急性心衰竭 (心衰竭指引 ESC guidelines, 2021)
Part 2~~
key words:
AHF: 急性心衰竭(Acute heart failure)
ADHF: 急性失償心衰竭(Acute decompensated heart failure)
Cardiogenic shock: 心因性休克
MCS:機械式循環輔助 (Mechanical circulation Support)
RRT:腎臟替代療法(Renal replacement therapy)
Natriuretic peptides (BNP, NT-proBNP, MR-proANP)
MR-proANP = mid-regional pro-atrial natriuretic peptide
NT-proBNP = N-terminal pro-B-type natriuretic peptide
AHF流行病學、診斷和預後
AHF 是指 HF 的症狀和/或癥兆迅速或逐漸發作,嚴重到足以使患者尋求緊急醫療照護,導致意外入院或急診就診。AHF患者需要緊急評估,隨後開始或積極治療,包括經由靜脈治療或裝置步驟。AHF在院內死亡率為4%-10% 。出院後一年死亡率: 25–30%,死亡或再入院率高達 45% 以上。
AHF 可能是 HF第一次發作,或者是由於慢性 HF 的急性失償。與急性失償心衰竭相比,新發HF患者的院內死亡率可能較高,但出院後死亡率和再住院率較低。
AHF的診斷檢查包括心電圖、心超、胸部X光、檢查和肺超檢查。尤其無法檢測Natriuretic peptides(NP)時。如果診斷無法確定是否心因性心衰竭時,則檢驗血漿 NP數值(BNP 或 NT-proBNP 或 MR-proANP)。
NPs正常:排除AHF 的診斷。
急性 HF 的臨界值是:
BNP <100 pg/mL、
NT-proBNP <300 pg/mL
MR-proANP <120 pg/mL。
但NP值升高與多種非心臟疾病相關, 在一些患有晚期失償末期HF、肥胖、突發性肺水腫(flash pulmonary edema)或右側AHF的患者可測得低值NP。有AF和/或腎功能異常,其NP數值較高。
AHF診斷流程
• 初步驗血檢驗包括肌鈣蛋白(troponin)、血清肌酐、電解質、血尿素氮或尿素、TSH、肝功能檢查及D-dimer(疑似肺栓塞);和procalcitonin (感染),動脈血氧分析(呼吸窘迫),以及lactate(低灌注的情況)。(註:procalcitonin降鈣素原可用於肺炎的診斷,數據 >0.2 μg/L 時,可能有使用抗生素治療的適應症。)
• 特定檢查包括冠狀動脈造影(疑似 ACS)和 CT(疑似肺栓塞)。
• 急性心衰診斷的NT-proBNP臨界值:
<55歲:> 450 pg/mL
55 -75 歲:> 900 pg/mL
> 75 歲> 1800 pg/mL
AHF臨床表現
AHF呈現四種主要的臨床表現,主要根據充血和/或外周血流灌注不足的原因所呈現出來不同的臨床表現。(參考表21)
四種臨床表現分別是:
1.急性失償心衰竭
2.急性肺水腫
3.孤立性右心室衰竭
4.心因性休克
各種急性心衰竭的臨床表現:
1.急性失償心衰竭(Acute decompensated heart failure, ADHF)
急性失償心衰竭 (ADHF) 是 AHF 最常見的形式,佔臨床表現的 50-70%。它發生在有HF病史和心臟功能異常,包括 RV 功能異常。與急性肺水腫表型不同,發作時程呈現漸進,主要變化是導致全身充血,液體滯留。
治療:
a. 使用環利尿劑,減少水份滯留。
b. 強心增壓劑(Norepinephrine):於周邊低灌注時使用。
c. 短暫使用機械式循環輔助(MCS):於周邊低灌注,器官受損時使用
c.腎臟替代療法(RRT: Renal replacement therapy):如果利尿劑無效或腎病末期時,可考慮使用RRT (Class IIa)
2.急性肺水腫
急性肺水腫診斷的臨床標準包括:
呼吸困難合併端坐呼吸、
呼吸衰竭(低血氧症-高碳酸血症)、
呼吸急促、
>25 次/分鐘和呼吸功增加。
治療:
a. 給予氧氣,持續氣道正壓通氣、非侵入性正壓通氣和/或高流量鼻管。
b. 給予靜脈利尿劑。
c. 如果收縮壓 (SBP) 高,可以給予靜脈血管擴張劑,以減少 LV 後負荷。在少數晚期 HF 病例中,急性肺水腫可能與低心輸出量有關,在這種情況下,需要使用強心劑(Inotropics)、血管加壓藥(vasopressors)和/或MCS 來恢復器官灌注。
3. 孤立性右心衰竭 (Solitary RV Failure)
a. RV 衰竭是由於 RV 和心房壓力增加以及全身充血。RV 衰竭也可能損害 LV 填充功能,最後導致心輸出量減少。
b. 利尿劑通常是治療靜脈充血的首選藥物。
c. Norepinephrine,強心劑、血管加壓劑:適用於低心輸出量和血流動力學不穩定。可能優先選用能降低心臟充填壓的強心劑, 如,levosimendan, phosphodiesterase type III inhibitors。
d. 由於強心劑可能會使動脈低血壓更嚴重,必要時,可以與norepinephrine合用。
4.心因性休克
心因性休克是由於原發性心臟功能異常導致心輸出量不足的症候群,包括危及生命的組織低灌注狀態,可導致多器官衰竭和死亡。
心因性休克的診斷要件:
灌注不足的臨床症狀:例如四肢冷汗、少尿、精神錯亂、頭暈、脈壓變窄、低灌注。血清肌酐升高、代謝性酸中毒和血清乳酸升高,反映出組織缺氧和細胞代謝改變導致器官功能障礙。低灌注並不常合併低血壓,因為可以通過代償性血管收縮(使用/不使用升壓劑)來維持血壓。
應儘早開始治療心因性休克:早期識別和治療潛在原因。
尋找病因(口訣:CHAMPIT):(see photo)
包括急性冠心症,高血壓急症,快速心律不整,嚴重心搏過慢,傳導阻滯,機械性原因(如,急性瓣膜返流,急性肺栓塞,感染,心肌炎,心包填塞)
嚴重休克病人則需要考慮將MCS(Class IIa)作為移植的過渡時期使用。
急性心衰竭的藥物治療:
利尿劑
靜脈利尿劑是AHF治療的基本。它們增加鈉和水份的排泄,適用於治療大多數AHF患者的體液過度負荷和充血。
a. Furosemide: 起始劑量為 20-40 mg,或靜脈推注 10-20 mg。Furosemide可以每天 2-3 次推注或連續輸注。由於給藥後,會有鈉滯留的可能性,因此不鼓勵每日單次推注給藥。連續輸注時,可使用負荷劑量以更早達到穩態。
b. 利尿劑治療開始後應立即評估利尿反應,並可通過在2或6小時後進行當時尿鈉含量(urine sport sodium) 和/或通過測量每小時尿量來評估。
c. 適當的利尿反應可以定義為2小時後,尿鈉(urine spot sodium) >50–70 mEq/L and/or
d. 前6小時尿量 >100–150 mL/h。
e. 如果利尿反應不足, 環利尿劑IV劑量可以加倍,並進一步評估利尿反應。
f. 如果利尿反應仍然不足,即使利尿劑劑量加倍,但每小時利尿量<100 mL,可以考慮同時使用其他作用於不同部位的利尿劑,即thiazides, metaolazone, acetazolamide。但需要仔細監測血清電解質和腎功能。
血管擴張劑
a. 靜脈血管擴張劑,如nitrate,可以擴張靜脈和動脈,因此減少靜脈返回心臟,充血減少,後負荷降低,增加心搏出量,因此緩解症狀。
b. Nitrate主要作用於靜脈,而nitroprusside則是動靜脈擴張。由於它們的作用機制,靜脈注射後,血管擴張劑可能比利尿劑更有效。急性肺水腫是由於後負荷增加和液體重新分配到肺部,而沒有周邊積液。
c. 當 SBP > 110 mmHg 時,可以考慮使用靜脈血管擴張劑來緩解AHF症狀。它們可以以低劑量開始並逐漸增加以達到臨床改善和血壓控制。應注意避免因前負荷和後負荷過度降低而導致的低血壓。因此,對於 LVH 和/或嚴重主動脈瓣狹窄的患者,應謹慎地使用。
強心升壓劑 (Inotropes)
a. 低心輸出量和低血壓患者的治療需要強心升壓劑(見表 22)。使用於左室收縮功能障礙、低心輸出量和低收縮壓(例如 <90 mmHg)導致重要器官灌注不良的情況。必須從低劑量開始謹慎使用,並在密切監測下逐漸增加。
b. Inotropes其是那些具有腎上腺素能機制的藥物,可引起竇性心動過速,增加 AF 患者的心室率,可能誘發心肌缺氧和心律異常,增加死亡率。
血管加壓藥(Vasopressors)
a. Norepinephrine具有顯著動脈收縮,適用於嚴重低血壓患者。主要目的是增加對重要器官的灌注。但會增加 LV 後負荷。因此,可以考慮同時併用Intropes + Norepisnephrine,特別是對於晚期 HF 和心因性休克的患者。
a. 休克患者第一線血管加壓藥的比較:Dopamine vs Norepinephrine,顯示在心因性休克患者Dopamine發生較多的心律不整,和死亡率。但低血容量或敗血性休克則沒有。
b. 在另一項前瞻性隨機試驗中,在急性 MI 引起的心因性休克患者中比較了Epinephrine vs Norepinephrine,由於頑固性心因性休克發生率較高,該研究提前終止。
c. Epinephrine會有較快的心率和乳酸中毒。儘管存在樣本量相對較小、追蹤時間短以及缺乏有關最大達到劑量的數據,但該研究表明Norepinephrine有較好的療效和安全性。這些數據與一項包括 2583 位心因性休克患者的綜合分析一致,顯示與Norepinephrine相比,心因性休克患者使用Epinephrine的死亡風險增加了三倍。因缺乏有關劑量、持續追蹤時間,和病因,使這些結果仍需進一步探討。
鴉片類製劑(Opoid)
a. Opoid類藥物可緩解呼吸困難和焦慮,在非侵入性正壓通氣期間用作為鎮靜劑,以改善患者的適應能力。 副作用包括噁心、低血壓、心搏過緩和呼吸抑制。
b. Morphine給藥與會使機械通氣頻率更多、住院時間延長、重症監護病房入院次數增加和死亡率增加。因此,不推薦在AHF中常規使用opoid類藥物。嚴重頑固性疼痛或焦慮治療的情況下,亦可考慮使用opoid類藥物。
c. SBP <90 mmHg時,勿用Morphine.
d. Morphine會抑制呼吸,使用時特別注意呼吸狀況及保持呼吸道通暢。
Digoxin
a. AF患者使用了乙型阻斷劑,但仍有心室心率過快(AF with RVR) (>110 b.p.m.) ,可考慮使用Digoxin。
b. 如果未曾使用過Digoxin,可以靜脈推注 0.25–0.5 mg。
對於CKD或影響Digoxin代謝的其他因素(包括其他藥物)和/或老年人,維持劑量可能難以理論上估計,應檢查血清Digoxin level。
血栓栓塞預防
a. 推薦使用肝素(例如低分子量肝素)或其他抗凝劑預防血栓栓塞。
c. 若正服用服抗凝劑或禁忌,則不需使用肝素。
短期機械式循環輔助(MCS)
a. 心因性休克可能需要短期 MCS 以增加心輸出量和維持器官灌注。
b. 短期 MCS 可用作恢復前(BTR, bridge to recover),治療策略決定前(是否繼續積極治療或視為無效醫療, BTD, Bridge to decision) 暫時過渡期的使用。臨床研究證據仍然很少。因此,不支持在心因性休克患者中未經選擇地使用 MCS。
c. 心因性休克 II (IABP-SHOCK-II) 研究中的IABP-SHOCK-II顯示,主動脈內球泵浦 (IABP) 和合適藥物治療之比較,於心因性休克患者接受早期血管再灌注的急性 MI 後之休克中,30天和長期死亡率沒有差異。根據這些結果,不推薦 IABP常規用於 MI後的心因性休克(Class III)。然而,其他非ACS引起的心因性休克,對藥物治療無效,IABP作為BTD、BTR ,仍有幫助(Class IIb)。
d. 在小型隨機試驗和傾向匹配分析中將其他短期 MCS 與 IABP 進行了比較,但結果不確定。ECMO與 IABP或 MT進行比較的RCT亦無確定結果。
e. 一項僅包括觀察性研究的綜合分析顯示,與對照組相比,接受靜脈-動脈 (VA-ECMO) 治療的心因性休克或心臟驟停患者的預後良好。 VA-ECMO 也可用於治療暴發性心肌炎和其他導致嚴重心因性的疾病。
f. 根據心肌功能異常和/或合併二尖瓣或主動脈瓣閉鎖不全的嚴重程度,VA-ECMO 可能會增加 LV 後負荷,同時增加 LV 舒張末期壓力和肺充血。在這些情況下,可以通過經中隔/心室心尖通氣口或使用解除LV 負荷(例如 Impella 裝置) 。
本文出處:
https://reurl.cc/VEy9Gn
Ref:
European Heart Journal (2021) 00, 1-128
https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehab368/6358045#292214341
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SGLT2i 糖尿病藥Dapagliflozin用於治療心衰竭
SGLT2i 除了用來降血糖,亦可用於治療心衰竭。在NEJM 2019的論文已提出SGLT2i 糖尿病藥Dapagliflozin臨床療效。
根據這篇研究,使用Dapagliflozin治療NYHA Fc為 II-IV 級之心衰竭。在安慰劑-控制組試驗中,除了原先的建議治療,又分為每天服用一顆 10mg Dapagliflozin 的控制組或沒有使用Dapagliflozin之安慰劑組,來觀察因心衰竭須住院或緊急的靜脈注射治療或因血管病因死亡。
研究樣本數:4,744位心衰竭病人
平均年齡:66歲
糖尿病佔了42%
女性佔了24%
平均追蹤時間:18.2個月(2017年2月到2018年6月)
研究對象資格:
1. 有症狀之心衰竭(NYHA Fc II-IV)
2. 左心室射出分率≦40%
3. NT-pro-BNP ≥600 pg/ml (最近12個月住院者 ≥400 pg/ml,atrial fibrillation/flutter ≥900 pg/ml)
排除條件:
1. eGFR <30 ml/min/1.73 m2
2. 有症狀的低血壓,或收縮壓 <95 mm Hg
3. Type 1 DM
研究結果:
主要結果(Primary outcomes),包括心衰竭的住院,門急診次數,及心血管死亡率。
1.使用Dapagliflozin治療組:減少了26%因心衰竭的住院率或需要急診比率,及心血管死亡率。DAPA組: 16.3% vs 安慰劑組: 21.2%. (HR= 0.74; 95% CI, 0.65 to 0.85; P<0.001)
次要結果(Secondary outcomes)
1.使用Dapagliflozin治療組:減少了25% 心血管死亡率或心衰竭住院次數比例 (HR = 0.75; 95% CI = 0.65 to 0.85; P<0.001)
2.使用Dapagliflozin治療組:減少了18% 心血管死亡率
3.減少了25%住院次數及心血管疾病死亡率 (HR=0.75; 95% CI, 0.65 to 0.88);
4.腎功能惡化與任何原因的死亡率:兩組沒有差別
DAPA-HF Study解讀:
1. 對於低心室射出分率之心衰竭,使用Dapagliflozin是有益的。
2. 與安慰劑組比較,Dapagliflozin可以減少心血管死亡率及心衰竭事件。
3. Dapagliflozin可以減少心衰竭復發,及改善心衰竭症。
4. 這些效果無論在不同年齡,原本是否使用利尿劑,sacubitril/valsartan,是否有糖尿病,原本的健康狀況,都是有意義的。
5. 沒有出現不良事件。
6. 對於低心室射出分率之心衰竭的治療,Dapagliflozin是新方向。
有關Dapagliflozin:
使用禁忌:
(1) 對 Forxiga 嚴重過敏反應病史患者不可使用。
(2) 不可用於第一型糖尿病患、糖尿病酮酸中毒的治療。
(3) 重度腎功能不全、末期腎病(ESRD)、或透析病人禁止使用。
使用建議:
(1) Forxiga 的建議起始劑量為 5mg 每天一次,隨餐或空腹服用皆可。在耐受 Forxiga 5mg 每天一次的病人,需要額外血糖控制時,劑量可增加至 10mg 每 天一次。
(2) 腎功能差 eGFR< 45 ml/min/1.732之病人不建議使用,且當 eGFR 持續低於 30 ml/min/1.732時應停用 Forxiga。
健保規定:109/5/1
(1) 原則上第二型糖尿病治療應優先使用metformin,或考慮早期開始使用胰島素。除有過敏、禁忌症、不能耐受或仍無法理想控制血糖的情形下,可使用其他類口服降血糖藥物。
(2) TZD製劑、DPP-4抑制劑、SGLT-2抑制劑、以及含該3類成分之複方製劑,限用於已接受過最大耐受劑量的metformin仍無法理想控制血糖之第二型糖尿病病人,且SGLT-2抑制劑與DPP-4抑制劑及其複方製劑宜二種擇一種使用。
(3) 第二型糖尿病病人倘於使用三種口服降血糖藥物治療仍無法理想控制血糖者,宜考慮給予胰島素治療。
(4) 特約醫療院所應加強衛教第二型糖尿病病人,鼓勵健康生活型態的飲食和運動,如控制肥胖、限制熱量攝取等措施。
(5) 第二型糖尿病病人使用之口服降血糖藥物成分,以最多四種(含四種)為限。
備註:本規定生效前已使用超過四種口服降血糖藥物成分之病人,得繼續使用原藥物至醫師更新其處方內容。
*目前台灣健保針對Forxiga的適應症除了第二型糖尿病之外,也新增了「預防心血管事件:用於具第二型糖尿病且已有心血管疾病(CVD)或多重心血管風險因子的成人病人時,Forxiga 可降低心衰竭住院的風險」
*治療心衰竭建議劑量為10 mg QD。
Ref:
DAPA-HF (Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure)
N Engl J Med 2019; 381:1995-2008
#SGLT2
#Dapagliflozin
#DM
#Heart_Failure
heart failure type 在 AppWorks Facebook 的精選貼文
Interview with a Founder: Beryl Liu (Co-founder of Matters Lab)
By Norman Chi, Analyst
Beryl Liu is the co-founder and COO of Matters Lab and was previously the Operations Director of Initium Media. An experienced startup operator, Beryl once led the global operations of Aivvy, a music-tech startup which won the innovation award at CES. She was involved in running a Hong Kong-based NGO in Greater China.
1. What early experience shaped who you are?
I am always passionate about the media because it can bring social value to the public, it’s THE thing I value most and deeply rooted in my heart. But I will say other than my passion, the sum of my experiences also is a big part of who I am now.
After graduating from college, I chose to become an editor in Hong Kong's first all-electronic media as my first job. Before starting Matters, I’ve joined several different groups and startups, including one NGO, one silicon valley startup and Initium Media which allows me to step out of my comfort zone, broaden my horizons, know more about new disruptive technologies like blockchain and learn how startups work. All these unique experiences and passion for media shaped who I am now.
2. Who is your role model as a founder?
I will say there are two types of role models I look up to. One is successful and inspiring entrepreneurs, the other is someone who you are close to and can resonate with.
For the first type of role model, there are too many entrepreneurs I look up to. Among these successful stories, one key thing I will particularly be inspired by is how these entrepreneurs find a breakthrough and identify the right path to stand out. Like Stewart Butterfield’s founding journey of Flickr, even though the original online game idea wasn't working, he had the crazy vision and quickly learned and found out the true needs of users: real-time interaction around photos, and then based on the findings, he launched Flickr and turned it into a success. This type of founders are the role models I would especially look up to and want to share the same vision as they do.
But these great entrepreneurs are too far from our life and work, you can’t fully resonate with these entrepreneurs. So my mom became one of the role models I look up to since I can relate to her story more easily even though she’s not a founder. For the past 10 years, she had a relatively weak physical condition and underwent several severe surgeries which often left patients in pain and despair. But she kept fighting and fighting with a positive attitude, dealing with the pain and pressure, and always looked on the bright side, which really inspired me at my darkest moments, this is the kind of story you can always keep in mind and gather momentum from.
3. What is the biggest mistake and takeaway in your founder journey so far?
The entire entrepreneurship is the endless journey of trial and error until you find PMF (Product Market Fit), so before that, don’t rush to do premature scaling with limited resources. We tried to do too many things in 2018 because back at that time we thought we were ready to scale up, but actually we weren't, and we didn’t allocate the resources properly, leading to a bunch of conflicts both internally and externally. It was a costly lesson we learned after these series of poor decisions we made.
As a result, if you figure out you’ve made a bad decision, founders must learn how to set a stop-loss. Admitting and giving up on one decision you made is difficult, but when you admit something is wrong, it helps you to redirect to the right direction and potentially lower future costs. What’s more, it’s the failure that allows you to rethink and reflect on your goals.
About Matters Lab
Matters Lab is a decentralized content publishing platform for creators to publish, manage, license, and enable content providers to be paid for their content, rather than to have their content and revenue opportunities taken hostage by advertising algorithms and social media giants.
【We welcome all AI, Blockchain, or Southeast Asia founders to join AppWorks Accelerator: https://bit.ly/33e2JgH 】
heart failure type 在 一二三渡辺 Youtube 的精選貼文
今日初めて六甲の向こう側から来てくれました、
前から気になっていたそうです、
これを機会に遊びに来てくださいね、
ライダーズカフェMACHⅢ
大阪府堺市美原区北余部469-6
TEL&FAX072-361ー3171
http://www.h4.dion.ne.jp/~maltuha/index.html
It seems to have been anxious from ahead having come from the
opponent of six shells for the first time today.
It is Raidarzcafe MACH? to play on this occasion ..coming... 3171-..
Yo 469?6 TEL&FAX072?361.. V Osaka Prefecture Sakai City Mihara Ward
north .... http://www.h4.dion.ne.jp/~maltuha/index.html
CB400 SUPER FOUR (Shebe Suparfoa and abbreviation: CB400SF) is a motorcycle of 400cc naked type that Honda Motor Co., Ltd. is putting on the market. Alias Sufoa CB400SF(NC31)
CB400SF was developed under the concept of PROJECT BIG-1. In PROJECT BIG-1, the following requirements hang.
* Adopt four strokes and four DOHC water-cooled parallel cylinder engines in
the heart.
* The style of wild sexy &.
* Possess impressed performance that enchants the mind of the running
person.
The reference is exhibited to CB1000 SUPER FOUR in the 29th Tokyo Motor Show as a model of first PROJECT BIG-1, and it is put on the market in April afterwards in 1992.
It fought hard by sales because the style was more halfway on a practical side compared with the thing and the rival car with a little capacity of the fuel tank, and it reflected on the failure of CB-1, and CB400SF was put on the market in shape to take the style of a great car before though CB-1 was sold when HONDA till then did naked by four cylinders though CB-1 was excellent in the sports performance.
As the main change point from CB-1
* It changes from the style with a sporty feeling to the style of the old car style
of CB750F and CBX400F.
* Szasz
* It changes to a large-scale tank of the CB1100R type.
* Double disk making about reception desk brake
* The cam gear train is abolished from NC23E that is four water-cooled parallel cylinder engine that continues from CBR400R from generation to generation, the fin is added, and it installs it.
Version R appeared in the minor change, and Version S of Bikinicaulres appeared afterwards. Moreover, the model named CB400FOUR that takes the style of the CB750FOUR style based on NC31 exists, too.
CB400SF HYPER VTEC Revo (NC42)
Sale on December 25, 2007. It equips with PGM-FI that is a fuel jet device, HYPER VTEC is evolved further, and HYPER VTEC Revo is installed. [4]。 The engine takes the place from NC23E installed from CBR400R put on the market in 1986 for 20 years or more of NC42E of the new design, and the line is improved to the antilock braking and the system adoption model. Moreover, the lineup is done as for SUPER BOL D 'OR.
![post-title](https://i.ytimg.com/vi/KgzjiZAo-FA/hqdefault.jpg)
heart failure type 在 一二三渡辺 Youtube 的最佳解答
Do it come for the first time today, and did it like it ..him of the
Shiga number..?
It is Raidarzcafe MACH? to play on this occasion ..coming... 3171-..
Yo 469?6 TEL&FAX072?361.. V Osaka Prefecture Sakai City Mihara Ward
north .... http://www.h4.dion.ne.jp/~maltuha/index.html
CB400 SUPER FOUR (Shebe Suparfoa and abbreviation: CB400SF) is a motorcycle of 400cc naked type that Honda Motor Co., Ltd. is putting on the market. Alias Sufoa CB400SF(NC31)
CB400SF was developed under the concept of PROJECT BIG-1. In PROJECT BIG-1, the following requirements hang.
* Adopt four strokes and four DOHC water-cooled parallel cylinder engines in
the heart.
* The style of wild sexy &.
* Possess impressed performance that enchants the mind of the running person.
The reference is exhibited to CB1000 SUPER FOUR in the 29th Tokyo Motor Show as a model of first PROJECT BIG-1, and it is put on the market in April afterwards in 1992.
It fought hard by sales because the style was more halfway on a practical side compared with the thing and the rival car with a little capacity of the fuel tank, and it reflected on the failure of CB-1, and CB400SF was put on the market in shape to take the style of a great car before though CB-1 was sold when HONDA till then did naked by four cylinders though CB-1 was excellent in the sports performance.
As the main change point from CB-1
* It changes from the style with a sporty feeling to the style of the old car style
of CB750F and CBX400F.
* Szasz
* It changes to a large-scale tank of the CB1100R type.
* Double disk making about reception desk brake
* The cam gear train is abolished from NC23E that is four water-cooled parallel cylinder engine that continues from CBR400R from generation to generation, the fin is added, and it installs it.
Version R appeared in the minor change, and Version S of Bikinicaulres appeared afterwards. Moreover, the model named CB400FOUR that takes the style of the CB750FOUR style based on NC31 exists, too.
CB400SF HYPER VTEC Revo (NC42)
Sale on December 25, 2007. It equips with PGM-FI that is a fuel jet device, HYPER VTEC is evolved further, and HYPER VTEC Revo is installed. [4]。 The engine takes the place from NC23E installed from CBR400R put on the market in 1986 for 20 years or more of NC42E of the new design, and the line is improved to the antilock braking and the system adoption model. Moreover, the lineup is done as for SUPER BOL D 'OR.
![post-title](https://i.ytimg.com/vi/8coUP-jScAc/hqdefault.jpg)
heart failure type 在 一二三渡辺 Youtube 的最讚貼文
今日初めて六甲の向こう側から来てくれました、
前から気になっていたそうです、
これを機会に遊びに来てくださいね、
ライダーズカフェMACHⅢ
大阪府堺市美原区北余部469-6
TEL&FAX072-361ー3171
http://www.h4.dion.ne.jp/~maltuha/index.html
It seems to have been anxious from ahead having come from the
opponent of six shells for the first time today.
It is Raidarzcafe MACH? to play on this occasion ..coming... 3171-..
Yo 469?6 TEL&FAX072?361.. V Osaka Prefecture Sakai City Mihara Ward
north .... http://www.h4.dion.ne.jp/~maltuha/index.html
CB400 SUPER FOUR (Shebe Suparfoa and abbreviation: CB400SF) is a motorcycle of 400cc naked type that Honda Motor Co., Ltd. is putting on the market. Alias Sufoa CB400SF(NC31)
CB400SF was developed under the concept of PROJECT BIG-1. In PROJECT BIG-1, the following requirements hang.
* Adopt four strokes and four DOHC water-cooled parallel cylinder engines in
the heart.
* The style of wild sexy &.
* Possess impressed performance that enchants the mind of the running
person.
The reference is exhibited to CB1000 SUPER FOUR in the 29th Tokyo Motor Show as a model of first PROJECT BIG-1, and it is put on the market in April afterwards in 1992.
It fought hard by sales because the style was more halfway on a practical side compared with the thing and the rival car with a little capacity of the fuel tank, and it reflected on the failure of CB-1, and CB400SF was put on the market in shape to take the style of a great car before though CB-1 was sold when HONDA till then did naked by four cylinders though CB-1 was excellent in the sports performance.
As the main change point from CB-1
* It changes from the style with a sporty feeling to the style of the old car style
of CB750F and CBX400F.
* Szasz
* It changes to a large-scale tank of the CB1100R type.
* Double disk making about reception desk brake
* The cam gear train is abolished from NC23E that is four water-cooled parallel cylinder engine that continues from CBR400R from generation to generation, the fin is added, and it installs it.
Version R appeared in the minor change, and Version S of Bikinicaulres appeared afterwards. Moreover, the model named CB400FOUR that takes the style of the CB750FOUR style based on NC31 exists, too.
CB400SF HYPER VTEC Revo (NC42)
Sale on December 25, 2007. It equips with PGM-FI that is a fuel jet device, HYPER VTEC is evolved further, and HYPER VTEC Revo is installed. [4]。 The engine takes the place from NC23E installed from CBR400R put on the market in 1986 for 20 years or more of NC42E of the new design, and the line is improved to the antilock braking and the system adoption model. Moreover, the lineup is done as for SUPER BOL D 'OR.
![post-title](https://i.ytimg.com/vi/PlT9k2ACEkA/hqdefault.jpg)
heart failure type 在 Congestive Heart Failure: Left-sided vs Right-sided, Systolic ... 的必吃
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Heart failures: pathophysiology, causes. Purchase PDF (script of this video + images) here: ... ... <看更多>
heart failure type 在 Types of Heart Failure – Cardiology | Lecturio - YouTube 的必吃
This video “ Types of Heart Failure ” is part of the Lecturio course “Cardiology” ▻ WATCH the complete course on ... ... <看更多>