主动脉瓣狭窄管理指南(2014年-英文版)

AorticStenosis2014AHA/ACCGuidelinefortheManagementofPatientsWithValvularHeartDiseaseDepartment1ofCardiovascularMedicine,GD2HChenWuqiAorticStenosis1.StagesofValularAS2.DiagnosesandFollow-Up3.MedicalTherapy4.TimingofIntervention5.ChoiceofIntervention1.StagesofValularAS1.1.4StagesstageA:riskofASstageB:progressiveASstageC:asymptomaticsevereASstageD:symptomaticsevereAS1.StagesofValularAS1.2.Definesby4factora.valveanatomycalcification,reducedleafletopeningb.valvehemodynamicspeakaorticvalvevelocity,meanaorticvalvegradientc.hemodynamicconsequencesLVdiastolicdysfunsion,LVhypertrophy,LVEFdescrease,LVchamberd.patientsymptomsexertionaldyspnea,angina,heartfailure,syncope2.DiagnosisandFollow-Up2.1InitialDiagnosisTTE(transthoracicechocardiography)Low-dosedobutaminestresstesting2.2ChangingSignsorSymptoms2.3RoutineFollow-Up2.4CardiacCatheterization2.5ExerciseTesting2.DiagnosisandFollow-Up2.1InitialDiagnosis2.1.1TTE(ClassI,B)concernbicuspidaorticvalve,cause,LVsize,systolicfunction,maximumtransvalvularvelocity,meanpressuregradient,continuityequationvalveareatiminganunexplainedsystolicmurmur,asinglesecondheartsound,ahistoryofabicuspidaorticvalve,symptomsthatmightbeduetoAS2.DiagnosisandFollow-Up2.1InitialDiagnosis2.1.2Low-dosedobutaminestresstesting(ClassI,B)inpatientswithstagesD2AS:a.Calcifiedaorticvalvewithreducedsystolicopening;b.LVEFlessthan50%;c.Calculatedvalvearea1.0cm2orless;andd.Aorticvelocitylessthan4.0mpersecondormeanpressuregradientlessthan40mmHg.2.DiagnosisandFollow-Up2.1InitialDiagnosis2.1.2Low-dosedobutaminestresstesting(ClassI,B):a.beginningat5mcg/kgperminuteb.increasinginincrementsof5mcg/kgperminutec.maximumdoseof20mcg/kgperminuteDefinitionofsevereASamaximumvelocity4.0m/swithavalvearea≤1.0cm2trueseverASprogressiveAS3thgroupaorticvelocity≥4.0m/s4.0m/s4.0m/smeanpressuregradient≥40mmHg40mmHg40mmHgvalvearea≤1.0cm21.0cm21.0cm2LVEFincrease20%20%20%2.DiagnosisandFollow-Up2.2ChangingSignsorSymptomsloudersystolicmurmurchangeinthesecondheartsoundsymptomsoccurthatmightbeduetoASnoncardiacsurgeryrepeatTTEpregnancyanemiagastrointestinalbleeding2.DiagnosisandFollow-Up2.3RoutineFollow-UpStagevmax(m/s)developintervalsB2-2.910%/5y3-5y3-3.90.3m/s/y1-2yC≥450-70%/2y0.5-1y2.DiagnosisandFollow-Up2.4CardiacCatheterizationnoninvasivedatanondiagnostic/discrepancyconcerntransaorticpressuregradientsaorticvalveareacoronaryangiography2.DiagnosisandFollow-Up2.5ExerciseTestingStageC(ClassII,B)a.asymptomaticpatientsb.acalcifiedaorticvalvec.aorticvelocity≥4.0m/sd.meanpressuregradient≥40mmHgStageD(ClassIII,B)2.DiagnosisandFollow-Up2.5ExerciseTestingpositivetestingresultsin29%ofasymptomaticpatients51%ofthemdevelopedsymptomsoverthenextyearpositive:stageCstageD1concernsymptomslimitedexercisecapacityabnormalBPresponse(hypotensionor20mmHgincrease)arrhythmiaST-segmentdepression(80%ofpatientswithAS)3.MedicalTherapy3.1Antihypertension(ClassI,B)hypertensioninstageA,stageB,stageCreducesthetotalpressureoverloadattentionstandardGDMT(guideline-diretedmedicaltherapy)startedatalowdose,graduallytitratedupwardfrequentclinicalmonitoring(symptoms)nospecificindicationdiureticsshouldbeavoidediftheLVchamberissmallBetaMockersareappropriateinpatientswithconcurrentCAD.3.MedicalTherapy3.2Vasodilatortherapy(ClassIIb,C)severeASandNYHAclassIVHFInvasivemonitoring:LVfillingpressures,cardiacoutput,systemicvascularresistanceattension:asuddendeclineinsystemicvascularresistancemightresultinanacutedeclineincardiacoutput3.3Statintherapy(ClassIII)4.TimingofIntervention4.TimingofInterventionClassI1.AVRisrecommendedinsymptomaticpatientswithsevereAS(stageD1)with(LOEB):a.Decreasedsystolicopeningofacalcifiedorcongenitallystenoticaorticvalve;andb.Anaorticvelocity4.0mpersecondorgreaterormeanpressuregradient40mmHgorhigher;andc.SymptomsofHF,syncope,exertionaldyspnea,angina,orpresyncopebyhistoryoronexercisetesting.4.TimingofInterventionClassI2.AVRisrecommendedforasymptomaticpatientswithsevereAS(stageC2)with(LOE:B):a.Decreasedsystolicopeningofacalcifiedaorticvalve;andb.LVEFlessthan50%;andc.anaorticvelocity4.0mpersecondorgreaterormeanpressuregradient40mmHgorhigher(136,137).4.TimingofInterventionClassI3.AVRisindicatedforpatientswithsevereAS(stageCorD)whenundergoingcardiacsurgeryforotherindicationswhen(LOE:B):a.calcifiedaorticvalve;andb.decreasedsystolicopening;andc.aorticvelocity4.0mpersecondorgreaterormeanpressuregradient40mmHgorhigher4.TimingofInterventionClassIIa1.AVRisreasonableforasymptomaticpatientswithverysevereAS(stageC1)with(LOE:B):a.Decreasedsystolicopeningofacalcifiedvalve;b.Anaorticvelocity5.0mpersecondorgreaterormeanpressuregradient60mmHgorhigher;andc.Alowsurgicalrisk.4.TimingofInterventionClassIIa2.AVRisreasonableinapparentlyasymptomaticpatientswithsevereAS(stageC1)with(LOE:B):a.Acalcifiedaorticvalve;b.Anaorticvelocityof4.0mpersecondto4.9mpersecondormeanpressuregradientof40mmHgto59mmHg;andc.AnexercisetestdemonstratingdecreasedexercisetoleranceorafallinsystolicBP.4.TimingofInterventionClassIIa3.AVRisreasonableinsymptomaticpatientswithlow-flow/low-gradientsevereASwithreduc