心血管影像检查在心衰患者中适宜性应用

第5种情况：HF的重复评估CRAUIHFHF患者AUI施了评级，评估了每种模式的临床适应症和影像参数对每种临床适应症重要性的证据。因此，本文件开发的方法突出了当前ACRACCF2供有意义的增量信息吗?这个循证文件提供了这种努力的结果。HF概6万新诊断的HF患者（7。50%（7在美国每年与HF相关的医疗费用超过392亿美元（7。曾报道医学影像是医疗费用增长1/3（8用率在下降，这可能反映了鼓励适宜性使用影像的持续努力（9。一般来说，ACCF/AHA指南对HF的管理和预防提供了深度信息（10。HF影像评估的主要对HF患者确立适宜性使用影像的方（AQA）原则”中的适宜性的定义（12A此原则是“医师绩效选择措施AQA参数”总则中是一个合理的人选（12A。3D于评级者做出这两种情况的区别。在某些情况下，缺血负荷的评估（即第2种情况)可与心4具体来说，要求每个评级小组成员通过以下步骤开展他们的个人评级1234审查HF影像检查的所有临床情况/适应首先通过适宜性水平为每一种影像模式对应每一种适应症评级（适宜/可能适宜适宜（在下一节描述新疑似或潜结构和功能基线评MI相关与产业和其他实体的关55种临床情HF的重复评4种临床情装置治疗的考虑和随血运重建前心肌活性/缺血负荷评考虑血运重建的HF评未被涵盖（见评论非缺血性HF病因2种临床情缺血性HF病因评未明确病因的确诊1种临床情况基于可用的证据,评级小组成员为一种特定的临床情况/适应症，按1-9组修改。由评级小组（适宜的、不确定的、和不适宜的）使用的新术语类似于UCLARAND的适宜性方法分类（11），但是正如在文件的其余部分和在会议期间与评级小组所讨论的，澄适宜的积分7-9可能适宜的积分4-6很少适宜的积分1-3关的内容，这些已呈现在ACCF/ACR方法学文件中（1。6（CMR（SPECT（PET第1种临床情况：对新疑似或潜在HF心脏结构和功能的初始HF的主要症状是由于液体潴留的各种组合（表现为肺充血及/或外周水肿）困难、疲劳及运动不耐受（10。HF的症状也可伴随有体征如心脏杂音,颈静脉压增高，肺部中，由于受损的心室收缩、松弛、充盈或排空能力的任何障碍所致（10。虽然HF可能是由（10，17）（1（10，19，20（10，21较低的LVEF与预后不良相关（22-25。2.LVEF7常而舒张功能异常的HF患者（33，34，并可预测将来的预后不良（35-37。CMR（37A（38对心肌灌注、心肌活性和纤维化的显像，可能有助于识别病因和评估预后（39。用CMR行LV质量定量检查可预测HF患者将来的危险（40。CMR的一个重要优势是对心脏及其周围结构各个方面解剖的高分辨率（41。这已导致其被推荐用于确诊或疑似复杂性先天性心脏病的患者（42。CMR的准确性及其在瓣膜功能初始评估中的应用看来是根本性的，虽然有些问题目（43，44放射核素心室造影别有用的。由于应用这种技术可以定量，故其有较高的可重复性（46。已有报道LV容量的系列RNV测量，可追踪对HF患者的各种治疗干预的效果（47-49。RNV是一种在今天不如过去8能做一次无创评估（C。ACC/AHASTEMI（51A）Ⅱa类推1表对于新疑似或潜在HF心脏结构和功能的初始评慢性缺血性心脏病（CIHD）的患病日益增多，反映了急性冠脉事件（如AMI）率改善的巨大成就，结合一般人口的老龄化（2-6），已经导致了HF能做一次无创评估（C。ACC/AHASTEMI（51A）Ⅱa类推1表对于新疑似或潜在HF心脏结构和功能的初始评慢性缺血性心脏病（CIHD）的患病日益增多，反映了急性冠脉事件（如AMI）率改善的巨大成就，结合一般人口的老龄化（2-6），已经导致了HF患病率升高。根据在随机治疗试验中患者的登记，约2/3的患者其HF症状的原因为缺血性（52。因此，识别出潜在的9适应症导管新疑似或潜在HF症状•气短或•运动耐量降低或•液体潴留的症状和HF所见•胸BNP、pro-BNP)异常或HF的体征•灌注受损的证据或•容量负荷过的证据AAMRARRRRMR恶性肿瘤•当前或计划心脏毒性药物治疗和•先前未行影估AARRARRRRRR一级亲属中家族性或遗传性扩张型心肌AMRRARRRRRR已知的成人先天性心脏AMRRARRRRMMAMI•初始住院时左室功能评AMMRAMMRRRA（53，54（55（541234研究为特征的，这些影像模式可证实诊断性能和另外的预后系列（56。最近发表的评价药物治疗与手术血运重建的STITCH（缺血性HF的手术治疗）试验（57），提供了血运重建在心泛的研究。CMR已在小样本进行了研究，用于评估HF患者的负荷室壁运动（61。高分辨率的（62，63持这持这样的概念，即有呼吸困难被提交行负荷心肌灌注显像（MPI）的患者是高危的（56。使用SPECT显像的一种获益是除了包括视觉（定性）和定量测量在内的MPI测量外（65），增加（40型的冠脉造影（B。Ⅱa类推Ⅱb类推Ⅱa类推的，除非患者不适宜做任何形式的血运重建（20（B。Ⅱb类推功能不全的患者为明确表2（79，并被认为由所致。做这样一种区别的重要意义在于如果存在足够的心肌活性（1234567表2（79，并被认为由所致。做这样一种区别的重要意义在于如果存在足够的心肌活性（1234567适应单静静息+负导心绞痛/心肌缺血等危综合MRRMMAAAAAA没有心绞痛/心肌缺血等危综合MRRMMAAAAMA（80，81使用多巴酚丁胺UCG检测收缩力储备，经UCG度降低（平均31%）的患者（76），可检出有功能恢复高度可能性的心肌节段。在左室壁变薄的患者中，收缩力储备可能受限（82。CMR检出冬眠心肌和LV心肌功能改善。梗死后用药物负荷CMR行危险分层的数据也已可用（85。多巴酚丁胺负荷CMR对诊断CAD也是有用的（86。此外，在小型观察性研究（87，88）中，已经显示CMR可证实在2项随机试验中，一项氟脱氧葡萄糖(FDG)-PET运重建决策的标准检查相比较（(PARR1PARR2[正电子发射断层扫描和血运重建后的恢复试验1和2（91，9。这些研究表明,心肌存活进行了血运重建的患者有心肌功能改善的明（94。（9596CCTACC地/AHA对于有CABG（BⅡa类推对于有1对于有1或2支冠脉病变、LAD表3（在缺血性病因SPECT(EFMRAAAAAAAMR心室功能中度降低(EFMRMAAAAMAM1对于有1或2支冠脉病变、LAD表3（在缺血性病因SPECT(EFMRAAAAAAAMR心室功能中度降低(EFMRMAAAAMAMR心室功能轻度降低(EFMRMMAAAAAMR第4种临床情况：对植入性心脏复律除颤器（ICD）/心脏再同步化治疗（RT）的考虑和随访的最常见的心律（10，97。HF的心源性猝死率可通过使用ICD而降低（98。（10，98123451234LEF817CRT与标准的药物治疗相比，还可降低因NYHA心功能III-IV级HF109（1098110111目前，在考虑ICD或CRT装置植入的情况下，影像检查的主要原因是，首先，证实1234考虑ICD植入的心血管影像主要是根据对LV收缩功能的评估。在SCD-HeFT（（112114ICD和CRT植入后——随访影像检（119，120（119，120的患者，并未显示临床获益（121。（122，123（124，125CMR已被证明能可靠地使LV收缩功能显像，但至今对要考虑ICD植入的患的患者，特别是靠近导线植入的区域，用CRT没能证明临床改善（129。一项研RNV和门控（46，112而且作为CAD评估的一部分具有高度的可重复性（65。对植入了CRT的患者，已（130（131，13211HF患者为延长生存率行二级预防：A目前或既往有HF症状；BLVEF1心室不同步（定义为QRS波时限≥0.12s，CRT（联用或不联用ICD。表4植入ICD/CRTR评估确定患者候选资格(133)AAMRARRRRMRRRRRRRRRRRR植入后的随访•心律失常状态没有变化•适宜的ICDARMRRRRRRMRARMRRRRRRRR初始评估确定患者候选资格(133)•满足已发表的AAMRARRRRMR装置资格标准•候选资格需评估ARRRARRRRARBLVEF1心室不同步（定义为QRS波时限≥0.12s，CRT（联用或不联用ICD。表4植入ICD/CRTR评估确定患者候选资格(133)AAMRARRRRMRRRRRRRRRRRR植入后的随访•心律失常状态没有变化•适宜的ICDARMRRRRRRMRARMRRRRRRRR初始评估确定患者候选资格(133)•满足已发表的AAMRARRRRMR装置资格标准•候选资格需评估ARRRARRRRAR植入后早期(<6AMMRRRRRRMRMRRRRRRRRRRHF的重复评1冠状动脉异常（包括动脉粥样硬化病变心室整体收缩功能不全（包括EF降低瓣膜功能不全（狭窄/反流/其它异常1234567能可靠地证明在药物治疗后LVEF的变化（134-138。然而，对临床情况没有变化（64，139门控（64139量的作用（47-49。心室整体收缩功能不全（包括EF降低瓣膜功能不全（狭窄/反流/其它异常1234567能可靠地证明在药物治疗后LVEF的变化（134-138。然而，对临床情况没有变化（64，139门控（64139量的作用（47-49。重构的严重程度对提供信息可能是有用的（C。表5HF的重复评症TCUPMCERGTTAMMMMAAMMMAHF和AMMRMAAMMMMRRRRRRRRRRRMRRRRRRRRRR中度(EF30%-39%)、和轻度(EF40%-49%)来提供分层的推荐。应当指出的是，疗的标准因此UCG和CMR被认为对患者选择是有用的此外CMR和CCT被评为1CarrJ.J.,HendelR.C.,WhiteR.D.;2013Appropriateutilizationofcardiovascularimaging:amethodologyforthedevelopmentofjointcriteriafortheappropriateutilizationofcardiovascularimagingbytheAmericanCollegeofCardiologyFoundationandAmericanCollegeofRadiology.JAmCollCardiol.BarkerW.H.,MulloolyJ.P.,GetchellW.;Changingincidenceandsurvivalforheartfailureinawell-definedolderpopulation,1970–1974and1990–1994.Circulation.2006;113:799-805.CrossRef|PubMedLoehrL.R.,RosamondW.D.,ChangP.P.;Heartfailureincidenceandsurvival(fromtheAtherosclerosisRiskin4KannelW.B.,BelangerA.J.;Epidemiologyofheartfailure.AmHeartJ.1991;121:951-957.CrossRef|FoxK.A.,StegP.G.,EagleK.A.;Declineinratesofdeathandheartfailureinacutecoronarysyndromes,1999–2006.JAMA.2007;297:1892-1900.CrossRef|PubMedMasoudiF.A.,HavranekE.P.,KrumholzH.M.;Theburdenofchroniccongestiveheartfailureinolderpersons:magnitudeimplicationsforpolicyandresearch.HeartFailRev.2002;7:9-16.CrossRef|7Lloyd-JonesD.,AdamsR.J.,BrownT.M.;He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