1

2014CMS#1 1 2 3 CMS#21

2

32 1 2

CMS#3 1RASS 2 3 4

RASS CMS#4 12345678910 111213 B-1415 ( ) 16)

CMS#5 RAS (MRAs) mineralocorticoid receptor antagonists r-BNP / :CMS#

CMS#

CMS# CMS#

()()ACEI() ()()ARB()()()HF-REF CMS#---

: (C): 0.51.0 kg20-40mg,1/d120-160mg25-80mg0.5-1.0mg,1/d6-8mg1-4mg10mg,1/d100mg10-40mg12.5-25.0mg,1-2/d100mg20-50mg2.5mg,1/d20mg2.5-10.0mg2.5mg,1/d5mg2.5-5.0mg2.5mgb/5.0mgc,/d20mg5-10mgb/10-20mgc25mgb/50mgc,1/d200mg100mgb/200mgcV27.5-15.0mg,1/d60mg7.5-30.0mg:abACEIARBcACEIARBHF-REF CMS#11---

:V2 RAASACEI(ARB)HF-REF CMS#---ACEI

ACEI

: LVEF(A)AACEI(aA)

: 12130% :(1)(Ang) (2) 6.25mg3/d2.5mg2/d5mg1/d5mg1/d2mg1/d2.5mg1/d2.5mg1/d50mg3/d10mg2/d2030mg1/d2030mg1/d48mg1/d10mg1/d1020mg1/dHF-REFACEIHF-REF CMS#--- LVEFMINYHA LVEFLVEF

(1):2448 hACEI (2): (3):55/min 11(3)LVEF412HF-REF CMS#--- 1/8 2412311.87523.750mg1/d1.25mg1/d3.1256.250mg2/d6.25mg23/d142.5190.0mg1/d10mg1/d2550mg2/d50mg23/d HF -REFHF-REF CMS#---

HF-REF AngACEIARB LVEF35% NYHA ACEI(ARB )(IA)AMILVEF40%(IB):12.5 mgl/d2550 mgl/d1020 mgl/d20 mgl/d5.0mmol/L[221mol/L (2.5 mg/dl)eGFR30 ml min-11.73 m-2]5.5 mmol/L-2CMS# ARBAngAng1(AT1R)AT1RARBAngAng2 ---ARBHF-REF 4mg1/d2040mg1/d25mg1/d75mg1/d40mg1/d10mg1/d32mg1/d8060mg2/d100150mg1/d300mg1/d80mg1/d2040mg1/dACEIACEI(IA)ACEI(bA)ACEI12)ACEI()CMS#

Na+/K+-ATPNa+Na+-Ca2+Ca2+(If)IfHF-REFACEI(ARB )LVEF45 %(aB)HF -REFACEIARB70/min(NYHA )(aB)70/min(bC)0.1250.25 mg/d0.3750.50 mg/d2.5 mg2/d 7.5 mg2/d60/min55/min---

HF-REF CMS#

HF-REF CIBIS ACEIACEIARB([436](ONTARGET)AMIACEIARBACEIARBACEIARBARBACEI

ARB

CMS#

HF-REF NT-proBNP GISSI-HF PUFAGISSI-Prevenzione1 g/dn-3 PUFAOMEGAn-3 PUFAAMIn-3(n-3PUFA)CMS# (ASTRONAUT) HF -REFCCB()

HF-REF (CCB)CMS#

HF-REF () ()-2CMS#ACEIHF-REFAHF-REFLVEF40%AACEIARBNYHA-LVEF35%AAMILVEF40%BARBLVEF40%ACEIALVEF40%ACEI ARBbACACEIARBLVEF45%aBLVEF45%bBLVEF35%ACEIARBARB70/minNYHA -aB70/minbC NYHA HF-REF

HF-REF CMS# HF -REF(NYHA )

HF-REF CMS#

HF-REF QRS120 msCRT(NYHA )CRTCRTICD(CRT-D)(CARE-HFCOMPANION)(CRT )CMS#HF-REF 36LVEF1 NYHA a:(1)LVEF35%LBBBQRS150 msCRTCRT-D (A)(2)LVEF35%: LBBB120 msQRS150 msCRTCRT-D(aB)LBBBQRS150 msCRT/CRT-D (aA)(3)CRTLVEF35%40 %QRS1CRT (aC) NYHA:(1)LVEF30%LBBBQRS150 msCRTCRT-D (A)(2)LVEF30%LBBB130msQRS150 msCRTCRT-D(aB)(3)LVEF30%LBBBQRS150 msCRTCRT-D (bB)LBBBQRS150 ms(B) NYHA I:LVEF30%LBBBQRS150 msCRTCRT-D (bC) NYHA aQRS120 msLVEF35% 13CRTCRT-D:(bC)(bB)60/min90/min(bB)

AVVV100%

CMS# HF -REF( NYHA )

a:NYHA IVAMI40 d IAIBb: QRS 150 msI A120 msQRS150 msaBc:NYHA bBNYHA a Ad:QRS 150 msI A130 ms QRS150 msaBICD:LBBB:CRT:CRT-D:HF-REF

CMS#HF-PEF HF-PEF() HF-PEF LVEF(45%) ( )()():BNP()NT -proBNP (e)E/eee9cm/s)E/ e(15) E/A(21)2CMS#HF-PEF HF-PEF ( PEP -CHFCHARM-PreservedI-PreserveJ-DHF)HF-REFACEIARBHF-PEFVALIDDHF-PEF12345 HF-REF130 /80 mmHg( IA)5ACEIARB(C)CCCBbCACE1ARBbCaCCMS#

CMS#123 () IB() 121ICIIaC2aB3aBCMS#() 11IA BNP100 ng/LNT-proBNP300ng/LNT-proBNP50NT-proBNP450 ng/L50900ng/L751800ng/L60ml/min1200ng/L2IANT-proBNP5000 ng/L1000 ng/L2CMS# 1 290%3CMS#1 (aC)COPD(aC)C 0.20.4 mg24h0.2 mgCMS#2B1()22040 mg540 mg/h6h80 mg24 h160 mg1020 mgCMS#3 4 2:rhBNP, bB

CMS#3 190 mmHgHF-PEF2CMS#3(BNP)CCB aB)510g/min510 min510 g/min200 g/min1015 min1(400 g)0.30.6 mg/CMS#(bB)0.3 gkg -1min -15 gkg -1min -172 hCMS#(BNP)(aB()RAASVMACPROACTIONASCEND-HF1.52 g/mg0.01 gkg -1min -13dCMS#ACEI(bC)AMI(aC)48 h(A)

:-2(serelaxin).CMS# 4.1 (85 mmHg) CO2:(aC)(3gkg -1min -1) (5gkg -1min -1) SaO2 ,CMS#(aC)(bC) 2575 g/kg(10min) 0.375 0.750gkg -1min -1 OPTIME-CHF CMS#(aB) TnCATP12 g/kg (10min)0.1gkg -1min -1CMS#3 12()CMS#567HF -REFCMS#1(IABP)I BAMI(AMI) (LVAD) CMS#2(aB)2CMS#31(aB)(110 mmol/L) 500mol/L (2)CMS#4 (aB) ( ECMO)() ECMO(ECMO)CMS#(B)

ACEIACEI

()()(35 d)(bC)(B)LVADCMS# 1.2.CMS# (1)COPD[ARVC)]

(2)A B

(3)A B C

CMS#

90%60 mmHg15 h60 mmHg

CMS#

-5MAP)25 mmHg-PCWP5 mmHg

CMS#(1)25 gkg-1 min-1

(2)

(3)

CMS#

(1)PaO26065 mmHg)

(2):

(3)

CMS# (1)

(2)

CMS#

CMS#MIMI

PCWP18 mmHgIABP

CMS#ARVCRCM)

ARVCA B

ARVC

CMS#Thank youCMS#

AHA/ACC*2001
NYHA1995
A
B
C
D




NYHA NYHA
* Hunt, SA, et al ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult, 2001

19952001 2001ACCAHANYHA 200112,/(ACC/AHA)(CHF),,,ABCD4 A:;(A ) B:; C:; D:() ......AHA: American Heart Association ACC: American Cardio College NYHA: New York Heart Association 1995Killip