ACC指南

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院内讲座：非心脏手术术前心血管风险评估ACC指南

针对中高危患者，推荐采取术前优化措施，如药物治疗、生活方式干预等，以降低围术期心血管事件的风险。
提供围术期心血管事件的管理建议，包括监测、预防和治疗措施，以确保患者的安全。
PART 04
非心脏手术术前心血管风险评估实践
评估工具和方法
风险评估量表
使用经过验证的风险评估量表，如ACC/AHA指南推荐的修订心脏风险指数（RCRI），综合考虑患者的临床因素，以评估非心脏
定期对术前心血管风险评估工作进行评估和改进，及时发现问题并采取措施加以改进，不断提高评估工作的质量和效率。
PART 06
结论和展望
研究结论和成果总结
01 02
术前心血管风险评估的重要性
通过本次讲座，我们了解到术前心血管风险评估对于非心脏手术患者具有重要意义，它可以帮助医生识别患者潜在的心血管风险，从而制定相应的预防措施和手术方案。
• 评估内容：包括患者的病史、体格检查、心电图、超声心动图、血液检查等多个方面，以全面了解患者的心血管状况。
评估的内容和步骤
评估步骤 1. 收集患者病史，包括心血管疾病史、高血压、糖尿病等；
2. 进行体格检查，包括血压、心率、心脏杂音等；
评估的内容和步骤
01
02
03
04
3. 进行心电图检查，了解心脏电活动情况；
适用范围
acc指南适用于所有进行非心脏手术的患者，特别是在术前需要进行心血管风险评估的患者。
适用对象
包括外科医生、麻醉师、心血管专科医生、护士以及其他参与患者术前评估的医疗团队成员。
acc指南的实践意义和价值
提高评估准确性和一致性
通过提供标准化的评估流程和方法，acc指南有助于提高不同医疗团队成员之间评估结果的一致性和准确性。

美国ACCAHA高血压指南

美国ACC/AHA高血压指南美国ACC/AHA更新了高血压的指南。

指南编写委员会主席，来自杜兰大学的Whelton教授说：“14年来高血压第一次被重新定义。

130 mmHg 是新高”。

新指南在四个方面做了修订;提出了新的疾病定义，新的降压起点，新的降压靶目标，新的测量方法。

这一修改，引起了学界甚至是普通市民的广泛热议，有一篇在微信圈广泛流行的文章说“一觉醒来，你就变成了高血压”。

参与程度之广泛，前所未有。

新指南首次将高血压定义修改为血压≥130/80mmHg即被诊断为高血压。

指南中引用了大量观察性研究讨论血压值与心血管风险的关系，多项研究表明血压值超过130/80mmHg的患者，未来发生CVD事件的风险明显增加。

指南也是基于这些研究做出的修订。

但是反对的声音也是此起彼伏。

当代医学有一种趋势，将诊断某些疾病的“阈值”放得越来越低，在血压；血脂；血糖；BMI；肾小球滤过率等方面都有类似的现象。

Messerli2018年发表在JACC上的一篇述评里说到“就好像打鱼的时候，将鱼钩钓鱼变成了打鱼网”。

在过去几个月里，美国的高血压人数迅速上升到超过1亿。

可是仅仅在几个月以前，ACP/AAFP指南还推荐年龄≥60岁，收缩压≥150mmHg才启动降压治疗，以取得收缩压＜150mmHg的目标。

导致指南更新的最主要的证据来源于SPRINT研究，该研究中严格血压控制组（SBP<120mmHg）平均使用2.8种药物,比标准血压控制组（SBP<140mmHg）平均使用1.8种药物多一种,这一额外多出来的一种药物导致了在平均3.26年的随访中主要复合终点(心梗;ACS;中风;心衰;心血管死亡)0.54％的下降,统计学有明显差异。

由于在死亡率方面的明显差异，研究提前结束了。

SPRINT是一个很好的研究，但当将这一研究结果用于指南的临床实践时，需要很谨慎，这些获益不可争议地存在着，问题是怎样去解释这些获益。

2. ACC/AHA新指南将血压≥130/80mmHg定为启动降压治疗的起点，具体是否需要药物治疗或是仅仅是生活方式干预取决于患者是否合并ASCVD以及10年ASCVD的风险是否≥10％。

ACC心衰指南再更新，要点抢先看！

ACC心衰指南再更新，要点抢先看！2022年4月2日美国心脏病学会/美国心脏协会/美国心力衰竭学会（ACC/AHA/HFSA）联合发布心力衰竭（简称心衰）管理指南。

该指南”取代“2013 ACC/AHA/HFSA 心力衰竭管理指南和在其基础上更新的2017 ACC/AHA/HFSA心力衰竭管理指南用于心力衰竭的管理。

2022版的心力衰竭指南（以下简称“新指南”）旨在为临床医生提供以患者为中心的建议，以预防、诊断和管理心力衰竭患者。

下面一起来看看新指南更新要点吧！1、对于心衰的分类有了新定义，增加了射血分数改善的心力衰竭（HFimpEF）的概念新指南根据左心室射血分数值（LVEF）将心衰分为4类，如下：•射血分数降低的心力衰竭（HFrEF）：患者LVEF≤40%；•射血分数保留的心力衰竭（HFpEF）：LVEF≥50%并伴左室充盈压力增加；•射血分数轻度降低的心力衰竭（HFmrEF）：LVEF在41%~49%，伴左室充盈压力增加；•射血分数改善的心力衰竭（HFimpEF）：既往LVEF≤40%，后提升至＞40%2、心衰的阶段定义和标准，以更好指导临床医生对心衰诊疗注：BNP：B型利钠肽； CKD：慢性肾病； CVD：心血管疾病；GDMT：指南指导的药物治疗。

3、对于C期心衰患者治疗策略更新1）对于有症状（NYHA II~III级）稳定的慢性HFrEF（LVEF为35%）患者，他们正在接受GDMT，包括最大耐受剂量的β受体阻滞剂，并且处于窦性心律，静息时心率为≥70 bpm，伊伐布雷定有助于减少心衰住院和心血管死亡（推荐类别为IIa）。

2）对于有症状的HFrEF患者（或不能耐受GDMT的患者），地高辛可能被认为可以减少HF的住院率（推荐类别为IIb）。

3）在确诊的HFrEF高危患者中，近期已经使用GDMT的心衰恶化，可考虑使用口服可溶性鸟苷酸环化酶刺激剂（vericiguat）来减少心衰住院率和心血管死亡率（推荐类别为IIb）。

2022 ACC心衰管理指南

2022 ACC心衰管理指南心衰是指心脏结构或功能异常导致心室收缩或充盈障碍引起的症状和体征的复杂的临床综合征。

心衰的分期2022版ACC心衰指南对心衰分期进行了修订，并提出了两个新的术语来分别强调A期和B期患者的风险预防。

根据心衰发展的过程，可分为A、B、C、D四期，从A到D严重程度依次递增。

A期防治是针对危险因素进行治疗；B期防治措施是针对结构异常与药物进行干预；C期需要加用控制症状的药物；D期防治需要通过器械手段，甚至心脏移植进行解决。

具体分期定义如下:A期（有心衰风险）：有心衰风险但当前或既往无心衰症状、体征且无结构性、功能性心脏疾病或异常生物标志物的患者。

患有高血压、CVD、糖尿病、肥胖、服用心脏毒性药物、有心肌病基因变异或心肌病家族史的患者。

B期（心衰前期）：患者无心衰症状或体征，但存在下述情况之一：➤结构性心脏病：如左心室或右心室收缩功能下降、射血分数降低、心肌肥厚、心腔扩大、室壁运动异常或瓣膜性心脏病等；➤充盈压增加：通过有创血流动力学或无创超声心动图等检查发现；➤具有A期的危险因素，并伴有B型利钠肽（BNP）水平升高或心肌肌钙蛋白持续升高（提示心肌损伤），同时无导致此类生物标志物水平升高的其他病因，如急性冠脉综合征、慢性肾脏病、肺栓塞或心肌心包炎。

C（有症状的心衰）期：目前或既往有心衰症状、体征的患者。

D期（晚期心衰）：尽管尝试了最优GDMT，但仍存在明显影响日常生活且反复住院的症状。

心衰的治疗心衰不同分期有相应的治疗方案，对于A、B期患者来说，一级预防很重要。

指南强调A期和B期患者的风险预防。

1.A期的预防患者有心衰风险，需要加强预防，积极控制血压、血糖、血脂，戒烟、戒酒。

A 期预防相关推荐如表1所示：表1：A期预防的推荐2.B期的治疗心衰前期需要控制危险因素，有心肌梗死病史和心功能下降者应用ACEI和β受体阻滞剂。

B期治疗的相关推荐如表2所示：表2：B期治疗的相关推荐3.C期的治疗C期为有症状的心衰，患者的病情较严重，如果没有控制高危因素，很容易导致病情加重甚至危及生命。

解读ACCAHA 心衰指南

对于合并房颤的心衰患者，可维持窦性心律或单纯控制心室率〔Ⅱa/A〕。左室射血分数〔LVEF〕≤35％，QRS间期 ≥0.12 s合并房颤者，根据建议接受最正确药物治疗后，纽约心脏学会〔NYHA〕心功能分级为Ⅲ级或非卧床的心功能Ⅳ级患者，可给予心脏再同步〔有或无埋藏式心律转复除颤器〕治疗〔Ⅱa/B〕
A阶段：有心衰高危因素〔如高血压、冠心病、糖尿病等〕，但无结构性心脏病或心衰病症。治疗重点在于积极干预危险因素。 B阶段：有结构性心脏病〔包括左室肥厚、左室重构和心室扩张等〕，但无心衰病症或体征。治疗重点在于阻断或延缓心肌重构。 C阶段：有结构性心脏病，当前或既往有心衰病症。治疗重点在于改善心衰病症，提高生活质量，降低心衰住院率和死亡率。 D阶段：终末期心衰。治疗重点为在上述3期治疗根底上，辅以心脏移植、血液透析等特殊治疗。
C期治疗：改善心衰转归
患者在标准抗心衰治疗根底上，加用缬沙坦可降低复合终点事件〔全因死亡及发病〕发生率13.2％，且心衰住院风险也显著降低了27.5％。总之，ARB防治心衰的证据充分，代表药物缬沙能为心衰患者提供全面有效的保护〔图3〕，尤其对于心衰A、B期的高血压及高危高血压患者，缬沙坦能在高品质降压的同时，延缓心室重构进展，预防心衰发生，是2021年版指南中唯一拥有心衰A、 B、C三期治疗指征的ARB。
新知·开展指南建议与时俱进-3
对于接受最正确药物治疗后，LVEF≤35％、 NYHA心功能Ⅲ级或非卧床的心功能Ⅳ级且时常依赖心室起搏的患者，可给予心脏再同步治疗〔Ⅱa/C〕。认识以下导致急性心衰的常见潜在诱因和〔或〕合并症对于指导治疗很重要：急性冠脉综合征或冠脉缺血、重度高血压、房性和室性心律失常、感染、肺栓塞、肾功能衰竭、药物治疗或饮食控制的依从性不良〔Ⅰ/C〕。对于或疑似由冠脉闭塞导致急性心肌缺血的急性心衰患者，尤其是存在体循环灌注缺乏的病症和体征时，可给予急诊心导管术及冠脉血运重建治疗，或能延长患者的生存时间〔Ⅱa/C〕。

发出版ACC9指南-文档资料

对于有房颤（包括阵发性房颤）史的缺血性卒中或短暂性脑缺血发作患者，若不适宜口服抗凝治疗（非大出血的原因），我们推荐阿司匹林联合氯吡格雷治疗优于阿司匹林（1B）。
Chest 2019;141;7S-47S.
目录
ACCP9简介冠心病一级预防的抗栓建议冠心病患者的抗栓建议卒中患者的抗栓建议行手术治疗患者的抗栓建议房颤患者的抗栓建议 PAD患者的抗栓建议特殊人群的抗栓治疗
急性缺血性卒中或短暂性脑缺血发作患者抗栓建议
阿司匹林一级预防使用推荐
对于年龄大于或等于50岁的无心血管疾病人群，我们建议使用小剂量阿司匹林75-100mg/d（2B）。
Chest 2019;141;7S-47S. Nhomakorabea目录
ACCP9简介冠心病一级预防的抗栓建议冠心病患者的抗栓建议卒中患者的抗栓建议行手术治疗患者的抗栓建议房颤患者的抗栓建议 PAD患者的抗栓建议特殊人群的抗栓治疗
Chest 2019;141;7S-47S.
前壁心梗或者左室血栓或者左室血栓高危患者抗栓建议
对于前壁心梗或者左室血栓的患者或者左室血栓高危患者（射血分数＜40%，室壁运动异常）若未置入支架：我们推荐华法林（国际标准化比率2.0-3.0）+小剂量阿司匹林75-100mg/d优于单一抗血小板治疗；或者给予双联抗血小板治疗3个月（1B）。随后终止华法林并继续双联抗血小板治疗直至满12个月。12个月后，依据冠状动脉疾病推荐意见予以单一抗血小板治疗。
Chest 2019;141;7S-47S.
前壁心梗或者左室血栓或者左室血栓高危患者抗栓建议
对于前壁心梗或者左室血栓的患者或者左室血栓高危患者（射血分数＜40%，室壁运动异常）,若置入裸金属支架：我们建议予以三联疗法（华法林[国际标准化比率2.0-3.0]+小剂量阿司匹林+氯吡格雷75mg/d）一个月，且优于双联抗血小板治疗（2C）。

适应式巡航控制（ACC）操作指南说明书

Adaptive Cruise Control (ACC)*1Helps maintain a constant vehicle speed and a set following-interval behind a vehicle detected ahead of yours, without you having to keep your foot on the brake or the accelerator.Improper use of ACC can lead to a crash.Use ACC only when traveling on open highways in good weather.ACC has limited braking capability.When your vehicle speed drops below 25 mph (40 km/h), ACC will automatically cancel and no longer will apply your vehicle’s brakes.*1 - If equippedn Activating and Setting the Vehicle Speed1.Press the MAIN button. The ACC(green) indicator appears.2.Take your foot off the pedal andpress down the SET/– button whenyou reach the desired speed. Themoment you release the button, theset speed is fixed, and ACC begins.Note: When you completely disableVSA®, you cannot use ACC.n Adjusting the Vehicle SpeedIncrease or decrease the vehicle speed using the RES/+ or SET/– button on the steering wheel.1.Each time you press the RES/+ or–/SET button, the vehicle speed isincreased or decreased by about 1mph or 1 km/h accordingly.2.If you keep pressing the RES/+ or–/SET button, the vehicle speedincreases or decreases by about 5mph or 5 km/h accordingly.n Adjusting the Vehicle DistancePress the Interval button to change theACC following-interval. Each time youpress the button, the following-intervalsetting cycles through extra long, long,middle, and short following-intervals.n During OperationACC monitors if a vehicle ahead of youenters the ACC range. If a vehicle isdetected doing so, the ACC systemmaintains or decelerates your vehicle’sset speed in order to keep the vehicle’sset following-interval from the vehicleahead.When a vehicle whose speed is slowerthan your set speed is detected in frontof you, your vehicle starts to slowdown.If a vehicle detected ahead of you slows down abruptly or if another vehicle cuts in front of you, the beeper sounds and a message appears on the driver information interface.n Canceling ACCTo cancel ACC, do any of the following:•Press the CANCEL button.•Press the MAIN button.The ACC indicator (green) goes off.•Depress the brake pedal.•Depress the clutch pedal*1 for fiveseconds or more.Note: When you completely disableVSA® while ACC is activated, ACC willautomatically be canceled.*1 - If equippedn Switching to Standard Cruise ControlPress and hold the Interval button forone second.Cruise Mode Selected appears in thedriver information interface for twoseconds, and then the mode switchesto Cruise.To switch back to ACC, press and holdthe interval button again for onesecond.n Important Safety ReminderAs with any system, there are limits to ACC. Use the brake pedal whenever necessary, and always keep a safe interval between your vehicle and other vehicles.LimitationsYou may need to use the brake to maintain a safe interval when using ACC.Additionally, ACC may not work properly under certain conditions.Adaptive Cruise Control (ACC) with Low Speed Follow*1Helps maintain a constant vehicle speed and a set following interval behind a vehicle detected ahead of yours and, if the detected vehicle comes to a stop, can decelerate and stop your vehicle, without you having to keep your foot on the brake or the accelerator. When ACC with Low Speed Follow slows your vehicle by applying the brakes, your vehicle's brake lights will illuminate.n Activating and Setting the Vehicle Speed1.Press the MAIN button. The ACC(green) indicator appears.*1 - If equipped2.Accelerate to the desired speed.When driving at about 25 mph (40km/h) or above: Take your foot offthe pedal and press the SET/–button when you reach the desiredspeed. The moment you release thebutton, the set speed is fixed, andACC with Low Speed Follow begins.When driving slower than about 25mph (40 km/h): If the vehicle ismoving and the brake pedal is notdepressed, pressing the button fixesthe set speed to about 25 mph (40 km/h) regardless of current vehicle speed. If the vehicle is stationary, you can set the vehicle speed even with the brake pedal depressed.n Adjusting the Vehicle SpeedPress the RES button to increase speed or the SET button to decrease speed.Each time you press the switch up ordown, the vehicle speed is increased ordecreased by about 1 mph (1 km/h). Ifyou keep the switch pressed up ordown, the vehicle speed increases ordecreases by 5 mph or 5 km/h until yourelease it.n Adjusting the Vehicle DistancePress the Interval button to change theACC with Low Speed Follow following-interval. Each time you press thebutton, the following-interval settingcycles through extra long, long, middle,and short following-intervals.n During OperationACC with Low Speed Follow monitors ifa vehicle ahead of you enters the ACCwith Low Speed Follow range. If avehicle is detected doing so, the ACCwith Low Speed Follow systemmaintains or decelerates your vehicle’sset speed in order to keep the vehicle’sset following-interval from the vehicleahead. When a vehicle whose speed isslower than your set speed is detectedin front of you, your vehicle starts to slow down.You can temporarily increase the vehicle speed when you press theaccelerator pedal. ACC stays on unless you cancel it. When you release the accelerator pedal, the system resumes the set speed or a sufficient speed to maintain the following interval.If a vehicle detected ahead of you slows down abruptly or if another vehicle cuts in front of you, the beeper sounds and BRAKE appears on the driver information interface, and the head-up warning lights*1flash.You may need to use the brake to maintain a safe interval when using ACC with Low Speed Follow.Additionally, ACC with Low Speed Follow may not work properly undercertain conditions.n Canceling ACC with Low Speed FollowTo cancel ACC with Low Speed Follow, do any of the following:•Press the CANCEL button.•Press the MAIN button.The ACC with Low Speed Follow indicator (green) goes off.•Depress the brake pedal.When the Low Speed Follow function has stopped the vehicle, you cannot cancel ACC with Low Speed Follow by depressing the brake pedal.*1 - If equippedAfter you have canceled ACC with LowSpeed Follow, you can resume the priorset speed while it is still displayed.Press the RES/+ button. The set speedcannot be set or resumed when ACCwith Low Speed Follow has been turnedoff using the MAIN button. Press theMAIN button to activate the system,then set the desired speed.Exiting a vehicle that has been stopped while the ACC with Low Speed Follow system is operating can result in the vehicle moving withoutImproper use of ACC with Low Speed Follow can lead to a crash.Use ACC only when driving on expressways or freeways and in goodACC with Low Speed Follow has limited braking capability and may not stop your vehicle in time to avoid a collision with a vehicle that quicklyn Switching to Standard Cruise ControlPress and hold the Interval button for one second.Cruise Mode Selected appears on theDriver Information Interface for twoseconds, and then the mode switchesto Cruise.To switch back to ACC with Low SpeedFollow, press and hold the intervalbutton again for one second.Always be aware which mode you are in. When you are driving in Cruise mode, the system will not assist you to maintain a following interval from a vehicle ahead of you.n Important Safety ReminderAs with any system, there are limits to ACC with Low Speed Follow. Use the brake pedal whenever necessary, and always keep a safe interval between your vehicle and other vehicles.LimitationsYou may need to use the brake to maintain a safe interval when using ACC with Low Speed Follow. Additionally, ACC with Low Speed Follow may not work properly under certain conditions.。

AHAACC心脏瓣膜病管理指南解读(全文)

AHA/ACC心脏瓣膜病管理指南解读（全文）美国心脏病学会（ACC）与美国心脏协会（AHA）联合美国胸外科协会（AATS）、美国超声心动图学会（ASE）、美国心血管造影和介入协会（SCAI）、美国心血管麻醉师协会（SCA）和美国胸外科医师协会（STS）发布了《心脏瓣膜病患者管理指南》。

新指南更加强调早期干预、全程关注，强调团队合作，风险评估，并对心脏瓣膜病进行了重新分期。

在某些瓣膜病分级的诊断及治疗方案上也进行了更新及细化。

该指南在疾病的干预效果的随访、预后及生存质量的评估方面进行了较详细的阐述。

其中关于血栓形成、瓣膜性栓塞及脑卒中等并发症的防治方面。

下面就指南中的重要内容进行解读，并重点关注瓣膜病与血栓栓塞事件的防治及心源性脑栓塞相关的内容。

一、瓣膜病人诊治一般原则（一）瓣膜病人的拟诊及评估不管临床表现，所有确诊瓣膜病还是疑似瓣膜病都必须详细询问病史，体格检查，并行胸片和心电图检查。

通过心脏彩超可以获得一些有用的信息，例如瓣膜损害程度，对心腔、大血管的影响，心脏功能等。

其他辅助检查，如经食管心脏彩超（TEE），CT，磁共振，应激试验，诊断性心导管检查（还可以治疗瓣膜疾病病人）也常被采用。

对于存在外科风险的，尤其是存在并发症的病人，推荐进行心脏介入检查。

应定期对这类病人进行随访，随访应包括病史、体格检查等。

当病人出现症状加重时，随访的频率应该大于每年一次。

在无症状的左心衰，某些瓣膜可能导致无法预料的结局，这都迫使提高随访频率。

重复检查频率（心脏彩超）取决于瓣膜狭窄程度、对左右心室的影响以及瓣膜状态。

（二）评价瓣膜疾病严重程度新版指南参照2013年心衰管理指南，依据瓣膜血流动力学改变及其结局和相关症状，瓣膜的形态改变对心脏瓣膜病进行分期（见表1），疾病的分期对治疗方式和选择具有重要的指导意义。

指南将瓣膜疾病分为A、B、C、D四期，分别是危险期、进展期、无症状重度病变期和有症状重度病变期。

分期标准包括：(1)存在或者无临床症状；(2)瓣膜疾病的严重性；(3)因瓣膜病变导致心室腔的容积或者压力变化；(4)对体循环和肺循环的影响；(5)心音的改变。

奔驰 Adaptive Cruise Control (ACC) 用户指南说明书

Driving Adaptive Cruise Control (ACC)*Helps maintain a constant vehicle speed and a set following-interval behind a vehicledetected ahead of yours, without you having to keep your foot on the brake or theaccelerator.1Adaptive Cruise Control (ACC)*Important ReminderAs with any system, there are limits to ACC. Use thebrake pedal whenever necessary, and always keep asafe interval between your vehicle and other vehicles.Be careful not to severely impact the radar sensorcover.Shift up when the engine revolutions is increasing.Shift down when the engine revolutions is decreasing.You can keep the set speed if you change the shiftposition within five second after depressing theclutch pedal.3WARNINGImproper use of ACC can lead to a crash.Use ACC only when driving on expressways orfreeways in good weather conditions.3WARNINGACC has limited braking capability.When your vehicle speed drops below22 mph (35 km/h), ACC will automaticallycancel and no longer will apply yourvehicle’s brakes.Always be prepared to apply the brakepedal when conditions require.Manual transmission models■Vehicle speed for ACC: Desired speed in a range above roughly 25 mph(40 km/h) ~■Shift position for ACC: In D or S■Shift position for ACC: In 2 or higher positionThe radar sensor isinside the front grille.The camera islocated behindthe rearviewmirror.Driving■How to activate the system1Adaptive Cruise Control (ACC)*You can read about handling information for the camera equipped with this system.The radar sensor for ACC is shared with the collision mitigation braking system TM (CMBS TM )When not using ACC: Turn off adaptive cruise by pressing the MAIN button. This also will turn off the Lane Keeping Assist System (LKAS).When the MAIN button is pressed both ACC and the Lane Keeping Assist System (LKAS) are either turned on or off.ACC may not work properly under certain conditions.Do not use ACC under the following conditions:•On roads with heavy traffic or while driving incontinuous stop and go traffic.•On roads with sharp turns.•On roads with steep downhill sections, as the set vehicle speed can be exceeded by coasting. In such cases, ACC will not apply the brakes to maintain the set speed.•On roads with toll collection facilities or other objects between lanes of traffic, or in parking areas, or facilities with drive through access.■Press the MAIN button onthe steering wheel.ACC is on in the multi-information display.ACC is ready to use.Driving Take your foot off the pedal and press down the –/SET button when you reach thedesired speed. The moment you release the button, the set speed is fixed, and ACCbegins.When ACC starts operating, the vehicle icon,interval bars and set speed appear on themulti-information display.■To Set the Vehicle Speed1To Set the Vehicle SpeedYou can switch the displayed set speedmeasurements on the multi-information displaybetween mph and km/h.On when ACC beginsPress and release−/SET ButtonSet Vehicle SpeedDriving■There is a vehicle aheadACC monitors if a vehicle ahead of you enters the ACC range. If a vehicle is detected doing so, the ACC system maintains or decelerates your vehicle’s set speed in order to keep the vehicle’s set following-interval from the vehicle ahead.When a vehicle whose speed is slower than your set speed comes in or cuts in front of you, your vehicle starts to slow down.■When in Operation1When in OperationIf the vehicle detected ahead of you slows down abruptly, or if another vehicle is detected cutting in front of you, the beeper sounds and a message appears on the multi-information display.Depress the brake pedal, and keep an appropriate interval from the vehicle ahead.Even if the interval between your vehicle and thevehicle detected ahead is short, ACC may start accelerating your vehicle under the following circumstances:•The vehicle ahead of you is going at almost the same speed as, or faster than, your vehicle.•A vehicle that cuts in front of you is going faster than your vehicle, gradually increasing the interval between the vehicles.You can also set the system to beep when a vehicle in front of you comes in and goes out of the ACCdetecting range. Change the ACC Forward Vehicle Detect Beep setting.BeepACC Range: 394 ft. (120 m)A vehicle icon appears on the multi-information display.Driving■There is no vehicle aheadYour vehicle maintains the set speed withouthaving to keep your foot on the brake oraccelerator pedal.If there previously was a vehicle detected ahead that kept your vehicle from traveling at the set speed, ACC accelerates your vehicle to the set speed, and then maintains it.■When you depress the accelerator pedalYou can temporarily increase the vehicle speed. In this case, there is no audible or visual alert even if a vehicle is in the ACC range.ACC stays on unless you cancel it. Once you release the accelerator pedal, the system resumes an appropriate speed for keeping the following-interval while a vehicle ahead is within the ACC range.1When in OperationLimitationsYou may need to use the brake to maintain a safe interval when using ACC. Additionally, ACC may not work properly under certain conditions.A vehicle icon with dotted-line contour appears on the multi-information display.DrivingThe system may automatically shut off and the ACC indicator will come on under certain conditions. Some examples of these conditions are listed below. Other conditions may reduce some of the ACC functions.■Environmental conditions•Driving in bad weather (rain, fog, snow, etc.).■Roadway conditions•Driving on a snowy or wet roadway (obscured lane marking, vehicle tracks,reflected lights, road spray, high contrast).■Vehicle conditions•The outside of the windshield is blocked by dirt, mud, leaves, wet snow, etc.•An abnormal tire or wheel condition (Wrong sized, varied size or construction,improperly inflated, compact spare tire, etc.).•The camera temperature gets too high.•The parking brake is applied.•When the radar sensor cover is dirty.•The vehicle is tilted due to a heavy load or suspension modifications.•When tire chains are installed.■ACC Conditions and Limitations1ACC Conditions and LimitationsThe radar sensor for ACC is shared with the collision mitigation braking system (CMBS ).TM TM You can read about handling information for the camera equipped with this system.Always keep the radar sensor cover clean.Never use chemical solvents or polishing powder for cleaning the sensor cover. Clean it with water or a mild detergent.Do not put a sticker on the radar sensor cover or replace the radar sensor cover.If you need the radar sensor to be repaired, or removed, or the radar sensor cover is stronglyimpacted, turn off the system by pressing the MAIN button and take your vehicle to a dealer.Have your vehicle checked by a dealer if you find any unusual behavior of the system (e.g., the warning message appears too frequently).If the front of the vehicle is impacted in any of the following situations, the radar sensor may not work properly. Have your vehicle checked by a dealer:•The vehicle mounted onto a bump, curb, chock,embankment, etc.•You drive the vehicle where the water is deep.•Your vehicle has a frontal collision.■Detection limitations• A vehicle suddenly crosses in front of you.•The interval between your vehicle and the vehicle ahead of you is too short.• A vehicle cuts in front of you at a slow speed, and it brakes suddenly.•When you accelerate rapidly and approach the vehicle ahead of you at highspeed.•The vehicle ahead of you is a motorcycle, bicycle, mobility scooter, or other smallvehicle.•When there are animals in front of your vehicle.•When you drive on a curved or winding or undulating road that makes it difficultfor the sensor to properly detect a vehicle in front of you.•The speed difference between your vehicle and a vehicle in front of you issignificantly large.•An oncoming vehicle suddenly comes in front of you.•Your vehicle abruptly crosses over in front of an oncoming vehicle.•When driving through a narrow iron bridge.Driving•When the vehicle ahead of you brakes suddenly.•When the vehicle ahead of you has a unique shape.•When your vehicle or the vehicle ahead of you is driving on one edge of the lane.DrivingIncrease or decrease the vehicle speed using the RES/+ or –/SET buttons on the steering wheel.•Each time you press the RES/+ or –/SET button, the vehicle speed is increased or decreased by about 1 mph or 1 km/h accordingly.•If you press and hold the RES/+ or –/SET button, the vehicle speed increases or decreases by about 5 mph or 5 km/h accordingly.■To Adjust the Vehicle Speed1To Adjust the Vehicle SpeedIf a vehicle detected ahead is going at a speed slower than your increased set speed, ACC may notaccelerate your vehicle. This is to maintain the setinterval between your vehicle and the vehicle ahead.To increase speedTo decrease speedDrivingPress the (interval) button to change the ACC following-interval.Each time you press the button, the following-interval (the interval behind a vehicle detected ahead of you) setting cycles through short, middle, long, and extra long following-intervals.Determine the most appropriate following-interval setting based on your specific driving conditions. Be sure to adhere to anyfollowing-interval requirements set by local regulation.■To Set or Change Following-intervalInterval ButtonDrivingThe higher your vehicle’s following-speed is, the longer the short, middle, long or extra long following-interval becomes. See the following examples for your reference.Vehicle IntervalWhen the Set Speed is:50 mph (80 km/h)65 mph (104 km/h)Short84 feet 26 meters 1.1 sec 102 feet 31 meters 1.1 sec Middle111 feet 34 meters 1.5 sec 139 feet 43 meters 1.5 sec Long155 feet 48 meters 2.1 sec 202 feet 62 meters 2.1 sec Extra Long204 feet 62 meters 2.8 sec265 feet 81 meters 2.8 secDrivingTo cancel ACC, do any of the following:•Press the CANCEL button.•Press the MAIN button.u The ACC indicator (green) goes off.•Depress the brake pedal.•Depress the clutch pedal for five seconds or more.■To Cancel1To CancelResuming the prior set speed: After you havecanceled ACC, you can resume the prior set speed while it is still displayed. Press the RES/+ button when driving at a speed of at least 25 mph (40 km/h) or more.The set speed cannot be set or resumed when ACC has been turned off using the MAIN button. Press the MAIN button to activate the system, then set the desired speed.CANCEL ButtonMAIN ButtonManual transmission modelsDriving■Automatic cancellationThe beeper sounds and a message appears on the multi-information display when ACC is automatically canceled. Any of these conditions may cause the ACC to automatically cancel:•Bad weather (rain, fog, snow, etc.)•When the radar sensor inside the front grille gets dirty.•The vehicle ahead of you cannot be detected.•An abnormal tire condition is detected, or the tires are skidding.•Driving on a mountainous road, or driving off road for extended periods.•Abrupt steering wheel movement.•When the ABS, VSA ® or CMBS is activated.TM •When the ABS or VSA ® system indicator comes on.•When you manually apply the parking brake.•When the detected vehicle within the ACC range is too close to your vehicle.•The camera behind the rearview mirror, or the area around the camera, including the windshield, gets dirty.•When you do not shift down about for ten seconds after the shift down indicator coming on•When the engine speed reaches the tachometer’s red zonen •When the engine speed reaches 1,000 rpm or less •When you keep N while driving•When you put the transmission into N without depressing the clutch pedal1Automatic cancellationEven though ACC has been automatically canceled, you can still resume the prior set speed.Wait until the condition that caused ACC to cancel improves, then press the RES/+ button.DrivingPress and hold the (interval) button for onesecond. Cruise Mode Selected appears onthe multi-information display for two seconds,and then the mode switches to Cruise and theCruise Mode indicator is displayed.To switch back to ACC, press and hold thebutton again for one second. ACC ModeSelected appears on the multi-informationdisplay for two seconds.■When to useDesired speed in a range above roughly 25 mph (40 km/h) ~.Take your foot off the pedal and press the –/SET button when you reach the desiredspeed.The moment you release the –/SET button, the set speed is fixed, and cruise controlbegins. The CRUISE CONTROL indicator comes on.Each time you press the RES/+ or –/SET button, the vehicle speed is increased ordecreased by about 1 mph (1 km/h).If you keep the RES/+ or –/SET button pressed, the vehicle speed increases ordecreases by about 5 mph or 5 km/h accordingly.■To Switch ACC to Cruise Control1To Switch ACC to Cruise ControlAlways be aware which mode you are in. When youare driving in Cruise mode, the system will not assistyou to maintain a following-interval from a vehicleahead of you.■To Set the Vehicle Speed■To Adjust the Vehicle SpeedDrivingTo cancel cruise control, do any of the following:•Press the CANCEL button.•Press the MAIN button.•Depress the brake pedal.•Depress the clutch pedal for five seconds or more.The CRUISE CONTROL indicator goes off.■To Cancel1To CancelResuming the prior set speed:After cruise control has been canceled, you can still resume the prior set speed by pressing the RES/+ button while driving at a speed of at least 25 mph (40 km/h) or more.You cannot set or resume in the following situations:•When vehicle speed is less than 25 mph (40 km/h)•When the MAIN button is turned off.At vehicle speeds of 22 mph (35 km/h) or less, cruise control canceled automatically.。

ACC冠心病双抗指南更新

ACC冠心病双抗指南更新冠心病是一种常见的心血管疾病，也是导致死亡的主要原因之一。

在冠心病的治疗中，抗血小板治疗和降脂治疗是常用的方法。

ACC(American College of Cardiology)是国际公认的心脏病学权威组织之一，最近更新了冠心病的双抗指南，本文将对其进行介绍。

抗血小板治疗1.选药根据指南，对于患有冠心病的患者，建议使用阿司匹林(Acetylsalicylic Acid，ASA)作为抗血小板治疗的首选药物。

而对于患有糖尿病的患者，则建议使用阿司匹林同时联合使用其他抗血小板药物，以减少心血管事件的发生率。

2.剂量指南中推荐的阿司匹林剂量为75mg/天~162mg/天，平均剂量为100mg/天。

值得注意的是，氯吡格雷(Clopidogrel)和他汀类药物(Statins)的使用可能影响阿司匹林的代谢，影响其疗效，因此应当结合患者的具体情况进行选择。

降脂治疗1.目标LDL-C水平根据指南，对于冠心病患者，靶向的降低低密度脂蛋白胆固醇(LDL-C)的水平是非常重要的。

指南建议患者的LDL-C水平应该控制在70mg/dL以下，同时强调减轻超重和肥胖是达到该目标的重要手段之一。

2.治疗方法在指南中，强调了使用他汀类药物作为主要的降脂治疗手段。

他汀类药物在临床应用中已被证明是非常有效的药物，并且具有很好的耐受性，患者通常可以长期使用。

对于不能耐受他汀类药物的患者，可以使用其他降脂药物。

3.药物治疗选择在药物治疗选择方面，指南中对多种药物进行了介绍，如异质甾醇类(Different types of statins can be used for lipid lowering in secondary prevention of patients with coronary artery disease.)ACC针对冠心病的双抗治疗进行了更新，这对临床医生和患者都具有重要意义。

医生们可以根据指南提供的建议，结合患者的具体情况进行个体化的治疗方案制定。

非心脏手术术前心血管风险评估ACC指南课件

准确评估有助于制定更合理的治疗方案，提高患者术后恢复效果和生活质量。
02 ACC指南概述
指南发布机构和目标
发布机构
美国心脏病学会（ACC）
目标
为非心脏手术术前心血管风险评估提供指导和建议，降低手术风险，提高患者安全
适用范围和对象
适用范围
适用于所有接受非心脏手术的患者，无论年龄、性别和种族
指导临床实践和决策
提供决策依据
ACC指南为医生提供了具体的评估指标和标准，使医生能够根据评估结果制定个性化的治疗方案
和手术计划。
降低医疗风险
通过准确的术前心血管风险评估，医生可以提前采取措施降低手术风险，提高手术的安全性和成功率。
优化医疗资源配置
医生可以根据评估结果合理安排手术时间和资源，提高医疗资源的利用效率。
05 非心脏手术术前心血管风险评估实践
实践中的问题与挑战
评估标准不统一
01
目前缺乏统一的评估标准，导致评估结果存在差异。
数据采集困难
02
心血管风险的评估需要采集患者详细的病史和检查结果，但实
际操作中可能存在数据采集不全或误差。
评估结果与实际风险关联度不高
03
由于评估模型和指标的局限性，评估结果与实际心血管风险可
患者心血管疾病风险较高，手术风险较大，需进行严格的术前评估和准备。
风险控制建议
针对患者的个体化建议
根据患者的具体情况，制定个性化的风险控制方案。
术前准备
进行必要的术前检查，如心电图、心脏超声等，确保患者心功能良好。
围手术期管理
加强术中监测，合理使用药物，预防和处理心血管并发症。
术后随访
定期随访患者，监测心血管状况，及时发现和处理问题。

ACC11 乙醛酯封封闭剂（液体）用户指南说明书

SAFETY DATA SHEETACC11 ACRYLIC CONFORMAL COATING ( AEROSOL)ACC SILICONES LIMITEDSUPPLIERAmber House, Showground RdBridgwater, Somerset TA6 6AJTEL: +44 (0)1278 411400FAX: +44 (0)1278 411444**************************EMERGENCY TELEPHONE DEUTSCHLAND +49 613 3162 91880 (24hrs)ITALIA +39 029880913 (24hrs)UK +44 (0)1278 411400 (24hrs)Highly flammable. Irritating to eyes. Repeated exposure may cause skin dryness or cracking. Vapours may cause drowsiness and dizziness.The Full Text for all R-Phrases are Displayed in Section 16COMPOSITION COMMENTSINHALATIONRemove victim immediately from source of exposure. Get medical attention if any discomfort continues.INGESTIONDO NOT induce vomiting. Get medical attention immediately.SKIN CONTACTWash skin thoroughly with soap and water. Get medical attention promptly if symptoms occur after washing.EYE CONTACTImmediately flush with plenty of water for up to 15 minutes. Remove any contact lenses and open eyes wide apart. Get medical attention ifEXTINGUISHING MEDIAExtinguish with foam, carbon dioxide or dry powder. Do not use water jet as an extinguisher, as this will spread the fire.SPECIAL FIRE FIGHTING PROCEDURESNo specific fire fighting procedure given.UNUSUAL FIRE & EXPLOSION HAZARDSAerosol cans may explode in a fire.SPECIFIC HAZARDSENVIRONMENTAL PRECAUTIONSDo not discharge into drains, water courses or onto the ground.SPILL CLEAN UP METHODSExtinguish all ignition sources. Avoid sparks, flames, heat and smoking. Ventilate. Absorb spillage with non-combustible, absorbentUSAGE PRECAUTIONSAvoid contact with skin and eyes. Avoid inhalation of vapours. Eliminate all sources of ignition.STORAGE PRECAUTIONSAerosol cans: Must not be exposed to direct sunlight or temperatures above 50°C.STORAGE CLASSINGREDIENT COMMENTSWEL = Workplace Exposure LimitsPROTECTIVE EQUIPMENTHAND PROTECTIONFor prolonged or repeated skin contact use suitable protective gloves.EYE PROTECTIONAPPEARANCE Colourless liquidODOUR Fruity.STABILITYStable under normal temperature conditions and recommended use.CONDITIONS TO AVOIDAvoid contact with acids and oxidising substances.HAZARDOUS DECOMPOSITION PRODUCTSINHALATIONMay cause irritation to the respiratory system.INGESTIONHarmful: may cause lung damage if swallowed.SKIN CONTACTProduct has a defatting effect on skin. Prolonged and frequent contact may cause redness and irritation.EYE CONTACTIrritating to eyes.ECOTOXICITYNo data on possible environmental effects have been found.MOBILITYThe product contains volatile organic compounds (VOC) which will evaporate easily from all surfaces. The product hardens to a solidimmobile substance.DEGRADABILITYThe product is expected to be biodegradable.DISPOSAL METHODSUK ROAD CLASS 2.1PROPER SHIPPING NAME AEROSOLSUK ROAD PACK GR.1950UN NO. ROAD Not ApplicableADR CLASSADR CLASS NO.Class 2: Gases2ADR LABEL NO.ADR PACK GROUP 2.1Not ApplicableRID CLASS NO.CEFIC TEC(R) NO.220G5FRID PACK GROUP1950UN NO. SEANot ApplicableIMDG CLASS 2.1IMDG PAGE NO.2.1EMSIMDG PACK GR.F-D, S-UNot ApplicableMARINE POLLUTANTSee GuideMFAG No.AIR CLASSUN NO. AIR 2.11950LABELLINGIrritant Highly FlammableRISK PHRASESR11Highly flammable.R36Irritating to eyes.R66Repeated exposure may cause skin dryness or cracking.R67Vapours may cause drowsiness and dizziness.SAFETY PHRASESS9Keep container in a well-ventilated place.S16Keep away from sources of ignition - No smoking.S23Do not breathe vapour/spray.S25Avoid contact with eyes.S26In case of contact with eyes, rinse immediately with plenty of water and seek medicaladvice.S37Wear suitable gloves.S38In case of insufficient ventilation, wear suitable respiratory equipment.S60This material and its container must be disposed of as hazardous waste.UK REGULATORY REFERENCESChemicals (Hazard Information & Packaging) Regulations.EU DIRECTIVESDangerous Preparations Directive 1999/45/EEC. System of specific information relating to Dangerous Preparations. 2001/58/EEC.STATUTORY INSTRUMENTSChemicals (Hazard Information and Packaging) Regulations.NATIONAL REGULATIONSThe Chemicals (Hazard Information and Packaging for Supply) Regulations 2002. No. 1689. Workplace Exposure Limits 2005 (EH40) TheREVISION COMMENTSThis is first issue.ISSUED BYHS&E Manager.REVISION DATE21/08/2007REV. NO./REPL. SDS GENERATED2SDS NO.10307SAFETY DATA SHEET STATUSApproved.DATE6/8/2004RISK PHRASES IN FULLR10 Flammable. , R11 Highly flammable. , R12 Extremely flammable. , R36 Irritating to eyes. , R37Irritating to respiratory system. , R51/53 Toxic to aquatic organisms, may cause long-term adverseeffects in the aquatic environment. , R65 Harmful: may cause lung damage if swallowed. , R66 Repeatedexposure may cause skin dryness or cracking. , R67 Vapours may cause drowsiness and dizziness.DISCLAIMERThis information relates only to the specific material designated and may not be valid for such material used in combinationwith any other materials or in any process. Such information is, to the best of the company's knowledge and belief, accurateand reliable as of the date indicated. However, no warranty guarantee or representation is made to its accuracy, reliability orcompleteness. It is the user's responsibility to satisfy himself as to the suitability of such information for his own particular use.。

AHA和ACC关于指南的建议和分级

证据水平 A 级：数据来自多项随机临床试验或荟萃分析。 B 级：数据来自单项随机临床试验或多项非随机临床试验。 C 级：仅有专家共识意见、病例研究或治疗规范。
AHA/ACC 实据支持和/或一致同意某种操作或治疗有益、有用、有效。 II 类：某种操作或治疗有益、有用、有效，但存在相互矛盾的证据和/
或分歧意见。 Ⅱa：证据和/或意见支持有益、有用、有效。 Ⅱb：证据和/或意见不能充分支持有益、有用、有效。
Ⅲ类：有证据表明和/或一致同意某种操作或治疗无用、无效，在某些情况下可能有害。

2022ACC心衰指南更新要点

2022AHA/ACC/HFSA心衰管理指南解读2022 ACC年会期间AHA/ACC/HFSA三大学会联合重磅发布心衰指南新版指南•重新定义了心力衰竭的分期和分类•全面更新了管理策略及治疗方案•更加强调心衰预防以及心衰专业团队的管理协调2022版指南在2013年和2017年版心衰指南的基础上进行了更新和整合•Circulation.2022Apr1:101161CIR0000000000001063.•JAmCollCardiol.2022May3;79(17):e263-e421.doi:10.1016/j.jacc.2021.12.012.Epub2022Apr1.N E W目录1心力衰竭的分期、A、B期的建议2心衰C、D期基于射血分数的分类及建议3急性失代偿心衰住院患者的建议4合并症的管理2022版ACC 心衰指南修订了心衰的分期，强调A 、B 期患者的一级预防Ø对于有心衰风险（A期）或心衰前期（B期）的人来说，一级预防很重要。

新版指南对HF分期进行了修订，并提出了两个新的术语来分别强调A期（“有心衰风险”）和B期（“心衰前期”）患者的风险预防。

N E WA 期有心衰风险B 期心衰前期C 期有症状的心衰D 期晚期心衰有心衰风险但当前或既往无心衰症状/体征且无结构性/功能性心脏疾病或异常生物标志物的患者患有高血压、CVD 、糖尿病、肥胖、服用心脏毒性药物、有心肌病基因变异或心肌病家族史的患者目前或既往无心衰症状/体征但存在以下任意1种证据支持的患者:有结构性心脏病有充盈增加的证据尚未存在明确诊断但有危险因素且存在•利钠肽水平升高或•心肌肌钙蛋白持续升高目前或既往有心衰症状/体征的患者尽管尝试了最优GDMT,但仍存在明显影响日常生活且反复住院的症状•Circulation.2022Apr1:101161CIR0000000000001063.•JAmCollCardiol.2022May3;79(17):e263-e421.doi:10.1016/j.jacc.2021.12.012.Epub2022Apr1.心衰风险期（StageA）和心衰前期（StageB）的推荐高血压T2D 合并CVD 或CVD 高危CVD心毒性物质暴露患者一级亲属相关的基因和遗传性心肌病患者有心衰风险的患者有心衰风险的患者血压优化控制（1）SGLT2i （1）CVD 的优化管理（1）多学科评估管理（1）基因筛查和就诊（1）利钠肽筛查（2a ）经验证的多变量风险评分（2a ）LVEF ≤40%近期心梗和LVEF ≤40%LVEF ≤40%LVEF ≤30%；＞1年生存期；心梗后>40天非缺血性心肌病ACEi （1）ARB 如ACEi 不耐受（1）β受体阻滞剂（1）ICD （1）遗传咨询和检测（2a ）持续生活方式调整和管理策略执行颜色表示推荐级别*在心衰风险期（A 期）患者中实施的管理策略应持续至 B 期。

ACC心衰治疗指南

1990年，日本首次报道，急性期左室收缩末期形状像日本捕章鱼的“篓”
由应激诱发，表现为急性可逆性左室功能障碍，而无冠心病史
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应激性心肌病（Takotsubo）
女性多见，约占82－100％，尤其是绝经后中老年妇女
大多数病人有明显诱因（应激），如脑血管病
胸痛、胸闷约占2/3，可有剧烈胸痛，气促晕厥，类似急性心肌梗死
拮抗剂的患者，加用ARB（Ⅱb，A）不推荐常规联用“ACEI+ARB+醛固酮受体拮抗剂”
（有害，Ⅲ，C）
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ACEI/ARB的通常用法及剂量
药物
卡托普利依那普利福辛普利雷米普利培哚普利缬沙坦氯沙坦
初始剂量
最大剂量
6.25mg tid
50mg tid
2.5mg bid
10-20mg bid
慢性心衰合并房颤，且有脑卒中危险因素（高血压，糖尿病，既往脑栓塞或TIA病史，或年龄>75岁）应给予抗凝治疗；采用个体化治疗，并监测INR
※ Class Ⅱa，Level B
慢性心衰合并房颤，无脑卒中危险因素的患者，给以抗凝治疗
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利尿剂
所有HFrEF的患者，如有液体潴留，均须应用利尿剂改善症状，除非有禁忌症
利尿剂包括：噻嗪类、袢利尿剂、潴钾利尿剂
利尿剂应与ACEI、β-B、醛固酮受体拮抗剂合用
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ACEI/ARB
所有HFrEF的患者，均须应用ACEI/ARB降低发病率和死亡率，除非有禁忌
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结构性心脏病及其他原因
扩张性心肌病家族性心肌病内分泌及代谢因素导致的心肌病：肥胖、糖