2013年美国心力衰竭管理指南(心衰指南)-英文

reporting better HRQOL than other ethnic groups in the United States (71). Other determinants of poor HRQOL include depression, younger age, higher body mass index (BMI), greater symptom burden, lower systolic blood pressure, sleep apnea, low perceived control, and uncertainty about prognosis (70, 72-76). Memory problems may also contribute to poor HRQOL (76).

Pharmacological therapy is not a consistent determinant of HRQOL; therapies such as angiotensin-

converting enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) improve HRQOL only modestly or delay the progressive worsening of HRQOL in HF (77). At present, the only therapies shown to improve HRQOL are cardiac resynchronization therapy (CRT) (78) and certain disease management and educational approaches (79-82). Self-care and exercise may improve HRQOL, but the results of studies evaluating these interventions are mixed (83-86). Throughout this guideline we refer to meaningful survival as a state in which HRQOL is satisfactory to the patient.

See Online Data Supplement 4 for additional data on HRQOL and functional capacity.

4.5. Economic Burden of HF

In 1 in 9 deaths in the United States, HF is mentioned on the death certificate. The number of deaths with any mention of HF was as high in 2006 as it was in 1995 (51). Approximately 7% of all cardiovascular deaths are due to HF.

As previously noted, in 2012, HF costs in the United States exceeded $40 billion (51). This total includes the cost of healthcare services, medications, and lost productivity. The mean cost of HF-related hospitalizations was $23,077 per patient and was higher when HF was a secondary rather than the primary diagnosis. Among patients with HF in 1 large population study, hospitalizations were common after HF

diagnosis, with 83% of patients hospitalized at least once and 43% hospitalized at least 4 times. More than half of the hospitalizations were related to noncardiovascular causes (87-89).

4.6. Important Risk Factors for HF (Hypertension, Diabetes Mellitus, Metabolic Syndrome, and Atherosclerotic Disease)

Many conditions or comorbidities are associated with an increased propensity for structural heart disease. The expedient identification and treatment of these comorbid conditions may forestall the onset of HF (14, 27, 90). A list of the important documents that codify treatment for these concomitant conditions appears in Table 2.

Hypertension. Hypertension may be the single most important modifiable risk factor for HF in the United States. Hypertensive men and women have a substantially greater risk for developing HF than normotensive men and women (91). Elevated levels of diastolic and especially systolic blood pressure are major risk factors for the development of HF (91, 92). The incidence of HF is greater with higher levels of blood pressure, older