?a?d?a?? ??ep???e?a

1
?a?d?a?? ??ep???e?a

• ?a???? ????a??e??
• ?p??????? ?a????t??

2
(No Transcript)
3
?a?d?a?? a?ep???e?a
S?µpt?µata s?µf???s??
??ap???a ?e?????sµ?? d?ast????t?t??
?????µ?e?
??sa????? se ??s???µe?? - ??st??
?e??s? ep?ß??s??
4
???????S ?????????? ??????S?OS ??S ????????S
?????S?S

• ???f??t??
• ??es? e?sf???se?? p?e?µ?????? t????e?d??
• ?e??d?ast?????? ????? t?? ??
• ?etaf??t??
• S?st????? ??
• ???e?a??? a?t?st?se??
• S?spast???t?ta
• ???sµa e????s?? ?? (f?s???????? µetaf??t??)
• dP/dtmax AK (sta?e??? ??? ??)
• ?e??s?st?????? ????? ? d??µet??? ??
• S?st????? ?e?t?????a
• ???sµa e????s?? ??
• ???? pa?µ??

• ??ast????? ?e?t?????a
• ??es? e?sf???se?? t?? p?e?µ?????? t????e?d??
• ?a??t?ta d?aµ?t??e?d???? ????
• ?a??t?ta ???? st?? p?e?µ?????? f??ße?
• ?a??µet??? Doppler (IVRT, ETDI, VP)
• S??????? ?a?d?a??e?a?? ?e?t?????a
• ???esµ?? µ??t?? f?eß???? a?µat??
• ??a??t?ta ?s??s??

Braunwald E, Zipes D, Libby P. Heart Disease, 6th
Ed. Saunders 2001
5
???????? ?????????? - ???S??S
? pa??f?s???????? e?e??? ?at?stas? ?at? t?? ?p??a
? ?a?d?? ad??ate? ?a a?t??se? a?µa µe ???µ?
a?tap??????µe?? st?? µetaß?????? a????e? t??
?st?? ? µp??e? ?a t? ep?t??e? µ??? µe a???s? t??
p??se?? p????se?? a?t?? ???pe? ?a d?a????eta? ap?
t? µ???a?d?a?? a?ep???e?a (??pt?s? t??
s?sta?t???t?ta?) ?a? ap? t?? ?????f?????
a?ep???e?a (?a?d?? ????? a?µat?? s?????t??s?
???a?µ?sfa?????? a??e?a?? d??t??)
Braunwald E, Zipes D, Libby P. Heart Disease, 6th
Ed. Saunders 2001
6
?a?d?a?? a?ep???e?a

• ?d??aµ?a pa????? a?µat?? se p?s?t?ta epa??? ??a
  t?? ?????? t?? µetaß?????? a?a???? t?? ?st?? ?a?
  t?? ???????

7
AHA/ACC Guidelines for the Evaluation and
Management of Chronic Heart Failure

• ?a?d?a?? a?ep???e?a e??a? ??a p???p???? ???????
  s??d??µ? p?? µp??e? ?a p?????e? ap? ?p??ad?p?te
  d?µ??? ? ?e?t??????? p???s? t?? ?a?d??? p??
  ep??e??e? t?? ??a??t?ta t?? ?a?d??? ?a ?eµ?se? µe
  a?µa ? ?a a?t??se? a?µa st?? pe??f??e?a
• ?a ????a s?µpt?µata e??a? ? d?sp???a ?a? ? ??p?s?
  p?? pe????????? t?? ??a??t?ta ?s??s?? ?d????? se
  ?ata???t?s? ?????, s?µf???s? p?e?µ???? ?a?
  pe??fe???? ??d?µa

8
?a?d?a?? a?ep???e?a

• ? ?a?d?a?? d?s?e?t?????a se ?? ?d??e? se a???s?
  t?? p??se?? p????s?? t?? ?a?d?a??? ?????t?t??
• ?e???? ???p?? ap? 2-5 se gt 7-20 mmHg p?? ?d??e?
  se as??t?, s?µf???s? ?pat?? ?a? pe??fe???? ??d?µa
• ???ste??? ???p?? ap? 5-12 se gt18-40 mmHg p??
  ?d????? se d?sp???a, p?e?µ????? ??d?µa ? ?a?
  ?pe????t??? s??????

9
??????s?

• ?ts? ? ?????? st???? st? d?????s? t?? ?a?d?a???
  a?ep???e?a? e??a? ? a????e?s? s?µe??? ?a?
  s?µpt?µ?t?? a???µ???? p??se?? st?? a??ste?? ?a?
  de??? ???p?, ap?t??esµa
• ?pe?f??t?s?? ?????
• ?aµ???? ?a?d?a??? pa?????

10
? ?a?d?? sa? a?t??a st?? ?a?d?a?? a?ep???e?a
11
??????????G?? ?.?.

• ? a???µ??? ep?pt?s? t?? ?a?d?a??? a?ep???e?a?
  fa??eta? ?t? ?fe??eta? st? ???a?s? t?? p????sµ??
• ? ep?pt?s? t?? ?a?d?a??? a?ep???e?a? e??a?
  ?????te?? st??? ??d?e?

?aste?????? S. ?a?d?a?? ??ep???e?a. ??d?se??
?a??s????? 2001
12
S?µpt?µat??? ?? ? ????f? t?? pa??ß?????!
S?µpt?µat??? ??
Stefa??a?a ??s?? ?a?????te? ???d????
?pe?t??f?a a?. ?????a?
?s?µpt?µat??? ??
S?
?d??pa?? s???e?? a?t?a
???
?p??tas?
13
???????G?? ?.?.
?p? ???????? ap??e?? ta a?t?a t?? ?a?d?a???
a?ep???e?a? ta????µ???ta? se 3 µe???e?
?at?????e? ??at?µ??? (ep??t?te? ? s???e?e??
pa??se?? p?? ep??e????? t? µ?????d??, t??
?a?d?a??? ßa?ß?de?, t? pe?????d?? ? t??
stefa??a?e? a?t???e?) ?a? ???a pa???e?et??? a?t?a
(p.?. a?t???a?? ?p??tas?) p?? a??????? t?
a?µ?d??aµ??? f??t?? t?? ?a?d??? ??µ???
(e????tta????? ?a? e?d???tta????? µetaß????) ?a?
?e?????µ????? a?t?a p?? e?????ta? ap?
pa??f?s?????????? pa?????te? (p.?. ?s?a?µ?a,
?pe?f??t?s? ????? ? p?es??) ?a? p?? a?????
?e?t??????? ?? a?t?sta?µ?st????
µ??a??sµ?? ????t??? a?t?a (p.?. a?a?µ?a,
???µ??e??) p?? ep?spe?d??? st? 50-90 t?? as?e???
t?? eµf???s? t?? s?µpt?µ?t?? t?? ?a?d?a???
a?ep???e?a?
?aste?????? S. ?a?d?a?? ??ep???e?a. ??d?se??
?a??s????? 2001
14
??t?a ?a?d?a??? a?ep???e?a?

• ?d??pa??? ????a?d??p??e?e? (d?atat???,
  ?pe?t??f???, pe?????st???)
• Stefa??a?a ??s?? ??e?a ?s?a?µ?a, ???, a?e???sµa
  a?. ?????a?
• ?pe?f??t?s? ??es?? ?p??tas?, St???s? a??t??
• ?pe?f??t?s? ????? a?ep???e?a µ?t??e?d??? ?
  a??t??
• ??????? ??s?e? ????p?e?µa, ???a???
• ?etaß????? ??d???????? S?, T??e?t?????s?,
  ???e??? ?e?aµ????
• ?????t??? ?µ???e?d?s?, ??µ????µ?t?s?
• F?e?µ???d? ???e??? µ???a?d?t?da

15
???????G?? ?.?.
Am Heart J 1991 1211852-3
16
??????T?S???? ????G????S ?.?.
? ep?d?as? t?? pa???s?a? pa?a???t?? ???d????
(????ste????, ??p??sµa, ??, d?aß?t?? ?a?
?pe?t??f?a t?? ?? st? ??G) st? s????t?ta
eµf???s?? ?? sta d?? f??a
?aste?????? S. ?a?d?a?? ??ep???e?a. ??d?se??
?a??s????? 2001
17
??p?? ?a?d?a??? ??ep???e?a?

• S?st????? ? ??ast?????
• ?????? ? ?aµ???? pa?????
• ?e??? ? ???ste??
• ??e?a ? ?????a

18
??p?? ?a?d?a??? ??ep???e?a?

• S?st????? a?epa???? ?s??? ?d??pa???
  µ???a?d??p??e?a
• ??ast????? pa???????? ???as? µ???a?d???,
  a?epa???? p????s? t?? a?. ?????a? ?pe?t??f???
  µ???a?d??p??e?a, aµ???e?d?s?, sa???e?d?s?

19
(No Transcript)
20
??p?? ?a?d?a??? ??ep???e?a?

• ?????? pa????? a???µ??e? apa?t?se?? ?st?? p??
  de? µp????? ?a ?a??f???? a?a?µ?a, ???e?t?????s?
• ?aµ???? pa????? s??d??µ? ?aµ???? ?a?d?a???
  pa?????

21
??p?? ?a?d?a??? ??ep???e?a?

• ?e??? af??? t?? de??? ?a?d?? ßa??? p?e?µ?????
  eµß???
• ???ste?? af??? t?? a??ste?? ?a?d?? ??? µe????
  p??s??? ?µf?a?µa
• S?µf???t??? ?a?d?a?? ??ep???e?a (S??) af??? ?a?
  t?? 2 ?????e?
• ??e?a ???, ???? ßa?ß?da?
• ?????a a??pt??? s?µpt?µ?t?? st?? p??e?a t??
  ?????? se p???p?????sa ?a?d?a?? ??s?

22
???a??sµ?? p??sa?µ????

• ??t????p?st???? µetaß????
• ?etaß??? ????? a?. ?????a?
• ?etaß??? p?es?? a?. ?????a?
• ???p?as? t?? ??????? µ??e???, s??µa, µ??a
• ?e?????µ?????? µ??a??sµ?? s?st?µa
  ?e?????-a??e??tas????-a?d?ste?????, ßa??p?es???,
  S?S (t???? a?t?????, s????t?ta, s?sta?t???t?ta)
• ???? ?S, ??
• ?? p??f??t??, µetaf??t??, s?sta?t???t?ta
  µ???a?d???

23
???S????G?S S??? ????OS? ??S ????????S ???????G??S
???S????G? ????????T?S?? ????????T?S?? ?ata???t?
s? ??at?? ????s? p??f??t??? ??e?µ?????
s?µf???s? ?a? ?dat?? ?a? ??d?µa
?st?? ???e??s?spas? ??at???s? t??
p??se?? ????s? µetaf??t??? ?a? a?µat?se??
?a?d???-e??ef???? ?ata?a??se??
e????e?a? S?µpa??t??? d???e?s? ?????e? t?? ?S
?a? e????s? ? ?ata?a??se?? e????e?a? S?µpa??t???
ape?a?s??t?p???s? ????????µ?s?
e????e?a? ?pe?t??f?a ?p?f??t??e? t??
ep?µ????? ?d??e? se ap?d???????s? µ???a?d?a???
??e? ?a? ???at? t?? ??tt???? t??
µ???a?d??? ?e??µ???? a???µ?? t????e?d?? ??de?a
e????e?a? ?????t?ta µ?t????d???? ? ?d??e? se
?????? t?? e?e??e?a??? ? ?d??e? se
??de?a a?a???? e????e?a? ?µf???s? ß?ade?a?
µ??f?? ????????µ?s? e????e?a? µ??s???? ?a??tas
? t?? d??aµ???? e?e??e?a? ? s?spast???t?t??
?a? ?ata?a??se?? e????e?a? ?e??µ???
p????t?ta a?t???? Ca2 ??ade?a ???as?
p??a?? t?? sa???p?asµat???? d??t??? e???????µ?
s? e????e?a? ????s? ????a????? ?p??e? ?a µe??se?
t? d??tas? ??ata??sse? t? ???as?
Katz AM. NEJM 1990 322100
24
(No Transcript)
25
(No Transcript)
26
??µ?? Frank-Starling
????? pa?µ?? S?sta?t???t?ta ???f??t?? ?etaf??t??
???? ?S, ?? ?? p??f??t??, µetaf??t??,
s?sta?t???t?ta µ???a?d???
27
(No Transcript)
28
??T?F?S????G?? ?.?.
S??s? µeta?? te??d?ast?????? ????? ?a?
s?spast???t?t?? t?? ?? ?? p??? t?? ?a?d?a??
ap?d?s? se ??eµ?a ?a? ?s??s?
Braunwald E, Zipes D, Libby P. Heart Disease, 6th
Ed. Saunders 2001
29
?a??f?s??????a S?? Remodeling a??ste??? ?????a?

• ?etaß??? t?? ?e?µet??a?, t?? µ??a? ?a? t?? ?????
  t?? a?. ?????a?

30
(No Transcript)
31
??t?µ?s?

• ?st?????
• F?s??? e??tas?
• S?µe?a pe??fe???? ??d?µa (??t? ?????), a???s?
  ?S, ????? ??????, d??tas? sfa??t?d??
  (?pat?sfa??t?d??? s?µe??), 3?? ?a?d?a??? t????
  ?a?pasµ??, 4?? ?a?d?a??? t????
• S?µpt?µata d?sp???a (p??spa?e?a?, ??eµ?a?,
  ????p???a, pa????sµ??? ???te???? d?sp???a),
  ?ataß??? d???µe??, pe?????sµ?? d?ast????t?t??
• ??G, ?/a ???a?a

32
??????? ?????? ?.?.
S?µpt?µa ??a?s??s?a ??d???t?ta ???ß?ept???
a??a ? s?µe?? () ()
() ??sp???a st?? ??p?s? 66
52 23 ????p???a 21
81 2 ?a????sµ???
d?sp???a 33 76
26 ??d?µa (a?afe??µe??) 23
80 22 ?S ??eµ?a? gt100/min
7 99 6 ?????
?????? 13 91
21 3?? t???? 31 95
61 ???tas? sfa??t?d?? 10
97 2 ??d?µa (?at? t??
e??tas?) 10 93
3
?aste?????? S. ?a?d?a?? ??ep???e?a. ??d?se??
?a??s????? 2001
33
??sp???a - ??d?µa
34
????t??da?t???a
35
???tas? sfa??t?d??
36
?e??fe???? ??d?µa
37
F?eß????µß?s?
38
???????? FRAMINGHAM G?? ?? ???G?OS? ??S ?.?.
?e????a ???t???a ?a????sµ??? ???te????
d?sp???a ???tas? t?? t?a??????? f?eß?? ?????
?????? ?e?a???a?d?a st?? a/a ???a??? ???
p?e?µ????? ??d?µa ?a?past???? ???µ??
(S3) ?e?t???? f?eß??? p?es? gt16 cm H2O ??????
?????f???a? ?25 sec ?pat?sfa??t?d???
pa???d??µ?s? ??e?µ????? ??d?µa, s?µf???s?
sp?????? ? µe?a???a?d?a st?? pa??????a?at?µ???
e??tas? ?p??e?a ß????? ?4,5 kg se 5 ?µ??e? ??
ap??t?s? st? ?e?ape?a ???ss??a ???t???a ?µf?te??p?
e??? ??d?µa sf???? ???te????? ß??a? ??sp???a st?
s????? ??p?s? ?pat?µe?a??a ??e???t???
s?????? ?e??s? t?? ??t???? ????t???t?t?? ?at? t?
1/3 t?? µ???st?? t?µ?? ?a???a?d?a (?120
pa?µ??/min)
Ho KL, Pinsky JL, Kannel WB, Levy D. JACC 1993
22(Supl A)6A
39
(No Transcript)
40
??e?e???s? ??

• ??G
• ?/a ???a???
• ?pe?????a?d?????f?µa
• ?ad???s?t?p???? µ???d??
• ?a?d?a??? ?a?et???asµ?? - a??e???a?d????af?a
• ?a?d??a?ap?e?st??? ??p?s? - sp???µ?t??s?
• ?????µ???? a?µat???????? ??e???? ?e????
  a?µat??, ß????µ???, ?e???? ?????, ??e?t????te?,
  ??p?da?µ??? p??f??, ???e?e?d??, t?t???
  a?t?s?µ?t?? ??a?t? ???

41
??G
Braunwald E, Zipes D, Libby P. Heart Disease, 6th
Ed. Saunders 2001
42
?/? TO????S
http//info.med.yale.edu/intmed/cardio/imaging/con
tents.html
43
ECHO
www.mayoclinic.org
Braunwald E, 2001
www.kentmedicalimaging.co.uk
44
??????S???????S ??T????
Braunwald E, Zipes D, Libby P. Heart Disease, 6th
Ed. Saunders 2001
45
????????S ??T??????S??S - ?GG?????????G??F??
www.chh.org
Braunwald E, Zipes D, Libby P. Heart Disease, 6th
Ed. Saunders 2001
46
?????????????S???? ???OS?
patientrecruitment.nhlbi.nih.gov
Braunwald E, Zipes D, Libby P. Heart Disease, 6th
Ed. Saunders 2001
Grossman W. In Grossman W, Baim DS Cardiac
Catheterization, Angiography and Intervention,
5th ed. Philadelphia, Lea Febiger 1996, p 110
47
BNP
www.nanken.or.jp/work/ repo2001/repo2_08.html
www.ilsdk.dk
Jose JV, Gupta SN, Selvakumar D. Indian Heart J
2003 553539
48
???????G??? ????????S? ?.?. ???? N.Y.H.A.
49
S????? T???????S

• ??????? - ??e???? t?? a?t??? p?? ?d????? se
  ?a?d?a?? d?s?e?t?????a ?a? ??
• ??????? e??????? t?? e??atest?µ????
  d?s?e?t?????a? se ??
• ?e?t??s? ??s???t?ta? (d?at???s? - ße?t??s?
  p???t?ta? ????)
• ?e?t??s? ???t?t?ta? (pa??tas? d????e?a? ????)
• ESC HF-Guidelines, Eur Heart J 2001

www.shapestudy.info
50
G????? ?????

• ???µ???s? ??a t? t? e??a? ??, ta a?t?a, ta
  s?µpt?µata, t? ?e?ape?a ?a? t?? p?????s?
• ??e???? s?µat???? ß????? s??d???eta? µe ?
  ???t?t?ta
• WHARF trial (Am Heart J 2003)
• ??e???? d?a?t?t???? p??s????? Na ?a? ????? se
  s?ßa?? ??
• (class I, evid. B)
• ?µß???asµ?? ?at? p?e?µ?????????? ?a? a?µ?f????
  ??f?????t?a?
• ?p?f??? ?ap??sµat??, ?pe??ata????s?? a????? ?a?
  ????a????
• (class I, evid. C)
• ACC/AHA HF-Guidelines, JACC 2001
• ESC HF-Guidelines, Eur Heart J 2001

51
G????? ?????

• ?p?f??? NSAIDs, class I a?t?a????µ????,
  a?ast????? Ca2, ???t???ste??e?d??, t??????????
  a?t??ata???pt???? ?a? ?????? se s?µpt?µat??? ??
• (class I, evid. B) - Feenstra, JACC 1999
• ????????s? p????aµµ?t?? ?s??s?? p??? ße?t??s? t??
  ???????? ?at?stas?? se sta?e??p???µ????? as?e?e??
• (class IIa, evid. A st? st?d?? G)
• ? s?µpt?µ?t??, ? ??a??t?ta? ?s??s?? ?at? 15-25
  ?a? ? p???t?ta? ????
• ??s???t?ta ?a? ???t?t?ta ()
• Working Group for Exercise Testing in HF, Eur
  Heart J 2001
• Eur H.F. Training Group, Eur Heart J 1998
• Adamopoulos, Int J Cardiol 2003

52
??t?µet?p?s?

• ?? fa?µa?e?t??? ?e?ape?a µe??s? p??s?????
  ?at???? ?a? ?e???, µe??s? ß?????, p?????µµata
  ap??at?stas??
• Fa?µa?e?t??? a????
• ??????t??? f????seµ?d?
• ???e??d?asta?t?? a?ast??e?? µetat?ept????
  e???µ??, d?a???? asßest???, ?d?a?a????,
• ???t??pa da?t???t?da,
• ß-a?ast??e?? µet?p??????
• ??t?p??t??? ßa?fa????

53
??????t??? ??ast??e?? ?a?ß?????? a??d??s??
(a?eta???aµ?d?) ??ast??e?? t?? s?µµetaf????? Na,
K, 2Cl- (d?????t??? t?? a??????) ??ast??e?? t??
s?µµetaf????? ?a/Cl- (?e?a??de?) ??ast??e?? t??
ep?????a??? d?a???? ?a (t??aµte????,
aµ?????d?) ??ta????st?? t?? ?p?d???a t?p?? 1 t??
a?at?-/????????t???e?d?? (sp??????a?t???) ??ta????
st?? ?p?d????? ßa??p?ess???? V2 ?at??????t???
pept?d?a ???e??d?asta?t??? ??t??d? ?µesa d???ta ?
a???st?? µ??a??sµ?? d??se?? ??ast??e?? d?a????
asßest??? ??e???p???t?? t?? ATP-e?a?t?µe???
d?a???? ? ???e??d?asta?t???? p??sta??a?d??e? ?at?
?????t??? pept?d?a ?e?????µ?????? a?ast??e??
F?????? ?.?.
Braunwald E, Libby P. Heart Disease, 6th Ed.
Saunders 2001
54
Tet??? ???t??pa ?a?????a t?? da?t???t?da? ?????st?
? t?? ß-ad?e?e?????? ?p?d????? ??ast??e?? t??
f?sf?d?este??s?? ??ast??e?? t?? f?sf?d?este??s??
µe d??s? e?a?s??t?p???t? Ca2 ?a?a???
e?a?s??t?p???t?? Ca2 ?e?????µ?????? a?ast??e?? ?
a?ast??e?? ??tta??????? ??ast??e?? t?? s?st?µat??
?e?????-a??e??tas????-a?d?ste????? ??t?ad?e?e?????
? e??se?? ??ta????st?? t?? e?d???????? ??ast??e??
t?? ??d?te??? e?d?pept?d?s?? ??ast??e?? t??
TNF-a ?e????t???? ?ate????se?? G???d?a??
?e?ape?a Fa?µa???e?et??? ???? µ???a??? st????
F?????? ?.?.
Braunwald E, Zipes D, Libby P. Heart Disease, 6th
Ed. Saunders 2001
55
?p?µ??? ?a?d?a?? a?ep???e?a
56
S?s?e??? ?a?d?a??e?a??? ?p?st??????

• ??d?a?a?t??? a?t??a µe ae?????aµ?

57
(No Transcript)
58
??F????S???? ???????S??S
59
??F????????? ??????????S?
www.hopkinsmedicine.org
60
Resynchronisation Improves Function
Myocardial dysfunction remains but synchrony
improves efficiency
61
??p???t?s? ß?µat?d?t?
62
?µf?te?s? ap???d?st?
63
???????G???S ???????S

• ?pa?a?µ?t?s? µ???a?d??? µe a??t?stefa??a?a
  pa???aµ?? (CABG) se as?e?e?? µe ?s?a?µ???
  ?a?d??µ??p??e?a (ICM), µe e?de??e?? ß??s?µ?t?ta?
  ???????? (st??????) ? e??ast???a???
  (sp?????????f?µa/stress echo) ?a? µe µ?s?e?s?µa
  a??e?a (?a??? pe??f??e?e? ?a? st???? st?
  stefa??a?? d??t??)
• ACC/AHA CABG-Guidelines, JACC 1999
• ?µ?? ? e??e???t??? ???t?t?ta se as?e?e?? µe ??
  ?? ?a? ? NYHA
• CABG Patch Trial, 1999
• off pump ep?µßas? µe t?? ?a?d?? p?????sa ?a?
  a????t?p???s? µ??? t?? a??e??? p?? d??eta? t?
  µ?s?e?µa d??at? ?a ? t? ?e????????? ???d???,
  a??? ??e?????ta? pe?a?t??? µe??te?
• Antunes, Eur J Cardiothor Surg 1999
• se ???µß? ????f??/a?e???sµa ?? µet? e?tetaµ???
  p??s??? ?? ???µße?t?µ?/a?e???sµate?t?µ?
  (e?d?a?e???sµat???af? p?? d?at??e? t? ?e?µet??a
  t?? ??)
• RESTORE group, 1999

64
???????G???S ???????S

• e? e?e???e? µe??te?
• HEART-UK optimal a???? vs optimal a????
  CABG se ICM
• STITCH CABG vs CABG ??????p?ast??? se ICM
• ?e???? a??ste?? ?????e?t?µ? (e??e???s? Batista)
  ?a? ?a?d??µ??p?ast??? ????? ?fe??? ?a? ?
  ???t?t?ta ? de s???st??ta?
• Hayward, Heart 1999
• McCarthy, Eur J Cardiothor Surg 1998
• ??µ?d??aµ??? s?µa?t???? ßa?ß?d?p??e?e? d?????s?
  ? a?t??at?stas? ßa?ß?d?? (st?d?? ?, class ?,
  evid. ?)
• s?ßa?? de?te??pa??? a?ep???e?a µ?t??e?d??? ????
  d??tas?? da?t????? ?a? ?????a??? a?ad?aµ??f?s??
  se ?? stad??? ? a?a?atas?e?? µ?t??e?d??? µe
  da?t????p?ast??? ? p???µa ?a? µes?p???esµa ?f???,
  a??? ??e?????ta? pe?a?t??? µe??te? (class ?Ib,
  evid. C)
• ACC/AHA HF-Guidelines, JACC 2001
• Bolling, J Thor Cardiovasc Surg 1995, 1998

65
???????? ???S??????
66
(No Transcript)
67
(No Transcript)
68
???????? ???S??????

• ?s?e?e?? µe s?ßa??? ßa?µ?? ?? gt50 ???at?? se lt1
  ?t??
• Cleland, Eur J HF 1999
• ?p???f??? as?e?e?? NYHA IV ??a ?28 ?µ??e? pa??
  t?? optimal ?e?ape?a, CI lt2 lt/min/m2, S?? ?80
  mmHg, p?es? ???p?? gt20 mmHg, ???a?a d?????s? lt20
  ml/h ?a? SVRs gt2.100 dyn/sec/cm5
• Ventricular assist devices (VADs)
• ??f??a p??? a?????? µ???a?d??? (bridge to
  recovery-BTR) as?e?e?? µe ?a?d???e?? ?atap????a
  -p.?. s??d??µ? µet? ?a?d??t?µ?- ? µet? ???
  (?p?st????? ??? ?µ??e?/eßd?µ?de?),
  µ???a?d??p??e?e? ???e?e?? -p.?. ?e?a???ß????
  µ???a?d?t?da- ? µet? t??et? (?p?st????? ???
  eßd?µ?de?/µ??e?)
• Hetzer, Ann Thor Surg 2001
• IABP, ABIOMED-BVS 5000, f????e?t??? a?t??a
• ?? TNF-a ?a? p???µ? ? BNP p??sµat?? e?de??t???
  a??????? t?? µ???a?d???
• Guillermo, Circulation 1999
• Sodian, JACC 2001

69
???????? ???S??????

• ??f??a p??? µetaµ?s?e?s? (bridge to
  transplantation-BTT) as?e?e?? se ??sta ??a
  µetaµ?s?e?s? µe ep?de????µe?? ??
• Novacor, Heartmate ?a? Jarvik 2000 (LVADs) ?a?
  Thoratec (LVADRVAD) eµf?te?s?µe? s?s?e???
  ???st?? ß??s?µßat?t?ta? µe p???? d?ast????p???s?
  ?a? e??t???? t?? as?e???? ap? t? ??s???µe??
• Goldstein, NEJM 1998
• µ???st?? ?????? ?p?st?????? 4,1 ?t? (Novacor)
• ep?ß??s? 38-75 ?? t? µetaµ?s?e?s? ?a? 33-59 ??
  t?? ???d? ap? t? ??s???µe??
• Portner, Ann Thor Surg 2001
• Jarvik 2000 se 10 as?e?e?? µe ?p?st????? 84
  ?µ??e? ?.µ.?., 8? ap? NYHA IV se NYHA I, 7?
  µetaµ?s?e????a? ?a? 3? apeß??sa?
• Frazier, Circulation 2002
• 30-50 a??st??f? a?ad?aµ??f?s? ?a? ??? 17
  a?????? t?? µ???a?d??? µet? pa?atetaµ???
  ap?f??t?s? a?t?? ?a? afa??es? t?? VAD
• Rose, NEJM 2001

70
???????? ???S??????

• se a?aµ??? ??a µetaµ?s?e?s? (1) 25-40 SCD se ?
  ?p? VAD ? AICD (), (2) ? non-SCD ???at?? se ?
  ?p? AICD ? VAD (). S??d?asµ?? ef??t??, a???
  ??e?????ta? µe??te? ep?ß??s??
• Duru, Eur Heart J 2002
• ??a??a?t??? ??s? t?? µetaµ?s?e?s?? (destination
  therapy) Novacor ?a? Heartmate
• REMATCH 129 ? NYHA IV µe te????? stad??? ?? ?
  VADs vs f??µa?a ? (1) 27 ? ???t?t?ta? se 1 ?t??
  ?a? 48 ? ???d???? ?a??t?? ap? ???e a?t?a
  (p0,001), (2) ep?ß??s? et?s?a 52 vs 25
  (p0,002), st??? de ? ?????a? lt60 et?? 74
  (µetaµ?s?e?s??), d?et?? 23 vs 8 (p0,09) ?a?
  µ?s? 408 vs 150 ?µ??e? a?t?st???a, (3) ße?t??s?
  t?? p???t?ta? ????, (4) ep?p????? s????te?e? ?at?
  2,35 f???? (a?µ???a??e?, ???µ??e??,
  ???µß?eµß????, de??? ??)
• NEJM 2001

71
???????? ???S??????

• ?e???t? ?a?d?? (TAH)
• Cardiowest-TAH se 225 ? ? 72 ep?ß??s? µe
  ?p?st????? 24 µ??e? ?.µ.?.
• Copeland, Ann Thor Surg 2001
• ?? BTT ?at? p??t?µ?s? se ? (1) µe p??????µ??? ??
  se ???s?µ? ?at?stas?, (2) ????? ?? ?d??? µe de???
  ??, ?PVRs ?a? p?e?µ????? ??d?µa, (3) ?ef???? ?
  ?pat??? a?ep???e?a ???? ?CO, (4) µa????
  µ???a?d?a?? ß??ß? -p.?. VSD µet? ap? ??- ? µ?
  a?ast????µ? ap?????? t?? ?a?d?a??? µ?s?e?µat??,
  (5) ßa?ß?d?p??e?a, (6) ape??a??e? a????µ?e? ?a?
  ??
• Abiocor-TAH e?????e?sa ap? t? FDA (7/2001) se
  p????aµµa µe st??? ep?ß??s? gt2 µ??e? ?a? ?????
  ep?p?????
• Samuels, Cardiol Clin 2003
• O? destination therapy se ? µ? ?p???f???? ??a
  µetaµ?s?e?s? µe ????? ?? ?a? p??sd???µ? ep?ß??s??
  lt1µ??a ? ep?t??? ap?te??sµata se 4/7 ? ??? t??a
• Pennstate-TAH se p????????? st?d??

72
Bicaval Orthotopic Heart Transplantation Technique
Hosenpud JD, Bennet LE, Keck BM, et al. J Heart
Lung Transplant 2000 19909-31
73
??????S???S?

• ?at?????a ep??e?µ???? as?e?e?? µe ?? stad??? ?
  (class ?, evid. ?)
• ACC/AHA HF-Guidelines, JACC 2001
• ?p???te? e?de??e?? (1) a?µ?d??aµ??? ?at???e???
  ???? ?? (a??e?t??? ?a?d???e??? shock,
  te?µ????µ??? e???t?s? ap? ?F ???t??pa, peak
  VO2lt10ml/kg/min µe ep?te??? a?ae??ß???
  µetaß???sµ??), (2) s?ßa?? s?µpt?µata ?s?a?µ?a?
  p?? sta?e?? pe????????? t? s?????sµ???
  d?ast????t?ta ?a? de? a?tap???????ta? se CABG ?
  PTCA, (3) ?p?t??p?????se? s?µpt?µat???? ?????a???
  a????µ?e? a??e?t???? se ??e? t?? ?e?ape?e?
• ?p?ß??s? se ???sµ??a ???t?a, ??? 80-90/?t??,
  70/5et?a, 50/10et?a. ??? 2/3 t?? as?e??? µet?
  ??a ????? ep?st??f??? se µe????/????? apas????s?
• Taylor, Ann Thor Surg 2003
• Hosenpud, 18th Official Report, J Heart Lung
  Transpl 2001

74
??????S???S?

• ???ß??µata (1) a???t??? ?s?????? p??sf???? -
  ??t?s?? µ?s?e?µ?t?? (st?? ??? µetaµ?s?e???ta?
  lt2500 as?e?e??/?t?? ?a? st?? ????da 1 e??efa????
  ?e???? d?t?? µ?s?e?µat?? ?a?d???/e?at?µµ????
  p????sµ??), (2) ap?????? t?? µ?s?e?µat?? ? p???µ?
  ???t?t?ta st?? 1? µ??a, ?a? (3) µa???p???esµa ??
  s???pe?e? t?? a??s??atast???? (???µ???, a?t???a??
  ?p??tas?, ?ef???? a?ep???e?a, ?a????e?a) ?a? ?
  a??e??p??e?a t?? µ?s?e?µat??
• Hertz, 20th Annual Reports, J Heart Lung Transpl
  2003
• ????µ? µete??e???t??? ???t?t?ta lt10. ?
  p?e????f?a t?? ?a??t?? s?µßa??e? µet? t?? 1?
  µ??a. ??a, st???? e??a? ? ße?t??s? t??
  a??s??atast????
• Tacrolimus vs ?????sp????? se µetaµ?s?e?se??
  s?µpa??? ??????? ?a? µ?e??? ?st?? ? t? ?d?? ? p??
  ap?te?esµat??? ?? p??? t?? ep?ß??s? as?e??? ?a?
  µ?s?e?µat??, ?e?ape?a a?ep???e?a? ?a? s????t?ta
  ????? ?a? a??e?t???? sta ???t???e?d? epe?s?d???
  ap???????
• Scott, Drugs 2003

75
(No Transcript)
76
??????? Te?ape?a S??
77
(No Transcript)
78
(No Transcript)
79
(No Transcript)
80
(No Transcript)
81
??e?µ????? ??d?µa
82
??e?µ????? ??d?µa ???sµ??

• ?a???????? a???s? t?? e??a??e?a??? ????? (?e???)
  t?? p?e?µ????, p??a? t?? f?s?????????

83
? ???e??d?t????e?d??? µeµß????
?S???e??da IS?es???tt????? ????? RBCe?????
a?µ?sfa???? BM?as??? µeµß???? EPep?????? Ee?d??
????
?p? J.Murray 1976
84
?? d???µe?? t?? Starling st?? p?e?µ??a
?d??stat???? p??se??
Osµ?t???? p??se??
Kfc capillary filtration coefficient, Pmv
microvascular hydrostatic pressure, Pi
interstitial hydrostatic pressure, s protein
reflection coefficient, pi interstitial oncotic
capillary pressure, and pmv microvascular
oncotic pressure
85
?? ?d?? t?? p?e?µ????

• . .
• Q flux Kf x (Pmv-Ppmv) s(pmv-ppmv) Q lymph
• 10 20 ml/h (x 5-10 f????)
• ????st? ????t???t?ta d?aµ?s?? ????? 300-500ml
  (30-50 t?? ß????? t?? p?e?µ??a)

86
Trans-vascular fluid flux (Staling Law)

• Kfc (Pmv Pi) s (pi pmv)
• Kfc capillary filtration coefficient,
• Pmv microvascular hydrostatic pressure,
• Pi interstitial hydrostatic pressure,
• s protein reflection coefficient,
• pi interstitial oncotic capillary pressure, and
• pmv microvascular oncotic pressure

87
Q K(Pcap - Pis) - l(Pcap - Pis)

• Q d????s? ?e???
• K sta?e?? (filtration coefficient)
• Pcap ?d??stat??? p?es? t????e?d?? p?? ?d??e? t?
  ?e?? ??? ap? ta t????e?d?
• Pis ?d??stat??? p?es? d??µes?? ????? p?? ?d??e?
  t? ?e?? µ?sa sta t????e?d?
• L reflection coefficient, de???e? t?? ??a??t?ta
  a?e?a??t?ta t?? t????e?d?? ?a ap?t?????? t??
  d??d? t?? p??te????
• Pcap ?????e?d?sµ?t??? p?es? p??sµat?? p??
  ?d??e? t? ?e?? µ?sa sta t????e?d?
• Pis ?????e?d?sµ?t??? p?es? d??µes?? ????? p??
  ?d??e? t? ?e?? ??? ap? ta t????e?d?

88
H d?????sa p?es?
Pmv-Pis12-(-4)16mmHg (pmv-ppmv) x s (20-12)x
0.7 6 ??16-610mmHg
89
(No Transcript)
90
??e?µ????? ??d?µa
91
??t?a p?e?µ?????? ??d?µat??

• ????s? p??se?? st? a??e?a?? d??t?? t?? p?e?µ????
• ???ste?? ?a?d?a?? a?ep???e?a
• ?s?a?µ??? ?a?d??p??e?a
• ????a?d??p??e?e?
• ?a?ß?d?p??e?e?
• St???s?
• ??ep???e?a
• ?pe?tas??? ???s?
• ?pe?f??t?s? ????? ?????

92
(No Transcript)
93
???

• S?µpt?µata
• ??S?????
• ???spa?e?a?
• ???te???? pa????sµ???
• ??eµ?a?
• ????p???a
• ????d?? a?ap???
• ?????a ?????
• ?a?a??????? ß??a?
• S????µ??
• ?a??p???a
• ?a???a?d?a

94
???

• ??t??e?µe???? e???µata
• ????? ??????
• ????µ??? ad?e?e????? d?ast????t?ta (ef?d??s?,
  ta???a?d?a)
• ???tas? sfa??t?d??
• ?pat?sfa??t?d??? s?µe??
• ?pat??e?a??a
• ??d?µata, as??t??, ?d?????a?a?
• ??a?ass?µe??? sf??µ??

95
?p?d?as? st?? a?ta??a?? ae???? - ?p??????a?µ?a
96
?????s? t?? ???e??d?? µe ?e??
97
?e??fe???? ??d?µa se ßa??? S??
98
???

• ????µata ap? ?a?d??
• S3
• ? P2
• S?st????? f?s?µata a?ep???e?a? ???p??????a???
  ßa?ß?d??

99
(No Transcript)
100
???

• ?/a ???a???
• ?a?d?? ?/T de??t??
• ??e?µ????? ped?a s?µf???s?, a?ast??f? ????,
  ???e??d??? ??d?µa
• p?es? p?e?µ?????? t????e?d?? ?a? a??ste???
  ???p?? 4-12mmHg
• ? t?? p??se??
• 13-17mmHg e??s?s? e????? a??e??? ??? ?a? ??t?
  p?e?µ?????? ped???
• 20-25mmHgd??µes? p?e?µ????? ??d?µa
• gt25mmHg p?e?µ????? ??d?µa

101
??t????????? e???µata se ???

• ????µ??? µe?e??? ?a?d???
• ???tas? a??e?a??? µ?s???
• ??ast??f? ????
• G?aµµ?? Kerley
• ?e??a??e?a??/ß??????? as?fe?a
• ?e?t???? ?ata??µ? ??d?µat??
• ?pe????t??? s??????

102
? s??desµ?????a ??a de??? ?a?et???asµ?
103
??es? e?sf???s?? p?e?µ?????? t????e?d??
104
?e???? ?a?et???asµ??
105
(No Transcript)
106
(No Transcript)
107
CXR f?s???????? ?a? se ??
108
CXR se p?e?µ????? ??d?µa
109
??e?µ????? ??d?µa
??????? p?e?µ?????? ??d?µat??
110
(No Transcript)
111
(No Transcript)
112
??a???st???? ??e???? se ???

• ?st????? f?s??? e??tas?
• ??t??? s?µe?a ??, Sf, ??????s?, ???efa????
  ?e?t?????a, Te?µ???as?a
• ??G s??e??? ?ata??af? ???µ??
• ??et?se?? a?µat?? ?e????, ß????µ???, ?a?d?a??
  ????µa
• ?a?µ??? ???µet??a a???a a?µat??
• ?/a ???a???
• ?pe?????a?d?????f?µa Doppler/Triplex
• ?a?d?a??? ?a?et???asµ?? de???? / a??ste???
  (stefa?????af?a)

113
(No Transcript)
114
??t?µet?p?s? ???

• T?s? as?e????
• ??d?f??ß??? ?a?et??a?
• ???????
• ??µ?d??aµ??? sta?e??p???s?
• ??????t??? f????seµ?d?
• ???f???
• ???e??d?asta?t??? ??t??????e????, ??t??p??ss???
• ???t??pa d?ß??taµ???, ?t?paµ???
• ??t?p??t??? ???µß???t???
• ???e??p?ast???
• ???a????? ae??sµ??
• Te?ape?a ?p??e?µe??? p???s?? (ßa?ß?d?p??e?a, S?)

115
(No Transcript)
116
???f???
117
???????µ?? a?t?µet?p?s?? ???
??????? s?µe?a ?a? s?µpt?µata ????? ??e?µ??????
??d?µat?? ? F????seµ?d? IV (0.5 1
mg/kg) ???f??? IV (2 4 mg) ??t??????e????
?p????ss??? ??fed?p??? ?p????ss??? ???????
??? ? ??t???a?? ??es? ? ? ? ? ?? gt 100
mmHg ?? 70 100 mmHg
?? ? 100 mmHg ??t??p??ss???
IV(0.15 µg/kg/min) ?t?paµ??? IV (515 µg/kg/min
?t?µp??taµ??? IV (220 µg/kg/min) ??t??????e????
IV (1020 µg/kg/min) ? ???e? d?a???st???? ?a?
?e?ape?t???? ep?????? ?e???? ?a?et???asµ?? ??d?a??
t??? a?t??a Stefa?????af?a ??as?????s? t??
t?a?e?a?  
118
??de??e?? d?as?????s?? ?a? ??? st? ?a?d???e???
??e?µ????? ??d?µa
?p?tas? s?? ???????? e?de??e?? µ? ?p???????t??
??d?µat?? ??ep???e?a a??ste??? ?????a?, a??e?t???
st?? ?e?ape?a S???p?????sa ??s?? t??
p?e?µ???? S?ßa??? a????µ?e? ?????? d?e????e?a?
?e???sµ?? (a??e????af?a ? e??e???s?)
119
?s?????? ?e??? ?a? a?ta??a?? ae???? se ???

• ????a a?µat??
• MV 100
• pH 7,48
• pCO2 29mm Hg
• pO2 56mm Hg
• HCO-3 21mmol/l
• S??????? ?s??????
• -300ml

120
?s?????? ?e??? ?a? a?ta??a?? ae???? se ???

• ????a a?µat??
• MV 100
• pH 7,46
• pCO2 35 mm Hg
• pO2 72 mm Hg
• HCO-3 24 mmol/l
• S??????? ?s??????
• -1350 ml

121
?s?????? ?e??? ?a? a?ta??a?? ae???? se ???

• ????a a?µat??
• MV 100
• pH 7,46
• pCO2 31 mm Hg
• pO2 86 mm Hg
• HCO-3 24 mmol/l
• S??????? ?s??????
• -1550 ml

122
?s?????? ?e??? ?a? a?ta??a?? ae???? se ???

• ????a a?µat??
• MV 100 ? MV 50
• pH 7,45 ? 7,40
• pCO2 35 ? 34 mm Hg
• pO2 117 ? 64 mmHg
• HCO-3 23 ? 23 mmol/l
• S??????? ?s??????
• -2980 ml

123
?s?????? ?e??? ?a? a?ta??a?? ae???? se ???

• ????a a?µat??
• MV 50 ? ?/? 5 l/min
• pH 7,46 ? 7,47
• pCO2 38 ? 33 mm Hg
• pO2 69 ? 63 mm Hg
• HCO-3 26 ? 23 mmol/l
• S??????? ?s??????
• -4280 ml

124
?s?????? ?e??? ?a? a?ta??a?? ae???? se ???

• ????a a?µat??
• ?/? 4 l/min
• pH 7,46
• pCO2 34 mm Hg
• pO2 72 mm Hg
• HCO-3 24 mmol/l
• S??????? ?s??????
• -4640 ml

125
?s?????? ?e??? ?a? a?ta??a?? ae???? se ???

• ????a a?µat??
• ?/? 4 l/min
• pH 7,46
• pCO2 34 mm Hg
• pO2 101 mm Hg
• HCO-3 24 mmol/l
• S??????? ?s??????
• -6374 ml

126
?s?????? ?e??? ?a? a?ta??a?? ae???? se ???
127
??ast????? d?s?e?t?????a

• ??t?a
• ??e?a ?s?a?µ?a
• ?????a ?p??tas?
• ?a??? st???s? a??t??
• ?????t??? µ???a?d????e?a
• ?pe?t??f??? µ???a?d??p??e?a

128
??ast????? d?s?e?t?????a

• ?a???????? ???as? a?. ?????a? ate??? p????s? ?
  a???s? t?? p?es?? st?? a?. ?????a, a?. ???p?,
  p?e?µ?????? f??ße?
• S?µe?a ?a? s?µpt?µata s?µf???t???? ?a?d?a???
  a?ep???e?a? ?d?a?te?a se as?e?e?? µe s???p?????sa
  s?st????? d?s?e?t?????a

129
??ast????? d?s?e?t?????a

• S?µpt?µata
• ??sp???a p??spa?e?a?
• ??? p?e?µ????? ??d?µa
• ??????s?
• U/S
• ?ad???s?t?p??? ????????af?a
• Te?ape?a
• ??????s? ?a? a?t?µet?p?s? a?t???

130
???S?????? ?.?.

• 20-50 t?? ? µe ??, s?????? ??????µ??e? ???a??e?,
  pa??sa??e?, µe ?? ?a? S?
• Jessup, NEJM 2003
• Hunt, JACC 2001
• T??t?t?ta ?a? ???µ?? e?sa????? p??se??????? t??
  s?st?????? ??
• Senni, JACC 2001
• ?µ?? de? pe???aµß????ta? st?? µe???e? ????????
  µe??te? ??, ep?µ???? ?e?p??? ?? ?e?ape?t????
  a??????µ?? ??a t? d?ast????? ??
• ? a?t?µet?p?s? t?t???? ? ßas??eta? st?? ??e???
  pa?a???t?? p?? e??a? ???st? ?t? ep??e????? t?
  d?ast????? ?e?t?????a
• Angeja, Circulation 2003

131
???S?????? ?.?.

• ??a???f?s? ap? t?? ?pe?f??t?s? ????? (class ?,
  evid. C) pe?????sµ?? ????? ?a? p??s????? Na,
  d?????t??? (??? ?? p??f??t???) ?a? a?µ?d????s? se
  ? µe ?ef???? a?ep???e?a
• ?e??s? ?a?d?a??? s????t?ta? ?a? ße?t??s? ??????
  d?ast?????? p????s??, ?d??? se AF (class ?, evid.
  C) ß-a?ast??e?? ?a? d??t?a??µ?/ße?apaµ???
  (ße?t??s? pa?aµ?t??? ?s??s??) ?a? ?s?? d???????
  (st? µe??t? DIG 1997, pa??µ??a ? e?sa????? se ?
  µe ?? µe/????? s?st????? d?s?e?t?????a)
• ?p??at?stas? SR se AF (class I?b, evid. C)
  a?t?a????µ??? ?a? DC shock p??? p??a?? ße?t??s?
  d?ast?????? p????s??, a??? ap?te?esµat???t?ta ?a?
  t?????t?ta t?? ?????a? a?t?a????µ???? a????? ()
• Yu, Pacing Clin Electrophysiol 2001

132
???S?????? ?.?.

• ?p???e?sµ?? ????a ?e?????-a??e??tas????
• a-??? ße?t??s? ???as?? ?a? d?atas?µ?t?ta? ?? ?a?
  µa???p???esµa a?ast??f? ?pe?t??f?a? ?a? ???
• Flesch, J Hypertens 1997
• Friedrich, Circulation 1994
• LIF? ??a gt4 ?t?, 9.193 ? µe ?? ?a? ?pe?t??f?a ??
  st? ??G ? ??sa?t??? vs ate?????? ? 13 ?
  s??d?asµ???? ?a?d?a??e?a??? ??s???t?ta? ?a?
  ???t?t?ta? (23,8 vs 27,9, p0,02) ?a?
  e?t???te?? ?p?st??f? t?? ?pe?t??f?a? t?? ?? st???
  6 µ??e? ?a? ??a ???e ????? ??? ta 5 ?t? (plt0,001)
  µe pa??µ??a ? st?? ?? ?a? ?a??te?? a????
• Lancet 2002 Circulation 2003
• CHARM-preserved ??a 36,6 µ??e? ?.µ.?., 3.023 ?
  µe s?µpt?µat??? ?? ?a? ??gt40 ? ?a?tesa?t??? 32
  mg/d vs placebo ? ? e?sa????? ??a ?? (p0,017),
  a??? pNS ?? p??? t?? ?a?d?a??e?a?? ???t?t?ta
• Lancet 2003

133
???S?????? ?.?.

• ??e???? ?? s?µf??a µe ta guidelines (class ?,
  evid. ?) a-???, ARBs, ß-a?ast??e??, d?????t???
• JNC 7, May 2003
• ??a???f?s? ap? t? µ???a?d?a?? ?s?a?µ?a f??µa?a
  ?a? epa?a?µ?t?s? p??? ße?t??s? s?µpt?µ?t?? ?a?
  ep?ß??s?? se ? µe S?
• ACC/AHA Chronic SA-Guidelines, Circulation 2002

134
S??????S??????

• ? ?a?d?a?? a?ep???e?a e??a?
• common (2 t?? p????sµ??)
• fatal (? ???t?t?ta)
• disabling (? ??s???t?ta)
• costly (2 t?? p???p?????sµ??)
• a??? treatable (µe t?? ?e?te?e? ?e?ape?e?), ?a?
• ??????, preventable
• Karl Swedberg, 24? ?a?e?. ?a?d???. S??. 2003
• ACC/AHA HF-Guidelines, JACC 2001