急性心衰竭的診斷與治療－準則應用與建議

The Diagnosis and Treatment of Acute Heart Failure-Guidelines and Comments

周嘉裕(Chia-Yu Chou)

《重症醫學雜誌》 11卷3期 (2010/10) Pp. 161-187

https://doi.org/10.30035/TCCM.201010.0002

摘要

急性心衰竭是先進國家主要的住院原因，估計佔5%左右的總住院率。它是一種臨床症侯群是突發不正常的心機能不良，造成血行力學的不穩定引起缺氧性及低心輸出量或休克的症狀衰現。病人常以急性肺水腫的緊急醫療狀況出現。它可以是有潛在心臟病或則是新有的初次心臟收縮或舒張機能不良，心瓣膜疾病，心律不正常，或前後負荷不均衡，生理無法代償所致所致，這常危及生命，需要緊急治療。在己有的冠狀動脈疾病的老年人（＞65歲），突發急性冠心症，約佔6-7成急性心衰竭原因。年輕患者，則主要是擴大性心肌病變，心律不整，先天性或瓣膜心臟病、心肌炎所致。唯有快速合適的診查，例如：病史詢問、理學檢查、心電圖、胸部X光、心臟超音波與實驗室檢驗及血液氣體分析還有特定的生物標記才能確定診斷。初步的臨床評估包括前、後負荷、有無二尖瓣閉鎖不全、其他的共病症例，如心瓣膜併發症、感染症、糖尿病、腎衰竭、呼吸道疾病、急性冠心症。AHF的所有患者在初步評估後，都應立即建立靜脈管路，監控心電圖、SpO2、臨床症狀，動脈管路也要建立。初步治療包括給予氧氣與CPAP，求SpO2介於94-96%，給予血管擴張劑Nitrates，nitroprusside，利尿劑furosimide bolus & IV,嗎啡，水分補充，矯正新陳代謝之異常，防治器官衰退治療，急性冠心症的診療，及冠狀動脈造影與介入性診療，及其他的藥物治療如Beta-blocker，、ACEI/ARB。而特定的治療方式則依臨床情境而分類考量，例如IABP主動脈內汞浦、ECMO体外循環機及換心手術等。急性心衰竭的處理原則包括立即的臨床評估、實驗室診斷、生理監控與重覆的急救決斷與治療措施，增進組織氧合，穩定血行力學以改善症狀、以增加存活。若能依致病因及潛在的病生理，再進一步的特需治療，急性心衰竭的病人可能恢復得非常好。

關鍵字

急性心衰竭 ； 心因性休克 ； 急性肺水腫 ； Hypertension crisis ； Rapid Atrial Fibrillation ； BNP ； NT-proBNP ； 肺動脈導管 ； 利尿劑 ； 血管擴張劑 ； 強心劑 ； Dopamine、Dobutamine ； 升壓劑 ； Noepinephrine ； 毛地黃Digitalization

並列摘要

Heart Failure is a leading cause of hospital admission in developed countries. Acute heart failure (AHF) is a clinical syndrome, caused by sudden deteriorated cardiac dysfunction, leading to hemodynamic instability and hypoxemia with low cardiac output or shock. Patient frequently present with acute pulmonary edema in acute setting. The pathophysiology of AHF may be right or left ventricle systolic, diastolic dysfunction, or preload Afterload mismatch, while some hospitalizatioll is due to new onset of AHF, but most hospitalization are caused by acute decompensated HF. In elderly population, coronary artery disease is the etiology of AHF accounting in 60 to 70% of patients. In young subjects, the etiologies of AHF most are dilated cardiomyopathy, arrhythmia, valvular or congenital heart disease and myocarditis. Initial diagnostic assessment should include evaluation of preload, afterload, and presence of MR and complicating medical disorders. Acute coronary syndromes are a frequent cause of AHF, coronary angiography with interventions should liberally delivery. Following initial assessment, Intravenous with arterial lines should be set up, and physical signs, EkG, SPO2 should be monitored. The initial treatment of AHF consists of oxygen therapy to target Sa02 94-96%, and vasodilators, loop diuretics bolus plus intravenous infusion Morphine, fluid challenge in low filling pressure condition, correct metabolic disorders, management of acute coronary syndrome, and appropriated medical agents, for example, beta-blocker, ACEI/ARB, etc. Further specific therapies applied should be based on the characteristic conditions, such as IABP, bridging ECMO for heart transplantation in refractory HF. The patient with AHF may recover extremely well, If initial and further managements met the merits of etiology and underlying pathophysiology of acute heart failure.

並列關鍵字

Acute heart failure ； Cardiogenic shock ； Acute pulmonary edema ； Hypertension crisis ； Rapid Atrial Fibrillation ； BNP ； NT-proBNP ； Pulmonary artery catheter ； Loop Diuretics ； Vasodilator ； Inotropics ； Dopamine ； Dobutamine ； Vasopressor ； Noepinephrine ； Digitalization