英文班内科学心力衰竭.ppt

HeartFailure HF Heartfailure HF Conception heartfailureisafinalcommonpathwayformanycardiacdisordersofdiverseetiologyandpathogenicmechanisms Itisaclinicalsyndrome manifestedasaresultoftheinabilityofthehearttomatchitsoutputtothemetabolicneedsofthebodyeventhoughthefillingpressureoftheheartisadequate CategoriesofHF 1 left rightandwhole2 acuteandchronic3 systolicanddiastolic stageofHF Pre heartfailurePre clincalheartfailureClinicalheartfailureRefractoryend stageheartfailure NewYorkHeartAssociationFunctionalClassification Class NolimitationofphysicalactivityNosympotomswithordinaryexertionClass SlightlimitationofphysicalactivityOrdinaryactivitycausessymptomsClass MarkedlimitationofphysicalactivityLessthanordinaryactivitycausessymptomsAsymptomaticatrestClass InabilitytocarryoutanyphysicalactivitywithoutdiscomfortSympotomsatrest StageandClassofHF 心衰分期是NYHA分级的补充 但不能替代NYHA分级NYHA分级 在具体病人可上下变动 对治疗的反应和 或疾病进程不同 分期 随心脏重构加重只能进展 6 minwalkdistance milddegree 450mmoderatedegree 150 450mseveredegree 150mEvaluationofchronicHFcardiacfunction Fundamentalcauses primarymyocardialdiseaseincreasedburdenstotheheart Fundamentalcauses 1 primarydecreasedmyocardialcontractilitycoronaryheartdiseasemyocarditis cardiomyopathymyocardialmetabolicdisorder Fundamentalcauses 2 increasedburdenstotheheart increasedafterload pressureload hypertensionaorticstenosispulmonarystenosispulmonaryhypertension Fundamentalcauses 2 increasedburdenstotheheart increasedpreload volumeload mitralincompetenceaorticincompetencetricuspidincompetenceatrialseptaldefect ASD ventricularseptaldefect VSD patentductusarteriosus PDA hyperthyroidismanemia Precipitatingcauses infection especiallyrespiratoryinfectionarrhythmias AFphysicaloremotionalexcessese g pregnancyanddeliveryrapidintravenousinfusion excessivesalttakingmalpraticeprimarydiseasedeteriorationoranewdiseasehappens Pathogenesisandpathophysiology 1 Compensateheartfailure2 Ventricularremodeling3 Aboutdiastolicinsufficiency4 Humoralfactorschange 1 Compensateheartfailure Frank Starlingprincipleneurohumoralactivationmyocardialhypertrophy 1 Compensateheartfailure cardiacdilatation bywayoftheFrank Starlingprinciple contractileforceincreases 1 Compensateheartfailure neurohumoralactivationa Increaseinsympatheticnervousactivityb RAASactivated renninangiotensionaldosteronesystem 心力衰竭 神经体液的代偿和失代偿 交感神经激活 水 钠潴留 水肿肺瘀血 血流动力学异常 血管收缩 心肌耗氧量增加心肌氧供应降低 心肌细胞功能障碍和坏死 心肌重塑 功能恶化疾病进展 血管紧张素 儿茶酚胺毒性作用 心肌细胞凋亡 肾素 血管紧张素系统激活 代偿 失代偿 心衰症状体征加重 治疗目标 增强心肌收缩 2 RAASinHeartFailure 2 RAASinHeartFailure 1 Compensateheartfailure myocardialhypertrophyMyocardialcellhypertrophysystolepowerNotincreasednumberMyocardialfibreincreasednumberenergyMyocardialcompliance 顺应性 2 Ventricularremodeling 2 Ventricularremodeling heartfailureistheresultofventricularremodeling ReducethemyocardialcellsdecreaseofthesystolicfunctionIncreasedmyocardialfibrosisdecreaseoftheVentricularcompliance Heartcavityexpansion myocardialhypertrophy extracellularmatrix collagenfibers Myocardialcells Compensatedstage Decompensatedstage 3 aboutdiastolicinsufficiency Characteristic inthesecases fillingoftheleftorrightventricleisabnormal Mechanism myocardialrelaxationisimpaired Myocardialcompliancedecreasing outcome diastolicpressures venousereturn fluidretention dyspnea intolerance 4 somecytofactorstakepartinheartfailure ANP atrialnatriureticpeptide BNP brainnatriureticpeptide AVP argininevassopressin Endothelin NE angiotensin Urinevolume peripheralvascular sympatheticnervous RAAS Ventricularremodeling Ventricularremodeling neurohumoralactivation heartfailure Chronicheartfailure CHF Clinicalmanifestations 1 Leftheartfailurepulmonarycongestionlesscardiacoutput2 Rightheartfailuresystemicvenouscongestion3 Wholeheartfailure 1 Leftheartfailure 1 dyspnea 1 exertionaldyspnea 2 paroxysmalnocturnaldyspnea 3 orthopnea 4 acutepulmonaryedema 1 Leftheartfailure 2 cough hemoptysis spitpinksputum3 fatigue dizziness palpitation 4 oliguria renaldysfunction sign 1 pulmonarybasalralesbilaterallyorright side2 enlargedleftheartpulsusalternans protodiastolicgallopP2increased Pulmonaryedema 2 Rightheartfailure symptom abdominaldiscomfortanorexia 厌食 nausea vomit exertionaldyspnea 2 Rightheartfailure sign liverenlargedascites distentionofjugularveinshepatojugularreflux peripheraledema mostmarkindependentparts cyanosis protodiastolicgallop functionalmurmursoftricuspidandpulmonaryvalve 3 Wholeheartfailure LHF RHF laboratoryexamination BNPandNT proBNP 呼吸困难 虚弱 运动受限等症状 NT proBNP 慢性心衰 转至心脏专科 继续下一步诊断 阳性 阴性 NT proBNP临床应用流程图 辅助诊断心衰 辅助判断进展期心衰患者预后 laboratoryexamination CnTIbloodroutineexaminationroutineurineexaminationbiochemicalexaminationFT3 FT4 TSH ECG electrocardiogram ischemiaOMIconductionblockarrhysmia X ray PulmonarycongestionPleuraleffusionKerlryBRightpulmonaryarterybroadeningPulmonaryhilarbutterflyshape Echocardiogram LVEF 50 E A 1 2LVEDV LVESVLVEDD LVESDventricularwallmotion Cardiacmagneticresonance CMR99MTC MIBISPECT radionuclide Coronaryangiography CardiacCatheterization Swan GanzPCWP 12mmHgCI 2 5L min m2 CardiopulmonaryExerciseTesting CPET ChronicstableHFMeasurementofrateofoxygenuptake VO2 rateofCO2production VCO2 duringmaximal symptom limited exercise Diagnosisanddifferentialdiagnosis Diagnosis medicalhistory symptoms signs examExam ECG rarelynormalinsystolicHF x ray todetectcardiomegalyandpulmonarycongestion 3 Echocardiogram Itiscriticalimportance todeterminetheunderlyingcausesofHF toassesstheseverityofventriculardysfunctiona functionofcontraction LVEF 50 b functionofrelaxation E A 1 2 2 Differentialdiagnosis 2 Differentialdiagnosis Pericardialeffusion Constrictivepericarditis distentionofjugularveins hepatojugularreflux liverenlarged ascitesperipheraledema mostmarkindependentpartsmedicalhistorysignsofheartandperivascularechocardiogram CMR themostsensitive specificnoninvasivemethod 2 Differentialdiagnosis Hepatocirrhosiswithascitesandedemaoflowerextremitydistentionofjugularveins hepatojugularreflux Treatmentofchronicheartfailure Principle alleviatesymptoms improvelifequality treatmentforprimarydiseaseandprecipitatingcausesAntagonismofneurohumoralactivationinhibitionofprogressiveventricularremodelingreducemortalityandextendlife Treatmentofchronicheartfailure GeneralPharmacologictreatmentNon medicinetreatment Generaltreatment decreasedburdens increasedsystolepower Anti neurohumoralactivation Generaltreatment decreasedburdens increasedsystolepower Anti neurohumoralactivation 1 LifestylemanagementEducationRegulateweightDietarymanagement salttake2 Restandaction3 Treatmentforprimarydiseaseandprecipitating Generaltreatment decreasedburdens increasedsystolepower Anti neurohumoralactivation 1 Rest2 Dietarymanagement salttake3 Diuretics furosemidedihydrochlorothiazide potassium losing antistone potassium sparing Themainpointofdiureticsapplication 对于有症状的心衰 当液体负荷过重已表现为肺淤血或外周水肿时 利尿剂是基本的治疗 应用利尿剂可迅速改善呼吸困难并增加运动耐量 I类建议 证据级别A 尚无大型随机对照试验评估这类药物对症状和生存的影响 如能耐受 利尿剂始终应与ACEI和 受体阻滞剂一起使用 I类建议 证据级别C 襻利尿剂应作为首选 噻嗪类仅适用于轻度液体潴留 伴高血压和肾功能正常的心衰患者 I类 B级 利尿剂通常从小剂量开始 氢氯噻嗪25mg d 呋塞米20mg d 托塞米10mg d 逐渐加量 一旦病情控制即以最小有效量长期维持 每日体重变化是最可靠检测利尿剂效果和调整利尿剂剂量的指标 长期服用利尿剂应严密观察不良反应的出现如电解质紊乱 症状性低血压 以及肾功能不全 特别在服用剂量大和联合用药时 类 B级 Themainpointofdiureticsapplication Generaltreatment decreasedburdens increasedsystolepower Anti neurohumoralactivation 1 Rest2 Dietarymanagement salttake3 Diuretics4 Vasodilator sodiumnitroprusside SNP nitroglecerinregitine 酚妥拉明 ThemainpointofVasodilatorapplication 直接血管扩张剂对于CHF的治疗无特殊作用 类 A级 血管扩张剂可用于不能耐受ACEI或ARBs的患者 伴有心绞痛或高血压可考虑应用 类 B级 禁忌证 血容量不足 低血压 肾功能衰竭心脏流出道或瓣膜狭窄患者 Generaltreatment decreasedburdens increasedsystolepower Anti neurohumoralactivation 1 Digitalis 1 effection Positiveinotropic inhibitNa K ATPenzyme introcellularNa K Na Ca2 exchange introcellularCa2 myocardialsystolepower introcellularK digitalispoisoning Generaltreatment decreasedburdens increasedsystolepower Anti neurohumoralactivation 1 Digitalis 1 effection Positiveinotropic ElectrophysiologicalInhibitcondutionsystem espiciallyatriventricularjunction Improvetheautorhythmictyofatrium junctionregionandventricle Generaltreatment decreasedburdens increasedsystolepower Anti neurohumoralactivation 1 Digitalis 1 effection Positiveinotropic ElectrophysiologicalParasympatheticstimulatinganti sympatheticnerveexciting Generaltreatment decreasedburdens increasedsystolepower Anti neurohumoralactivation 1 Digitalis 1 effection Positiveinotropic ElectrophysiologicalParasympatheticstimulatingRoleintherenaltubulecellsreducingsodiumreabsorptioninhibitthesecretionofrenin Generaltreatment decreasedburdens increasedsystolepower Anti neurohumoralactivation 1 Digitalis 2 applicationindication chroniccongestiveheartfailurecomplicatedbyatrailflutterandfibrillationandarapidventricularrate Generaltreatment decreasedburdens increasedsystolepower Anti neurohumoralactivation 1 Digitalis 2 applicationcontraindication WPWwithAF degreeAVB degreeAVBsicksinussyndrome SSS Hypertrophiccardiomyopathy HOCM severemitralstenosis SMS acutemyocardiacinfarction first24h Generaltreatment decreasedburdens increasedsystolepower Anti neurohumoralactivation 1 Digitalis 3 digitalispoisoningfactors K O2 RFClincalexpression gastricbowelreaction arrhythmia neurologicalandvisualchangeDiagnosis 2 0ng ml Arrhythmiaofdigitalispoisoning VentricularPrematurebeatNonparoxysmalatrioventricularjunctionaltachycardiaAtrialPrematurebeatAtrialfibrillatonAtrioventricularblockST Tchangelikefishhook Characteristicfeature Generaltreatment decreasedburdens increasedsystolepower Anti neurohumoralactivation 1 Digitalis Treatmentofdigitalispoisoningdrugwithdrawaltachycadia supplyK Lidocainivbradicadia atropiniv notsuitableforpacemakernotsuitableforisoprenalinedisablecardioerter Generaltreatment decreasedburdens increasedsystolepower Anti neurohumoralactivation 1 Digitalis2 excitant Dopamine NEprecursor2 g kg minDopamine R expandrenalartery2 5 g kg min 1 2 R myocardialcontractility Vasodilate5 10 g kg min R BP HR Dobutamine Dopaminederivatives2 g kg min 10 g kg minVasodilate HR smalleffects Generaltreatment decreasedburdens increasedsystolepower Anti neurohumoralactivation 1 Digitalis2 excitant3 Phosphodiesteraseinhibitors 1 effect restrainactivityofphosphodiesterase thedegradationofcAMP cAMP Ca2 channelactivation Ca2 inflow myocardialcontractility Generaltreatment decreasedburdens increasedsystolepower Anti neurohumoralactivation 1 Digitalis2 excitant3 Phosphodiesteraseinhibitors 1 effect 2 indications refractoryheartfailureend stageheartfailurebeforehearttransplantation Generaltreatment decreasedburdens increasedsystolepower Anti neurohumoralactivation 1 Digitalis2 excitant3 Phosphodiesteraseinhibitors 1 effect 2 indications 3 drugs 氨力农 Amrinone VD5 10 g kg min米力农 Milrinone VD0 5 g kg min Generaltreatment decreasedburdens increasedsystolepower Anti neurohumoralactivation 1 Digitalis2 excitant3 Phosphodiesteraseinhibitors 1 effect 2 indications 3 drugs 4 defect side effect mortality AII产生是通过多种通道 血管紧张素原 肾素 血管紧张素I 1 10 AngII 1 8 ACE AT1 AT2 血管收缩增殖醛固酮增加 血管扩张抗增殖 Ang1 7 Ang1 7受体激活 血管扩张抗增殖 Generaltreatment decreasedburdens increasedsystolepower Anti neurohumoralactivation 1 RAASinhibitor AngiotensinConvertingEnzymeInhibitors ACEI dilatebloodvesselsinhibitRAS sympatheticsystemreversetheventricularremodelingimprovearterystiffnessandsensitivityImproveendothelialfunction AT Inhibitthedegradationofbradykinin Generaltreatment decreasedburdens increasedsystolepower Anti neurohumoralactivation 1 RAASinhibitor AngiotensinConvertingEnzymeInhibitors ACEI Clinicalstatussymptoms exercisetolerance mortality delaytheprogressofheartfailurereducinghospitalizationratespreventHFaftermyocardialinfarction Generaltreatment decreasedburdens increasedsystolepower Anti neurohumoralactivation 1 RAASinhibitor AngiotensinConvertingEnzymeInhibitors ACEI Captopril6 25 25mg2 3 dEnalapril10mg2 dCilazapril2 5mg dBenazepril2 5 10mg dPerindopril2 4mg dFosinopril5 10mg dRamipril2 5mg d Generaltreatment decreasedburdens increasedsystolepower Anti neurohumoralactivation 1 RAASinhibitor AngiotensinConvertingEnzymeInhibitors ACEI applicationmethodsstartingwithsmalldosesiftolerated graduallyincreasethedosemonitoringofrenalfunctionandionsrenalfunctionchange highpotassium drycough angioedema Generaltreatment decreasedburdens increasedsystolepower Anti neurohumoralactivation 1 RAASinhibitor AngiotensinConvertingEnzymeInhibitors ACEI Contraindication anuricrenalfailure pregnancyandbrestfeedingwoman allerge RelativeContraindication renalarterystenosisbilaterally Cr 225 mol l k 5 5mmol l hypotension Generaltreatment decreasedburdens increasedsystolepower Anti neurohumoralactivation 1 RAASinhibitor AngiotensinConvertingEnzymeInhibitors ACEI AngiotensinIIreceptorantagonist ARB AT AT1receptor InhibitRASNoaffectingthedegradationofbradykinin Generaltreatment decreasedburdens increasedsystolepower Anti neurohumoralactivation 1 RAASinhibitor AngiotensinConvertingEnzymeInhibitors ACEI AngiotensinIIreceptorantagonist ARB applicationmethodslessdrycoughandangioedemawhenHF firstchoseACEIwhenHF shouldnotbecombinedapplicationofACEIandARBLosartan50mg d valsartan80mg d Generaltreatment decreasedburdens increasedsystolepower Anti neurohumoralactivation 1 RAASinhibitor AngiotensinConvertingEnzymeInhibitors ACEI AngiotensinIIreceptorantagonist ARB Aldosteroneantagonists spironolactone SPI potassium sparingdiureticreversetheventricularremodelingimproveprognosis Generaltreatment decreasedburdens increasedsystolepower Anti neurohumoralactivation 1 RAASinhibitor AngiotensinConvertingEnzymeInhibitors ACEI AngiotensinIIreceptorantagonist ARB Aldosteroneantagonistsrenininhibitor ACEI ARBincreasingplasmareninactivityrenininhibitiorhastheeffectofcardiorenalprotectionnotACEI ARBreplacementtherapy Generaltreatment decreasedburdens increasedsystolepower Anti neurohumoralactivation RAASinhibitor blocker sympatheticactivation b1receptors b2receptors a1receptors metoprololbisoprolol arrythmia dilatebloodvessels themyocardialO2 Cardiactoxicity carvedilol Generaltreatment decreasedburdens increasedsystolepower Anti neurohumoralactivation RAASinhibitor blocker Inhibitionofsympatheticactivationimproveprognosis 1 blockermetoprolol bisoprolol 1 2 blokercarvedilol applicationmethodsstartingwithsmalldosesiftolerated graduallyincreasethedosemonitoringofBp HR ECG Generaltreatment decreasedburdens increasedsystolepower Anti neurohumoralactivation RAASinhibitor blocker Contraindication bronchospasmseverebradycardia atrioventricularblocksevereperipheralvasculardiseaseacuteheartfailure Treatmentofchronicheartfailure TherecentadvancesaboutthetreatmentofHF Micturitionrestrainthesympatheticnervoussystemdilatebloodvessels rhBNP levosimendan IncreasetheCa2 sensitivity myocardialcontractility MediateATP K channel dilatebloodvessels ivabradine InhibiteSANIfcurrent tolvaptan CombineV2receptor H2O2reabsoption Treatmentofchronicheartfailure Non medicinetreatment CardiacResynchronizationTherapy CRT LeftVentricularAssistDevice LAVD TransitedtreatmentforhearttransplantationAdjuvanttherapyforacuteHF Treatmentofchronicheartfailure Non medicinetreatment hearttransplantationcellreplacementtherapy SCT stemcelltransplantation Acuteheartfailure AHF CategoriesofAHF 1 Acuteleftheartfailure2 Acuterightheartfailure3 non cardiacacuteheartfailure CategoriesofAHF Acuteleftheartfailuredecreasedmyocardialcontractilityincreasedburdenstothehearttightmitralstenosis especi