??af??e?a 1

1
?????S??S? ????S??????? ???????? ?????????? ???
???S?????? ??S???????G??
???st?? ? ?eµp????a?-??d??e??µe???
?a?d??????a? ??e???d?a Gaßa??
??e?µ????????-??tat???????? ?a?ep?st?µ?a?? ?.?.T.
- G.?.?. ???
2
?????S??S? 1?? ????S???????

• ?s?e??? 75 et?? e?s???? st? ??s???µe?? ????
  p????aµµat?sµ???? a????p?ast???? ?s???? (??).
• ?t?µ??? ??aµ??st??? ?? (Norvasc 5mg), ?
  (Salospir 100mg), ?/??? ??? ?e p?? ?t???.

3

• ?ete??e???t??? pa???s?ase s????t??? fa???µe?a
  ?a? t????e se a???? µe aloperidol.
• ??t?? 72 ???? ap? t? ?/? pe?a?t??? ep?de???s?
  t?? ?e?????????? t?? e????a? (GSC lt 8), ??e?a
  a?ap?e?st??? a?ep???e?a-a?ap?e?st??? ????s?
  (ta??p???a, ????a ??µat?? ph 7,03 pCO2 109mmHg
  pO2 45mmHg SO257).
• ?a?d??a?ap?e?st??? a?a??p?.

4

• ??e?e??????e ?????.
• ? as?e??? d?as????????e ?a? et??? se ???,
  µetaf?????e st? ???? ß?a?e?a? ??s??e?a? t?? ???
  t?? ??s???µe???.
• ?at? t?? a????? e?t?µ?s? ß??s??ta? ?p? ?atast???
  µe µ?da????µ? (GCS3), ?ta? ap??et??,
  a?µ?d??aµ??? asta??? ?p? e?d?f??ß?a ???ad?e?a????
  (?aµ???? d?se??) ?a? eµf????e ?a?? a?ta??a??
  ae???? (se A/C ?p? FiO21,0). ?fe?e ?????ast????
  s????a se pa????te?s? ?a? ? d?????s? t?? ?ta?
  ??a??p???t??? ?p? e?d?f??ß?a ??????s?
  f????seµ?d??.

5
??G

• ??G AF µe ta?e?a ?????a??
  a?tap????s?.
• t????e se Amiodarone.

6
?/a e?s?d?? st? ?.?.T.
7
CT

• CT e??ef???? ?p?e? e??efa????? a?????se??
  µ????a??e??p??e?a? e??efa????? ?µ?sfa?????,
  f????d?? e??efa???? at??f?a.
• CT ???a??? ????? e????a eµß????, a???s? t??
  d?ast?se?? t?? ?a?d??? ?a? ?d??? t?? de????
  ?????t?t??, p????ate?e?tas?e? ??t? ??ß?? ?µf?.

8
Triplex ???e???

• Triplex f?eß?? ??t? ????? a???t??? ??a
  f?eß????µß?s?.

9
Triplex ?a?d?a?

• aµf????p??? d??tas? (LA 50mm),
• LV sta a??te?a f?s???????? ???a (??? 56mm),
  ????? eµfa?? tµ?µat??? d?ata?a?? ????t???t?ta?
  (LVEF 55) ?p? a????µ?a.
• ??aµ?t??e?d??? ??? ???e??? ??µat?? ?,
  d?ast????? d?s?e?t?????a (pa??tas? Dt).
• ?p?a a?ep???e?a ???p??????a??? ßa?ß?d?? (1/4).

10

• ??s??eta? st?? ?a?/?? ?e?
• GSC 3/15 ?p? ?atast???
• ???e? se µ?s? µe F??() ?µf?
• a?µ?d??aµ??? asta??? ?p? Noradrenaline
• ???p??? µa?µa???? µe ?a?? ?????a?? a?tap????s?
  ?p? Amiodarone.

11

• ???ast???a?? e?s?d??
• Ht29, Hb10, WBC8300 (Neut 84) PLT149.000,
  INR1,8, APTT45, Fib5,6, D-dimers28,5,
  Glu128, U68, Cr2,3, Na139, K4,6, Ca8,4,
  P2,4, Mg2,1, Bil1,7/1,2, Chol84, Tg110,
  Amy83, ALP72, TP5,2, Alb3,2, SGOT4200,
  SGPT3267, ?GT44, LDH8944, CPK2956, MB 227,
  cTn-I 5,57, BNP 391.

12

• ?at? t? ??s??e?a t?? st?? ?e?
• ta p??ta t??a 24??a pa???s?a?e eµp??et? ???
  39?C, ep?de???s? t?? a?ta??a??? ae???? (FiO2
  100, PEEP 12, RR 16, TV 600ml, PO2/FiO2 lt100),
  a?µ?d??aµ??? ast??e?a ?p? Noradrenaline.
• d?e?e??????e de???? ?a?et???asµ?? ?p?? a?ede????
  e????a ?a?d???e???? ?atap????a? µe s?pt???
  pa?????ta (CI 2.3-3.1, PCWP 20-15).

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• ? as?e??? t????e se a?t?µ????ß?a?? a????
  (Targocid, Tazocin), se f????seµ?d? st??d??
  ????s? ?a? se a???t??? ?s?????? ?????
  pa???s?????ta? ße?t??s? t?? ???????? t?? e????a?
  (ße?t??s? t?? a?ta??a??? ae????, a?µ?d??aµ???
  sta?e??t?ta µe stad?a?? µe??s? ?a? d?a??p? t??
  ???t??p??, µe µe??s? t?? ?a?d?a??? s????t?ta?).

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• t?? ep?µe?e? ?µ??e?
• a??pt??? HIT e?? e??µßa?e enoxaparine (d?s?
  S??2) ?a? a?t??at?stas? t?? ap? fondaparinoux.
• pa???s?ase ep?de???s? t?? ?ef????? t??
  ?e?t?????a? (??eat 5,9 ????a 200).
• ??a CT e??ef???? ?p?p???e? a?????se?? st??
  pe????? t?? ßas???? ?a?????? ?µf? ?a? ?d???
  a??ste?? p??a??tata ?s?a?µ???? t?p?? a??e?a???
  ß??ße?.
• pa???s?ase pt?s? t?? Ht p?? ??e??st??e RBCs,
  ???? a?µ???a??a? st?? ?/?e?sa pe?????, e?? ?
  a?t?????????? ??e???? a??de??e ????? e??????µa
  t?? ?????? a????p?ast????, t? ?p???
  a?t?µet?p?st??e ?e????????? ?a? µe pa????te?s?
  t?? a?µat?µat??.
• ??a µ??a µet? ??e??st??e ?e?????????? ?a?a??sµ??
  t?? t?a?µat??.
• stad?a?? ße?t??s? a?ta??a??? ae????,
  a?µ?d??aµ???? ?a? ?e?????????? ?at?stas?? (GSC
  15/15).

19
S?????
?????p?ast??? ?s???? (??) ?a??a????µ?a
p?e?µ????? ??d?µa ??? S?? d?ast?????
d?s?e?t?????a S??? HIT ????? e??????µa
a????p?ast????-a?µ???a??a t?p???- ???µ???
t?a?µat??
20
S?????? ?????S??S? 2?? ????S???????

• ?s?e??? 49 et?? e?s???? st? ??s???µe?? ????
  eµp???t?? ?a? pt?s?? t?? ep?p?d?? s??e?d?s??.
• ?t?µ??? ??aµ??st??? S??????s? ?at? ????a,
  t????? µe?????? ?a? ???e?t?µ?, sa??a??d??
  d?aß?t?? t?p?? 2, ?µf?a?µa µ???a?d??? p??s????
  t????µat?? (STEMI) p?? ?t??? ?a? e?d?stefa??a?a
  d?ade?µ??? pa??µßas? µe e?d?p???es? st?? p??s???
  ?at???ta ???d? t?? a??ste??? stefa??a?a?
  a?t???a?.

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Triplex ?a?d?a?

• ???ste?? ?????a µe d?ast?se?? ?a? p????
  t????µ?t?? sta a??te?a f?s???????? ???a, µe
  ??pt??s? ?a? a????s?a µ?s?? ?a? ????fa?a? µ???a?
  ??? ?a? ????fa??? ?a? p??s???-????fa???
  t????µat??. S??????? s?st????? ap?d?s? s?µa?t???
  µe??µ??? (LVEF 30-35).
• ???p??????a??? ßa?ß?de? µe µ???? a?ep???e?a.
• ???p? e???µata e?t?? f?s????????? ?????.

22

• ???? pe?a?t??? ep?de???s?? t?? ep?p?d??
  s??e?d?s?? ap?fas?st??e ? d?as?????s? t??
  as?e???? ?a? µetaf?????e st?? ?a?/?? ?.?.T.
• ?at? t?? e?sa???? t??
• ?p??et?? (37oC)
• ?aµ??? CVP (4 cmH2O)
• a?µ?d??aµ??? sta?e??? ????? fa?µa?e?t???
  ?p?st????? µe ???t??pa f??µa?a (?? 130/60 mmHg,
  sf??e?? 90/min)
• ?a?? a?ta??a?? ae???? (PO2/FiO2 330)

?a? ap?fas?st??e ? ??????s? ????? µe st??? t?
?et??? ?s??????.
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• ?a ep?µe?a 24??a
• CVP 12 cmH2O
• pa??µe?e se ?et??? ?s??????
• µet? ??????s? Human Albumin (100cc) a?f??d?a
  ep?de???s? t?? ???????? ?at?stas?? ??
  160/85mmHg, sf??e?? 150/min, PO2/FiO2 63 (a???a
  a?µat?? pH 7,22 pO2 63mmHg pCO2 69mmHg HCO3 28).

25
??G f?eß???µß??? ta???a?d?a, ap??efa??sµ?? R
V1-V4
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t????e se d?????s? ?a? a??e??d?asta?t??? a???? µe
stad?a?? ße?t??s? (PO2/FiO2 360) ?? 130/70 mmHg,
sf??e?? 80/min.

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???????? ?????????? - ???S??S
O? ?a?d?a?? a?ep???e?a ????eta? ? 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??.
Braunwald E, Zipes D, Libby P. Heart Disease, 6th
Ed. Saunders 2001
32
AHA/ACC Guidelines for the Evaluation and
Management of Chronic Heart Failure 2005

• ?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

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Stages in the Development of Heart
Failure/Recommended Therapy by Stage ACC/AHA 2009
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DIASTOLIC HF
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??????????G?? ?.?.

• a???s? e?sa????? 171 ap? 1979-2005
• gt40y 20 ?a a?apt????? ??
• ??? 22 a?d???, 46 ???a???? ?a a?apt????? ?? se
  6y
• ??st?? 2008 35 d??
• µ?s?? ?????? ??s??e?a? 4,3 ?µ??e? µe ??st??
  40/h ??a ???e pa?ap??? ??a ??s??e?a?

44
??????????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
45
??????????G?? ?.?.

• ??
• 5 t?? e?sa?????
• 10 ??s??e??µ????
• ?????e?
• lt70y 2-3
• 70-80y 10-20
• F???
• ??d?e? ?e?te?e? ?????e? ???? S.?.
• ??????µ???? ????? d?af??? sta d?? f??a

ESC GUIDELINES 2008
46
??????????G?? ?.?.

• 50 pe?a????? se 4 ?t?
• 40 t?? e?sa????? ?a pe?????? ? ?a epa?e?sa?????
  se ??a ?t??
• ???S?????? ??
• µ????te??? ?????a?, ???a??e?, S.?., ?.?.
• 50 t?? as?e??? µe ??
• p?????s? ?d?a µe s?st????? ??

ESC GUIDELINES 2008
47
S?S?????? ?????? ???S??????S ?.?.
Zile MR. Mod Concepts Cardiovasc Dis 1990 591
48
???????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
49
???????G?? ?.?.

• Stefa??a?a ??s?? 70
• ??t. ?p??tas?
• ????a?d??p??e?e? 10
• F??µa?a (ß-block, Ca-ant, a?t?a????µ???,
  ??tta??t?????)
• ?????e? (a?????, ???a???, st???e?a ?a????,
  ??ß??t??)
• ??d???????????? (S.?., s?d?. Cushing,
  fa?????µ???tt?µa, ?pe?/?p????e?e?d?sµ??)
  
• ??a?t?t??? (a?ep. ?a???t????, ?a?e??a)
• ?????t??? ??s?µata (sa???e?d?s?, aµ???e?d?s?,
  a?µ????µ?t?s?, ?. s??det???? ?st??)
• HIV, ?. Chagas, te????? stad??? ?ef????
  a?ep???e?a, ???s?

ESC GUIDELINES 2008
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??????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
52
S?S?????? ?????? ???S??????S ?.?.
?a??µet??? S?st????? ??ast????? ?st????? Stefa?
?a?a ??s??
??t???a?? ?p??tas?
Sa??a??d?? d?aß?t??
?a?ß?d?p??e?a
- ?a????sµ??? d?sp???a
F?s??? e??tas? ?e?a???a?d?a
?????? ?a?d?a??? t????
?a?pasµ?? S3
?a?pasµ?? S4
??t???a?? ?p??tas?
??ep???e?a µ?t??e?d???
????? ??????
?e??fe????
??d?µa ???tas?
t?a??????? f?eß??
?/a ???a??? ?e?a???a?d?a
??e?µ????? s?µf???s?
??G ?pe?t??f?a a?. ?????a?
??µata Q
?aµ??? d??aµ???
- ????a?d?????f?µa ?pe?t??f?a a?.
?????a? ???tas?
a?. ?????a?
- ???tas? a?. ???p??
?e??µ??? ???sµa e????s??
-
Braunwald E, 2001
53
??????? ????????S? ?.?. ???? FORESTER
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???G?OS? ??

1. ?st?????-??????? e??tas? (s?µe?a, s?µpt?µata,
   a?t?a, e???t???? pa?????te?)
2. ??a???st???? te?????? (ape?????st????,
   e??ast???a??? ??e????)

56
???G?OS? ??

1. ?st?????-??????? e??tas? (s?µe?a, s?µpt?µata,
   a?t?a, e???t???? pa?????te?)
2. ??a???st???? te?????? (ape?????st????,
   e??ast???a??? ??e????)

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???G?OS? ??

1. ?st?????-??????? e??tas? (s?µe?a, s?µpt?µata,
   a?t?a, e???t???? pa?????te?)
2. ??a???st???? te?????? (ape?????st????,
   e??ast???a??? ??e????)

63
???G?OS????S ???????S

• ??G
• ?/a ???a???
• ??µat???????? ??e????
• ?pe??????af???? ??e???? (d?a???a????,
  d???s?f??e??, d??aµ??? ?pe??????af?a)
• MRI ?a?d???
• CT a??e????af?a
• ???????? µe??t?
• ????µas?e? p?e?µ????
• ????µas?a ??p?se??
• 24??? pe??pat?t??? ??G ?ata??af? (Holter)

64
??G
Braunwald E, Zipes D, Libby P. Heart Disease, 6th
Ed. Saunders 2001
65
?/? TO????S
http//info.med.yale.edu/intmed/cardio/imaging/con
tents.html
66
ECHO
www.mayoclinic.org
Braunwald E, 2001
www.kentmedicalimaging.co.uk
67
??????S???????S ??T????
Braunwald E, Zipes D, Libby P. Heart Disease, 6th
Ed. Saunders 2001
68
????????S ??T??????S??S - ?GG?????????G??F??
www.chh.org
Braunwald E, Zipes D, Libby P. Heart Disease, 6th
Ed. Saunders 2001
69
?????????????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
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T??????? ??
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G????? ?????

• ???µ???s? ??a t? t? e??a? ??, ta a?t?a, ta
  s?µpt?µata, t? ?e?ape?a ?a? t?? p?????s? (I, C)
• ??e???? s?µat???? ß????? s??d???eta? µe ?
  ???t?t?ta (I, C)
• ??e???? d?a?t?t???? p??s????? Na ?a? ????? se
  s?ßa?? ?? (IIa, C)
• ?µß???asµ?? ?at? p?e?µ?????????? ?a? a?µ?f????
  ??f?????t?a? (IIa, C)
• ?p?f??? ?ap??sµat??, ?pe??ata????s?? a????? ?a?
  ????a???? (I, C)
• ??????µµata ?s??s?? ??a ????? se sta?e??
  ?at?stas? (I,A)
• ?a??d?a ?? s?µpt?µat???? ?a ap?fe????? µe???a
  ??? gt1500m ?a? pa?aµ??? se p??? ?est? ???µata ?a?
  a???µ???? ???as?a? (I, C)
• Se???a???? d?ast????t?ta a?ast??e??
  f?sf?d?este??s?? (sildenafil) a?t??de??? ?
  s????????s? µe ??t??d? ?a? se p??????µ????
  stad??? ?? (???, ?)
• ACC/AHA HF-Guidelines, JACC 2009
• ESC HF-Guidelines, Eur Heart J 2008

86
G????? ?????

• ?e??s? S.?. se BMIgt30 ?a? ??? se p??????µ????
  stad??? ?? (IIa, C)
• ?a?e??a ? S.?.gt6 e?t?? 6 µ???? ?????
  ?ata???t?s? ????? ? a?st??? pa?a???????s? t??
  d?a?t??????? (I, C)
• ?at?????? (20) ?e?ape?a se s?µpt?µat????? (IIa,
  C)

ACC/AHA HF-Guidelines, JACC 2009 ESC
HF-Guidelines, Eur Heart J 2008
87
??????t??? ??ast??e?? t?? ?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?? t?? ?p?d????? t?? 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?? 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?? ??t?????? ??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
88
???S?????S ??? (? ?)

• Start low, go slow ??a??? µe ?aµ???? d?se??
  ?a?, ep? a?????, stad?a?? p??? ta ??? t?t??p???s?
  ??? a?e?t?? d?se??-st???, s?µf??e? µe t?? µe???e?
  ???????? µe??te? (85-90 a????). ??aµe??µe??
  ??????? a?tap????s? µet? ap? ?µ??e? ??? µ??e?
• ??e???? ?ef????? ?e?t?????a? p??, 1-2 eßd?µ?de?,
  a???s? µet? 2-4 eßd., ??eat-??e?t?. 1? ? 4? eßd.
  ?a? 1, 3, 6 µ??e?
• ???s??? ? gt 5,5 mmol/l, Cr gt 3 mg/dl,
  aµf?te??p?e??? st???s? ?ef????? a?t?????, S?? lt
  80 mmHg, ep?µ???? ß??a?, s????????s? d?????t????
  ?a? NSAIDs
• ??? ???s?, ?st????? a??e????d?µat?? ? a????????
  ?ef????? a?ep???e?a? se p??????µe?? ??????s?,
  ???d???? ?a?d???e???? shock
• CONSENSUS substudy 1997
• Park, Congest HF 2003
• ACC/AHA HF-Guidelines, JACC 2005
• ESC HF-Guidelines, Eur Heart J 2008

89
ß-???S?????S (? ?)

• Start low, go slow Se as?e?e?? ?p? ?e?ape?a
  ?d? µe a-??? ?a? ????? e?de??e?? ?ata???t?s??
  ????? ? a????? ?F ???t??p?? a?????, ??a??? µe
  ?aµ???? d?se?? ?a?, stad?a?? p??? ta ???
  t?t??p???s? a?? 1-2 eßd?µ?de? ??? a?e?t??
  d?se??-st???, s?µf??e? µe t?? µe???e? ????????
  µe??te? (85 a????). ??aµe??µe?? ???????
  a?tap????s? ??? µet? ap? 2-3 µ??e?
• ??de??e?? LVEFlt40, NYHA II-IV, sta?e??
  ?at?stas?
• ??? s?ßa?? ap?f?a?t??? ??s?? ae?a?????,
  s?µpt?µat??? ?p?tas?, s?µpt?µat??? ß?ad??a?d?a,
  ?????? ßa?µ?? ?a?d?a??? ap???e?sµ??
• ACC/AHA HF-Guidelines, JACC 2005
• ESC HF-Guidelines, Eur Heart J 2008

90
???????????

• ? C s?µpt. ?? AF (rate control)
• I C AF LVEFlt40 (rate controlßblock)
• IIa B SRSympt HF LVEFlt40
• ???????? p??sµat?? gt 1,2 ng ? 16 ? ???t?t?ta?
• Optimal d??????? p??sµat?? 0,6-1,2 ng ? 20
  ? ???t?t?ta?
• Rathore, JAMA 2003
• ??? ß?ad??a?d?a, 2?? ? 3?? ßa?µ?? ???, WPW,
  HOCM, ?pe?/?p??a??a?µ?a
• ESC HF-Guidelines, Eur Heart J 2008

91
??????????

• I B HF congestion
• ??a??? µe ?aµ???? d?se?? d?????t???? a?????? ?
  ?e?a??d?? ?a? a???s? a?t?? µe st??? t?? ? t??
  d?????s?? ?a? t? ? t?? S? ?at? 0,5-1 kg/d.
  ??aµe??µe?? ??????? a?tap????s? µet? ap? ??e? ?
  ?µ??e?
• ?p?fe??eta? ? ???s? t??? ?? µ????e?ape?a st?? ??
• ? ?at??????? ?e???sµ?? t??? ß???? st??
  ap?te?esµat???t?ta t?? s?????????µe??? fa?µ????
• ??a?t?t??? p??s???? Na lt3 gr/d ?a? d?a??p?
  NSAIDs
• ??????t??? a??????, 1?? ep?????? ? t?? ap????s?
  Na ??? t? 20-25 t?? f??t??? d????s?? ?a? e??a?
  d?ast??? ?a? µe GFR lt30 ml/min
• ?a???s??t???t??? d?????t??? se eµµ????sa
  ?p??a??a?µ?a pa?? t??? a-??? sp??????a?t???
• ACC/AHA HF-Guidelines, JACC 2001
• ESC HF-Guidelines, Eur Heart J 2008
• Brater, Am J Nephrol 2001

92
????GO??S??S ????S??????S

• I B LVEF lt35, NYHA III-IV
• ??d?ste???? µ???a?d?a?? ?a? a??e?a?? ???s?,
  e?e???p???s? t?? s?µpa??t???? ?a? a?ast??? t??
  pa?as?µpa??t????, e??a????s? K ?a? Mg2,
  d?s?e?t?????a tase??p?d?????
• Duprez, Eur Heart J 1998
• MacFadyen, Cardiovasc Res 1997
• ESC 2008
• ?a??? ?e?ape?a µe a-??? ?a? a?ast??e?? t??
  ?p?d????? ??-?? ?atast???e? a?epa???? ta ep?peda
  ?????f????sa? a?d?ste????? (fa???µe?? d?af????)
• ??te?de??e?? ?gt5, ??eatgt2,5, ACEIARBs
• Struthers, J Card Fail 1996

93
S?????S??S ??????????S ?????????? ?S?S??????

• IIa, B LVEFlt40 as alternative when intollerance
  ACEI-ARBs
• ?s?e?e?? µe s?µpt?µat??? ??, ?p? a???? µe
  da?t???t?da, d?????t??? ?a? ß-a?ast??e??, µ?
  a?e?t???? st??? a-??? ?a? st??? ARBs ????
  ?p?tas?? ? ?ef????? d?s?e?t?????a?
• (st?d?? G, class IIa, evid. ?)
• ? ?f??? st?? ep?ß??s? ??a?t? t?? a-???, ?
  pa?e????e?e? ?a? ? s?µµ??f?s? as?e???
• Cohn, NEJM 1991
• ESC 2008
• ??t??d? µe ß-a?ast??e?? ?/?a? d?????t??? se
  as?e?e?? µe ?? ?a? s???p?????sa st?????? (class
  I, evid. ?)
• Elkayam, JACC 1999

94
????GO??S??S Ca2

• Ge???? ap?fe????ta? st?? ?? ?a? e?d???te?a st?
  st?d?? G e??a? class III, evid. B
• ?p?de???s? ?? ?a? ? ???d???? ?a?d?a??e?a???
  s?µßaµ?t??
• MACH-1, 2000
• Packer, Circulation 1987
• ?µ??d?p??? ?a? fe??d?p??? ??d?te?? ep?d?as? st??
  ep?ß??s?. S?µp????µat??? ??????s? se s???p?????sa
  st?????? ? ?p??tas?
• V-HeFT III, 1997
• PRAISE, 1996

95
????T????O????

• St?? µe??te? ?? et?s??? ???d???? ??? 1-2 ?a?
  ?? 2-5,4
• et?s??? ???d???? ??? se as?e?e?? µe ???p???
  µa?µa???? ?a? ?????a ?? 10,3 ?a? se as?e?e?? µe
  p??sfat? ?? 17,7
• SPAF, 1992
• pa???s?a ???p???? µa?µa????? ? d?p??s??? ???d????
  eµß???? st?? ??
• ??t?p??t??? se as?e?e?? µe ?? ?a? pa????sµ??? ?
  ?????a ???p??? µa?µa???? ? p??????µe??
  ???µß?eµß????? epe?s?d?? (class ?, evid. ?)
• SPAF ??, 1996
• ??t?a?µ?peta??a?? se as?e?e?? µe ?? ???? S? p???
  p?????? ?? ?a? ?a??t?? (class IIa, evid. B)
• ACC/AHA HF-Guidelines, JACC 2001
• CAPRIE, 1996

96
????T????O????

• ??ta????st?? ß?t. ?
• se ?? µe AF pa????sµ??? ? µ???µ? ? µe
  p??s?et??? ßa?ß?da (µe??s? t?? ???d???? ??a ???
  60-70) (I,A)
• se ?pa??? e?d??a?d?a??? ???µß?? ? eµß??????
  epe?s?d??? (?, C)
• ??t?a?µ?peta??a??
• de? e??a? t? ?d?? ap?te?esµat??? st?? µe??s? t??
  ???µß?eµß?????? ???d????
• de? ?p?????? st???e?a ?t? µe?????? t??
  a????s?????t??? ???d???
• ? ???d???? e?sa????? e??a? µe?a??te???
  s?????t??? µe a?ta?. ??t ?
• ESC 2009

97
????????T????

• ?p?f??? t?? pe??ss?t???? p.?. ?µ?da? ? ?a?
  s?ta????? (class I, evid. B), ????
  ?a?d???atasta?t???? ?a? p??a????µ???? d??se??
• SWORD 1996, SPAF 1992, CAST 1989
• ?-a?ast??e?? p??t?µ??ta? t?? da?t???t?da? ??a
  ??e??? ?????a??? a?tap????s?? ep? ???p????
  µa?µa????? (class I, evid. ?) ???? e???????
  ep?d?as?? t??? st? f?s??? ?st???a t?? ?? ?a?
  ap?te?esµat???t?t?? t??? ?at? t?? ?s??s?
• Farshi, JACC 1999
• ? a?f??d??? ?a??t?? ?a? ?????? ???t?t?ta? se
  as?e?e?? µet? ?? ?a? se as?e?e?? µe ??
  a?e?a?t?t?? a?t?a? (CIBIS-II ?a? MERIT-HF 1999,
  USC-HF 1996) (class I, evid. ?)

98
????????T????

• ?µ??da???? ??e???? ?????a??? a?tap????s?? se ??
  ?a? ???p??? µa?µa???? ep? a?t??de???? / µ? a?????
  t?? ß-a?ast???a (class ?, evid. ?)
• CHF-STAT, 1998
• p?????? a?f??d??? ?a??t?? se as?e?e?? µe ?? ?a?
  as?µpt?µat???? ?????a??? a????µ?e? (class IIb,
  evid. B). ?sfa??? f??µa?? p?? de fa??eta? ?a ? t?
  ???t?t?ta a??? d??a?????e?ta? µ??? se
  ep??e?µ????? as?e?e?? p?? a?aµ??eta? ?a ?fe??????
  (CHF-STAT 1996, EMIAT ?a? CAMIAT 1997)
• Farre, Am J Cardiol 1999
• p?????? ?p?t??p?? ?a??????? ?????a??? a????µ?a?,
  µe/????? ß-a?ast???a/AICD, se as?e?e?? µe
  ?st????? a?f??d??? ?a??t??, VF ? ep????d???? VT
• ??fet???d? asfa??? ????? ep?de???s? t?? ??????
  ???t?t?ta? ?a? µe ? t?? e?sa????? ???? ??
• DIAMOND-CHF, 1999

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???????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

110
???????? ???S??????
111
??F????????? ??????????S?

• ??ata?a??? ?-? a????? ? LBBB gt30 t?? as?e??? µe
  µ?t??a ??? s?ßa?? ?? ? ??e?t????? ?a? µ??a?????
  d?s???????sµ?? t?? ??????? ? a?µ?d??aµ????
  d?ata?a??? ?a? pt??? p?????s?
• Nelson, Circulation 2000
• ????? QRS a?e???t?t?? p?????st???? pa?????ta? se
  as?e?e?? µe ??
• Schneider, Circulation 1981
• NYHA III/IV 60 t?? as?e??? µe ?? ? ???t?t?ta
  st? 1 ?t?? ??? 60 ?a? ?????? ???? p???de?t????
  a?ep???e?a? a?t??a?
• Braunwald E, 2001
• ?e????? aµf??????a??? ß?µat?d?t?s?? (BiVP) st?
  ?e?ape?a t?? ?a?d?a??? epa?as???????sµ?? (CRT)
• ? t?? e????? t?? QRS, ße?t??s? t?? s?st?????? ?a?
  t?? d?ast?????? ?a?d?a??? ?e?t?????a?, ? t??
  s?µpa??t???? d?ast????t?ta? ?a? ? t?? a???µ?? t??
  shocks ap? t??? AICDs
• Cohen, J Invas Cardiol 2002
• Kerwin, JACC 2000
• Morris Thurgood, Europace 2000
• Hamdan, Circulation 2000
• Higgins, JACC 2000

112
??F????????? ??????????S?
113
??F????S???? ???????S??S
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Bicaval Orthotopic Heart Transplantation Technique
116
???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

117
???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

118
???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

119
???S?????? ?.?.

• ??e???? ?? s?µf??a µe ta guidelines (class ?,
  evid. ?) a-???, ARBs, ß-a?ast??e??, d?????t???
• JNC 7, May 2003
• ESC 2008
• ??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

120
????? ???????? ?????????? (???). ???sµ??

• ?e? ?p???e?!
• S?et??? a?f??d?a e??at?stas? s?µpt?µ?t??
  ?a?d?a??? a?ep???e?a? p?? apa?t??? e?sa???? se
  ??s???µe?? ?a? ?µes? a?t?µet?p?s?
• De novo
• Acute decompensation
• Gheorghiade M, Zannad F, Sopko G, et al Acute
  heart failure syndromes Current state and
  framework for future research. Circulation 2005
  11239583968

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??????? p??f?? ???

• 90 µe s?µe?a ? p??se?? a??ste??? ?????t?t?? µe
  d?sp???a
• 40 d?sp???a ??eµ?a?
• 2/3 ????? s?µe?a ? p??se?? de???? ?a?d?a???
  ?????t?t?? µe pe??fe???? ??d?µa
• CXR 60-90 e????a s?µf???s??
• ?p?d?????s? µ? ?at?????? a????
• Zanad F et al, EJHF 2006 8(7)697

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??µ???af??? ???

• 75 et?? ???
• 71 et?? ????p?
• ???e?a gt 80
• ?e?t????/??at????? lt 70
• 50 ???a??e?
• 2/3 ????? ?st????? S.?, 30 p????e?ta? ?s?a?µ???
  epe?s?d??

128
??µ???af??? ???

• ??? vs. ????p?
• ?p??tas? (72 vs. 53)
• S? (44, vs. 27)
• ??? (30, vs. 17)
• ???p??? µa?µa???? (31, vs. 43)

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Natural History of Chronic and Acute Heart Failure
Normal heart
Chronic heart failure5 million in the US10
million in Europe
Death
Initial myocardial injury
Heart Viability
First ADHF episodePulmonary edemaER admission
Later ADHF episodesRescue therapyICU admission
Last year
Initial phase
Gheorghiade M. Am J Cardiol. 200596(suppl
6A)1-4G.
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??????S?O