成人心衰指南——慢性心衰的诊疗部分：心衰患者的临床评估

Part 1：Initial and Serial Clinical Assessment of Patients Presenting With Heart Failure (UPDATED) Part 1：Initial and Serial Clinical Assessment of Patients Presenting With Heart Failure (UPDATED) 第一部分：心衰患者的最初及系列临床评估： 总体上包括了以下几个内容：1.患者的识别（Identification of Patients）；2.识别结构和功能的异常（Identification of a Structural and Functional Abnormality）；3.寻找心衰的病因（Evaluation of the Cause of Heart Failure）；4.患者的进一步评估：运动耐量、容量状态、实验室指标、预后（Ongoing Evaluation of Patients）。 一、Recommendations for Initial Clinical Assessment of Patients Presenting With Heart Failure有心衰表现患者的最初临床评价建议 CLASS I 1. A thorough history and physical examination should be obtained/ performed in patients presenting with HF to identify cardiac and noncardiac disorders or behaviors that might cause or accelerate the development or progression of HF. (Level of Evidence: C) 1．采集完整的病史和进行全面体格检查，以确定可能导致HF发生或加速HF进程的心源性和非心源性疾病或行为（证据水平：C级）。 2. 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. (Level of Evidence: C) 2．仔细询问患者目前和过去饮酒、违禁药物应用史，目前或过去采用的标准或“替代疗法”及化疗药物的应用情况（证据水平：C级）。 3. In patients presenting with HF, initial assessment should be made of the patient’s ability to perform routine and desired activities of daily living. (Level of Evidence: C) 3．初诊时应评估患者完成日常活动和期望达到的活动的能力（证据水平：C级）。 4. Initial examination of patients presenting with HF should include assessment of the patient’s volume status, orthostatic blood pressure changes, measurement of weight and height, and calculation of body mass index. (Level of Evidence: C) 4．对患者的初次检查应包括评估容量状态、体位性血压变化，测量体重与身高和计算体重指数（证据水平：C级）。 5. Initial 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. (Level of Evidence: C) 5．初诊实验室评估包括进行全血细胞记数、尿液、血清电解质（包括钙和镁）、血尿素氮、血清肌酐、空腹血糖（糖化血红蛋白）、血脂、肝功能检查和促甲状腺素检测（证据水平：C级）。 6. Twelve-lead electrocardiogram and chest radiograph (posterioranterior and lateral) should be performed initially in all patients presenting with HF. (Level of Evidence: C) 6．所有患者初诊时均应行12导联ECG和X线胸片（后前位与侧位）检查（证据水平：C级）。 7. Two-dimensional echocardiography with Doppler should be performed during initial evaluation of patients presenting with HF to assess LVEF, left ventricular size, wall thickness, and valve function. Radionuclide ventriculography can be performed to assess LVEF and volumes. (Level of Evidence: C) 7．患者初诊时应行二维及Doppler超声心动图检查来估测LVEF、左室大小、室壁厚度与瓣膜功能。心室核素显像可用来测定LVEF及LV大小（证据水平：C级）。 8. 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 . (Level of Evidence: B） 8．无血管重建治疗禁忌症的心绞痛或有严重缺血的患者行冠脉造影检查（证据水平：B级）。 CLASS IIa 1. Coronary 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 revascularization. (Level of Evidence: C) 1．在有不能确定是否心源性原因引起胸痛的患者，未进行过冠脉解剖评估的患者以及没有血运重建治疗禁忌症的患者考虑做冠脉造影检查是合理的（证据水平：C级）。 2. 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. (Level of Evidence: C) 2．在已知或怀疑冠状动脉疾病，虽然没有心绞痛，只要无血运重建治疗禁忌的患者，考虑做冠脉造影检查是合理的（证据水平：C级）。 3. Noninvasive 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 . (Level of Evidence: B） 3．已知有冠脉疾病，虽然无心绞痛，只要患者无血管重建治疗的禁忌症，行无创影像检查检测心肌缺血和活力是合理的（证据水平：B级）。 4. Maximal 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. (Level of Evidence: C) 4．HF原因不明时，极限量运动试验同时测量或不测量呼吸性气体交换和/或血氧饱和度，可以帮助确定HF是否是运动受限的原因（证据水平：C级）。 5. Maximal 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．极限量运动试验同时测量呼吸性气体交换，以确定适合做心脏移植或其他先进治疗的高危患者（证据水平：B级）。 6. Screening for hemochromatosis, sleep-disturbed breathing, or human immunodeficiency virus is reasonable in selected patients who present with HF. (Level of Evidence: C) 6．对特定患者筛查血色素沉着症、睡眠呼吸障碍或HIV是合理的（证据水平：C级）。 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 of Evidence: C) 7．对可疑患者行风湿性疾病、淀粉样变或嗜铬细胞瘤的诊断实验检查是合理的（证据级别水平：C级）。 8. Endomyocardial biopsy can be useful in patients presenting with HF when a specific diagnosis is suspected that would influence therapy. (Level of Evidence: C) 8．怀疑有影响治疗的特殊诊断的患者可进行心内膜心肌活检（证据水平：C级）。 9. Measurement of natriuretic peptides (BNP and NT-proBNP) 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 (BNP and NT-proBNP) can be helpful in risk stratification. (Level of Evidence: A) 9．急诊患者HF诊断不确定时可测定钠尿肽（BNP与pro-BNP）。测定钠尿肽（BNP与pro-BNP）可以帮助危险分层（证据水平：A级）。 CLASS IIb 1. Noninvasive imaging may be considered to define the likelihood of coronary artery disease in patients with HF and LV dysfunction. (Level of Evidence: C) 1．HF和功能不全的患者可行无创影像检查确定冠状动脉疾病的可能性（证据水平：C级）。 2. 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 VT inducibility. (Level of Evidence: C) 2．有MI病史和心电生理检查可诱导VT的HF患者，可行Holter监测（证据水平：C级）。 CLASS III 1. Endomyocardial biopsy should not be performed in the routine evaluation of patients with HF . (Level of Evidence: C) 1．HF患者的常规评估时不应使用心内膜心肌活检（证据水平：C级）。 2. Routine use of signal-averaged electrocardiography is not recommended for the evaluation of patients presenting with HF. (Level of Evidence: C) 2．HF患者评估不推荐常规使用信号平均心电图检查（证据水平：C级）。 3. Routine measurement of circulating levels of neurohormones (e.g., norepinephrine or endothelin) is not recommended for patients presenting with HF. (Level of Evidence: C) 3．不推荐常规测量循环中的神经激素（去甲肾上腺素或内皮素）水平（证据水平：C级）。 二、Recommendations for Serial Clinical Assessment of Patients Presenting With Heart Failure有心衰表现患者的系列（指随诊时）临床评价建议 CLASS I 1. Assessment should be made at each visit of the ability of a patient with HF to perform routine and desired activities of daily living. (Level of Evidence: C) 1．每次就诊时均应评估患者完成日常活动和期望达到的活动的能力（证据水平：C级）。 2. Assessment should be made at each visit of the volume status and weight of a patient with HF. (Level of Evidence: C) 2．每次就诊时均应评估患者的容量状态与测量体重（证据水平：C级）。 3. Careful history of current use of alcohol, tobacco, illicit drugs, “alternative therapies,” and chemotherapy drugs, as well as diet and sodium intake, should be obtained at each visit of a patient with HF. (Level of Evidence: C) 3．每次就诊时均应仔细询问患者目前的饮酒、吸烟、违禁药物、“替代疗法”和化疗药物的应用情况，以及饮食、钠摄入情况（证据水平：C级）。 CLASS IIa 1. Repeat measurement of EF and the severity of structural remodeling can be useful to provide information in patients with HF who have had a change in clinical status or who have experienced or recovered from a clinical event or received treatment that might have had a significant effect on cardiac function. (Level of Evidence: C) 1．重复测量EF和结构重塑的严重性可为临床状态改善或从临床事件恢复或正在接受可能对心功能有显著影响的治疗的患者提供有用的信息（证据水平：C级）。 CLASS IIb 1. The value of serial measurements of BNP to guide therapy for patients with HF is not well established. (Level of Evidence: C) 1．连续地测量BNP以指导HF患者治疗的价值尚未确定（证据水平：C级）。 建议分类： Ⅰ类：有证据和/或共识证实采取的诊断措施/治疗实用并有效。 Ⅱ类：采取的措施/治疗的实用性和有效性的证据有矛盾和/或观点有分歧。 Ⅱa类：证据/观点倾向于实用/有效。 Ⅱb类：证据/观点不倾向于实用/有效。 Ⅲ类：有证据和/或共识证实采取的措施/治疗无实用性/无效并且在某些病例可能有害。 证据等级： A级：资料来自多项随机临床试验或荟萃分析； B级：资料来自单个随机临床试验或大的非随机研究； C级：专家共识的意见和/或小规模的研究。