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1 Guidelines for Treatment of Acute Heart Failure (JCS 2006) h Y X 2-5 3ICUCCU

2 ACLS IABP, PCPS, ACCAmerican College of Cardiology ACEangiotensin converting enzyme ACLSAdvanced Cardiovascular Life Support ACTaccelerated coagulation time AHAAmerican Heart Association AMIacute myocardial infarction APTTactivated partial thromboplastin time ARBangiotensin receptor blocker ATPadenosine triphosphate 3 BLSBasic Life Support BNPbrain natriuretic peptide BSAbody surface area Cacalcium campcyclic adenosine monophosphate CCUcoronary care unit CHDFcontinuous hemodiafiltration CIcardiac index CKcreatine kinase CPAPcontinuous positive airway pressure CRTcardiac resynchronization therapy CVVHcontinuous veno-venous hemofiltration - DCMdilated cardiomyopathy ECUMextracorporeal ultrafiltration method FIO2inspired oxygen fractional concentration hanphuman atrial natriuretic peptide HDhemodialysis HRheart rate IABPintraaortic balloon pumping ICUintensive care unit INRinternational normalized ratio ISDNisosorbide dinitrate LVASleft ventricular assist system LVEFleft ventricular ejection fraction NIPPVnoninvasive positive pressure ventilation NYHANew York Heart Association PCIpercutaneous coronary intervention PCPSpercutaneous cardiopulmonary support PCWPpulmonary capillary wedge pressure 2

3 PDperitoneal dialysis PDEphosphodiesterase PEEPpositive end-expiratory pressure PTprothrombin time QOLquality of life SVRsystemic vascular resistance V-Aveno-arterial VAPventilator-associated pneumonia ZEEPzero end-expiratory pressure 2000 Japanese Circulation Journal 64 Suppl ACLS 3

4 a b A B C 4

5 1 6 1 X X 90 % Paget NYHANew York Heart Association 2acute myocardial infarction, AMI Killip 3 Forrester 1a 2 21 Framingham Study Killip Forrester mmhg - - * mmhg 5

6 s m 50 % 50 % 90 mmhg a. Forrester b. L/min/m hypovolemic shock cardiogenic shock 18 mmhg dry-warm A dry-cold L wet-warm B wet-cold C Na cmh2o kg 1 1 6

7 1 2 a b c a b c d e f g h i j k 16 a b c d e f Paget 3 31 BNP Nohria Profile A 1b Killip

8 mmhg BLS ACLS FiO2 NIPPVIPPV X 12 Swan-Ganz 2 4 Swan-Ganz 7AMI Swan-Ganz Forrester, 1a Nohria 8

9 4 1b 3 8 C C C BNP 100 pgml 24 Kerley s B lineperibronchial perivascular cuffing sign vanishing tumor Swan-Ganz 7 Forrester 1a 8 1 CK-MB T I A 2 SaO2 C a Swan-Ganz B Swan-Ganz B C C b C 32 9

10 a B S0 Killip 3Nohria 1b Forrester 1a PDE IABPPCPSLVAS S1 X BNP ACE ARB S2 NYHA 2QOL BNP X peak VO2 6 ACE ARB 10

11 SaO295 %PaO280 mmhg C B B C C Ca C C C C NIPPV C a NIPPV A B PDE A C C b PDE A B B C K C PDE 4-4 a C 4-6 SaO295 %PaO280 mmhg C NIPPV C C C PDE C IABPPCPS C B C a NIPPV A B C a B PDE a B 15 ACCAHA D CRT C mga 10 2 mg 3 11

12 NIPPV PDE PDE ECUMCHDFIABPPCPSLVAS C C CPAPBiPAP NIPPVa A 18 C A C C C B B C Ca C C C CCU C b B C C Fowler a C C A C Swan- Ganz b C C 40 ml C kg C Ca a C C b C % CPAPNIPPV C 12

13 15 b, B B NYHA-- B a B C b 1 B C B K K 5.0 meql 1 ISDN ISDN C 2 Na a B gkgmin gkgmin gkg min 0.2 gkgmin a B 3 PDE camp PDE camp inodilator

14 a C Ca gkg min 10gkgmin a C gkgmin 2-10gkgmin gkgmina C 910 AMI 3 2 a C AMI WPW K Ca 3 PDE 6 PDE 9 a C b B 4 PDE inodilator PDE 9 b C , 2 90 mmhg 3 90 mmhg, 2-5gkgmin, IABP PCPS, 4 70 mmhg 14

15 50 40 CI iv-olp n32 hanp n 30 iv-mil60 n31 oral-pim240' n11 DA ID n 9 DBn 17 DAn oral-pra n 6 iv-amn90' n 30 HR: heart rate mbp: mean blood pressure SVR: systemic vascular resistance PCWP: pulmonary capillary wedge pressure CI: cardiac index SVI: stroke volume index DA: dopamine, 2-5g/kg/min DB: dobutamine, 2-5g/kg/min PCWP AMN90': amrinone 1 mg/kg loading 10g/kg/min 90 MIL60': milrinone 50g/kg loading 0.5g/kg/min 60 PIM240': pimobendan 0.25mg 90 DA ID: dopamine 3-5 ISDN 2mg/hr PRA: prazosin 1 mg hanp: carperitide 0.1g/kg/min OLP: olpurinone 10g/kg loading 0.3g/kg/min amrinone mga 2-5 mg mg 2-5 mghr mg ngml gkgmin5gkgmin 2-5gkgmin 5gkgmin gkgmin5gkgmin gkgmin 50gkg loading gkgmin 10gkg loading gkgmin gkgmin gkgmin 1-8 mghr gkgmin 0.5gkgmin 0.5-3gkgmin 0.025gkgmin gkgmin0.2 gkgmin gkgmin 15

16 , IABP PCPS ACE ARB ACE ARB A a B b C A a B 16 ATP 2 1 2ATP 16

17 C B B C 18 C B a NIPPV A gkgmin C 50 % PaO2 60 mmhg NIPPV PCWP 50 %PEEP 0ZEEP PaO2 80 mmhg 18 mmhg X ml ZEEP 40 % PaO2 80 mmhg CPAP NIPPV NIPPV 18 PEEP 19 2 SaO295 %PaO280 mmhg C NIPPV C NIPPV C a NIPPV A IABP PCPS 20 Norman NYHA 90 mmhg 2 Lminm 2 20 mmhg IABP B IABPPCPS C a B 17

18 AMI NYHA IV90 mmhg2.0 Lminm 2 20 mmhg PCI AMI IABPPCPS IABP PCPS BSA 1.5 m 2 18

19 a b c d 2 IABP PCI supported PCI LVAS PT INR mg 200 mg 1-2 APTT Ukg 2 : 3-2 DCM, a ACT a b c d 3-1 BSA 1.5 m 2 20 kg 3-3 bridge to transplant 'bridge to recovery' 7 54 a C 1 biventricular pacing NYHA QRS 19

20 msec EF 35 % Mobitz torsade de pointes humoral mediator 23 b 1 aextracorporeal ultrafiltration method: ECUM B bcontinuous veno-venous hemofiltration: CVVH B 2 ahemodialysis: HD B bperitoneal dialysis: PD B 3 acontinuous hemodiafiltration: CHDF C 56 1 C oozing blow-out pulseless electrical activity PCPS IABP IABP 3 IABP PCPS 20

21 C Ca ACE ARB C C 1 3 AMI A AMI C AMI Ca ACE ARB PCI Swan-Ganz IABPPCPS IABPPCPS LVAS Ca 24 21

22 IABPPCPS C b C C C 5 a ACE B ARB B C C C C C B B b C 2 Cockcroft 3 cardiorenal anemia syndrome mgdl 1 B a B a B PDE a C

23 A B A C a -1-b -1-c -2 VAP C D E F G or 2 3MRSA 1or 2or 4 1or 2 - or C VAP -- or VAP - or or or -3 H mg mgkg Mobitz QRS a C 2 12 AMI mg 5 b C common type b C b C 23

24 a C b C 52 Ca a C QOL C Ca C a Ca C b C 24

25 C a PDE C b PDE C ACE ACE ARB b ACE ARB C C CPAP NIPPV a b a Ca IABP PCPS a PDE a 25

26 a PCPSLVAS a PEEP ml 70 mmhg mmhg gkgmin gkgmin gkgmin gkgmin IABPPCPS 26

27 90 mmhg PDE IABP LVAS ACLS up to date AC QOL ACC AHA 2001, 2005 ESC

GL_高野班_D.indd

GL_高野班_D.indd Circulation Journal Vol. 72, Suppl. IV, 2008 1443 PCI CCU STEMI CABG ST ST1 EBM ST ST ST ST ST ST 1 EBMEvidence-Based Medicine 1444 Circulation Journal Vol. 72, Suppl. IV, 2008 ACS ST T ST CLBBB ST ACS