefulintheevaluationofpatientspresentingintheurgentcaresettinginwhomtheclinicaldiagnosisofHFisuncertain.Measurementofnatriureticpeptides(BNPandNT-proBNP)canbeusefulinriskstratification.(LevelofEvidence:A)Modifiedrecommendation(addedacaveatonnatriureticpeptidesandtheirroleaspartoftotalevaluation,inbothdiastolicandsystolicdysfunction).RecommendationsfortheInitialClinicalAssessmentofPatientswithHeartFailure第20頁/共98頁21UpdatestoInitialandSerialClinicalAssessmentsofPatientsPresentingwithHeartFailure2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassIIbNoninvasiveimagingmaybeconsideredtodefinethelikelihoodofcoronaryarterydiseaseinpatientswithHFandLVdysfunction.(LevelofEvidence:C)1.NoninvasiveimagingmaybeconsideredtodefinethelikelihoodofcoronaryarterydiseaseinpatientswithHFandLVdysfunction.(LevelofEvidence:C)2005recommendationremainscurrentinthe2009update.RecommendationsfortheInitialClinicalAssessmentofPatientswithHeartFailure第21頁/共98頁22UpdatestoInitialandSerialClinicalAssessmentsofPatientsPresentingwithHeartFailure2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassIIbHoltermonitoringmightbeconsideredinpatientspresentingwithHFwhohaveahistoryofmyocardialinfarction(MI)andarebeingconsideredforelectrophysiologicstudytodocumentventriculartachycardia(VT)inducibility.(LevelofEvidence:C)2.HoltermonitoringmightbeconsideredinpatientspresentingwithHFwhohaveahistoryofMIandarebeingconsideredforelectrophysiologicstudytodocumentVTinducibility.(LevelofEvidence:C)2005recommendationremainscurrentinthe2009update.RecommendationsfortheInitialClinicalAssessmentofPatientswithHeartFailure第22頁/共98頁23UpdatestoInitialandSerialClinicalAssessmentsofPatientsPresentingwithHeartFailure2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassIIIEndomyocardialbiopsyshouldnotbeperformedintheroutineevaluationofpatientswithHF.(LevelofEvidence:C)1.EndomyocardialbiopsyshouldnotbeperformedintheroutineevaluationofpatientswithHF.(LevelofEvidence:C)2005recommendationremainscurrentinthe2009update.RecommendationsfortheInitialClinicalAssessmentofPatientswithHeartFailure第23頁/共98頁24UpdatestoInitialandSerialClinicalAssessmentsofPatientsPresentingwithHeartFailure2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassIIIRoutineuseofsignal-averagedelectro-cardiographyisnotrecommendedfortheevaluationofpatientspresentingwithHF.(LevelofEvidence:C)2.Routineuseofsignal-averagedelectrocardiographyisnotrecommendedfortheevaluationofpatientspresentingwithHF.(LevelofEvidence:C)2005recommendationremainscurrentinthe2009update.RecommendationsfortheInitialClinicalAssessmentofPatientswithHeartFailure第24頁/共98頁25UpdatestoInitialandSerialClinicalAssessmentsofPatientsPresentingwithHeartFailure2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassIIIRoutinemeasurementofcirculatinglevelsofneurohormones(e.g.,norepinephrineorendothelin)isnotrecommendedforpatientspresentingwithHF.(LevelofEvidence:C)3.Routinemeasurementofcirculatinglevelsofneurohormones(e.g.,norepinephrineorendothelin)isnotrecommendedforpatientspresentingwithHF.(LevelofEvidence:C)2005recommendationremainscurrentinthe2009update.RecommendationsfortheInitialClinicalAssessmentofPatientswithHeartFailure第25頁/共98頁26UpdatestoInitialandSerialClinicalAssessmentsofPatientsPresentingwithHeartFailure2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassIAssessmentshouldbemadeateachvisitoftheabilityofapatientwithHFtoperformroutineanddesiredactivitiesofdailyliving.(LevelofEvidence:C)1.AssessmentshouldbemadeateachvisitoftheabilityofapatientwithHFtoperformroutineanddesiredactivitiesofdailyliving.(LevelofEvidence:C)2005recommendationremainscurrentinthe2009update.RecommendationsforSerialClinicalAssessmentofPatientsPresentwithHeartFailure第26頁/共98頁27UpdatestoInitialandSerialClinicalAssessmentsofPatientsPresentingwithHeartFailure2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassIAssessmentshouldbemadeateachvisitofthevolumestatusandweightofapatientwithHF.(LevelofEvidence:C)2.AssessmentshouldbemadeateachvisitofthevolumestatusandweightofapatientwithHF.(LevelofEvidence:C)2005recommendationremainscurrentinthe2009update.RecommendationsforSerialClinicalAssessmentofPatientsPresentwithHeartFailure第27頁/共98頁28UpdatestoInitialandSerialClinicalAssessmentsofPatientsPresentingwithHeartFailure2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassICarefulhistoryofcurrentuseofalcohol,tobacco,illicitdrugs,“alternativetherapies,”andchemotherapydrugs,aswellasdietandsodiumintake,shouldbeobtainedateachvisitofapatientwithHF.(LevelofEvidence:C)3.Carefulhistoryofcurrentuseofalcohol,tobacco,illicitdrugs,“alternativetherapies,”Andchemotherapydrugs,aswellasdietandsodiumintake,shouldbeobtainedateachvisitofapatientwithHF.(LevelofEvidence:C)2005recommendationremainscurrentinthe2009update.RecommendationsforSerialClinicalAssessmentofPatientsPresentwithHeartFailure第28頁/共98頁29UpdatestoInitialandSerialClinicalAssessmentsofPatientsPresentingwithHeartFailure2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassIIaRepeatmeasurementofejectionfraction(EF)andtheseverityofstructuralremodelingcanprovideusefulinformationinpatientswithHFwhohavehadachangeinclinicalstatusorwhohaveexperiencedorrecoveredfromaclinicaleventorreceivedtreatmentthatmighthavehadasignificanteffectoncardiacfunction.(LevelofEvidence:C)1.RepeatmeasurementofEFandtheseverityofstructuralremodelingcanbeusefultoprovideinformationinpatientswithHFwhohavehadachangeinclinicalstatusorwhohaveexperiencedorrecoveredfromaclinicaleventorreceivedtreatmentthatmighthavehadasignificanteffectoncardiacfunction.(LevelofEvidence:C)2005recommendationremainscurrentinthe2009update.RecommendationsforSerialClinicalAssessmentofPatientsPresentwithHeartFailure第29頁/共98頁30UpdatestoInitialandSerialClinicalAssessmentsofPatientsPresentingwithHeartFailure2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassIIbThevalueofserialmeasurementsofBNPtoguidetherapyforpatientswithHFisnotwellestablished.(LevelofEvidence:C)1.ThevalueofserialmeasurementsofBNPtoguidetherapyforpatientswithHFisnotwellestablished.(LevelofEvidence:C)2005recommendationremainscurrentinthe2009update.RecommendationsforSerialClinicalAssessmentofPatientsPresentwithHeartFailure第30頁/共98頁31UpdatestoPatientswithReducedLeftVentricularEjectionFraction2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassIMeasureslistedasClassrecommendationsforpatientsinstagesAandBarealsoappropriateforpatientsinStageC.(LevelsofEvidence:A,B,andCasappropriate)1.MeasureslistedasClassIrecommendationsforpatientsinstagesAandBarealsoappropriateforpatientsinStageC.(LevelsofEvidence:A,B,andCasappropriate)2005recommendationremainscurrentin2009update.PatientswithReducedLeftVentricularEjectionFraction第31頁/共98頁32DiureticsandsaltrestrictionareindicatedinpatientswithcurrentorpriorsymptomsofHFandreducedLVEFwhohaveevidenceoffluidretention(seeTable4).(LevelofEvidence:C)2.DiureticsandsaltrestrictionareindicatedinpatientswithcurrentorpriorsymptomsofHFandreducedLVEFwhohaveevidenceoffluidretention(LevelofEvidence:C)2005recommendationremainscurrentin2009update.UpdatestoPatientswithReducedLeftVentricularEjectionFraction2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassIPatientswithReducedLeftVentricularEjectionFraction第32頁/共98頁332005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassIAngiotensinconvertingenzymeinhibitorsarerecommendedforallpatientswithcurrentorpriorsymptomsofHFandreducedLVEF,unlesscontraindicated(LevelofEvidence:A)3.Angiotensin-convertingenzymeinhibitorsarerecommendedforallpatientswithcurrentorpriorsymptomsofHFandreducedLVEF,unlesscontraindicated(LevelofEvidence:A)2005recommendationremainscurrentin2009update.UpdatestoPatientswithReducedLeftVentricalEjectionFractionPatientswithReducedLeftVentircularEjectionFraction第33頁/共98頁34Betablockers(usingoftheproventoreducemortality,i.e.bisoprolol,carvedilol,andsustainedrelease metoprololsuccinate)arerecommendedforallstablepatientswithcurrentorpriorsymptomsofHFandreducedLVEF,unlesscontraindicated(LevelofEvidence:A)4.Betablockers(using1ofthe3proventoreducemortality,i.e.,bisoprolol,carvedilol,andsustainedreleasemetoprololsuccinate)arerecommendedforallstablepatientswithcurrentorpriorsymptomsofHFandreducedLVEF,unlesscontraindicated(LevelofEvidence:A)2005recommendationremainscurrentin2009update.UpdatestoPatientswithReducedLeftVentricularEjectionFraction2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassIPatientswithReducedLeftVentricularEjectionFraction第34頁/共98頁35AngiotensinIIreceptorlockersapprovedforthetreatmentofHFarerecommendedinpatientswithcurrentorpriorsymptomsofHFandreducedLVEFwhoareACEinhibitor-intolerant.(LevelofEvidence:A)5.AngiotensinIIreceptorblockers(seeTable3inthefull-textguidelines)arerecommendedinpatientswithcurrentorpriorsymptomsofHFandreducedLVEFwhoareACEinhibitor-intolerant(LevelofEvidence:A)2005recommendationremainscurrentbuttextmodifiedtoeliminatespecificagentstested.UpdatestoPatientswithReducedLeftVentricularEjectionFraction2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassIPatientswithReducedLeftVentricularEjectionFraction第35頁/共98頁36DrugsknowntoadverselyaffecttheclinicalstatusofpatientswithcurrentorpriorsymptomsofHFandreducedLVEFshouldbeavoidedorwithdrawnwheneverpossible(e.g.,nonsteroidalanti-inflammatorydrugs,mostantiarrhythmicdrugs,andmostcalciumchannelblockingdrugs;(LevelofEvidence:B)6.DrugsknowntoadverselyaffecttheclinicalstatusofpatientswithcurrentorpriorsymptomsofHFandreducedLVEFshouldbeavoidedorwithdrawnwheneverpossible(e.g.,nonsteroidalanti-inflammatorydrugs,mostantiarrhythmicdrugs,andmostcalciumchannelblockingdrugs;(LevelofEvidence:B)2005recommendationremainscurrentin2009update.

UpdatestoPatientswithReducedLeftVentricularEjectionFraction2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassIPatientswithReducedLeftVentricularEjectionFraction第36頁/共98頁37ExercisetrainingisbeneficialasanadjunctiveapproachtoimproveclinicalstatusinambulatorypatientswithcurrentorpriorsymptomsofHFandreducedLVEF.(LevelofEvidence:B)MaximalexercisetestingwithorwithoutmeasurementofrespiratorygasexchangeisreasonabletofacilitateprescriptionofanappropriateexerciseprogramforpatientspresentingwithHF.(LevelofEvidence:C)Modifiedrecommendation(changedclassofrecommendationfromItoIIa)UpdatestoPatientswithReducedLeftVentricularEjectionFraction2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClassIPatientswithReducedLeftVentricularEjectionFraction第37頁/共98頁38MaximalexercisetestingwithorwithoutmeasurementofrespiratorygasexchangeisrecommendedtofacilitateprescriptionofanappropriateexerciseprogramforpatientswithHF.(LevelofEvidence:C)7.MaximalexercisetestingwithorwithoutmeasurementofrespiratorygasexchangeisrecommendedtofacilitateprescriptionofanappropriateExerciseprogramforpatientswithHF.(LevelofEvidence:C)2005recommendationRemainscurrentin2009update.UpdatestoPatientswithReducedLeftVentricularEjectionFraction2005GuidelineRecommendations2009FocusedUpdateRecommendationsCommentsClass