英文版内科学心力衰竭

HeartFailure(HF),Heartfailure(HF),Conception:heartfailureisafinalcommonpathwayformanycardiacdisordersofdiverseetiologyandpathogenicmechanisms.Itisaclinicalsyndrome,manifestedasaresultoftheinabilityofthehearttomatchitsoutputtothemetabolicneedsofthebodyeventhoughthefillingpressureoftheheartisadequate.,CategoriesofHF,1.left,rightandwhole2.acuteandchronic3.systolicanddiastolic,stageofHF,Pre-heartfailurePre-clincalheartfailureClinicalheartfailureRefractoryend-stageheartfailure,NewYorkHeartAssociationFunctionalClassification,ClassNolimitationofphysicalactivityNosympotomswithordinaryexertionClassSlightlimitationofphysicalactivityOrdinaryactivitycausessymptomsClassMarkedlimitationofphysicalactivityLessthanordinaryactivitycausessymptomsAsymptomaticatrestClassInabilitytocarryoutanyphysicalactivitywithoutdiscomfortSympotomsatrest,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.increasedburdenstotheheartincreasedafterload(pressureload):hypertensionaorticstenosispulmonarystenosispulmonaryhypertension,Fundamentalcauses,2.increasedburdenstotheheartincreasedpreload(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,LHFRHF,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,LVEF50%E/A1.2LVEDV/LVESVLVEDD/LVESDventricularwallmotion,Cardiacmagneticresonance,CMR99MTC-MIBISPECT(radionuclide)Coronaryangiography,CardiacCatheterization,Swan-GanzPCWP12mmHgCI2.5L/（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.todeterminetheunderlyingcausesofHFtoassesstheseverityofventriculardysfunctiona.functionofcontraction:LVEF50%b.functionofrelaxation:E/A1.2,2.Differentialdiagnosis:,2.Differentialdiagnosis:,Pericardialeffusion,Constrictivepericarditis:distentionofjugularveins,hepatojugularreflux(+)liverenlarged,ascitesperipheraledema,mostmarkindependentpartsmedicalhistorysignsofheartandperivascularechocardiogram,CMRthemostsensitivespecificnoninvasivemethod,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+-ATPenzymeintrocellularNa+、K+Na+-Ca2+exchangeintrocellularCa2+myocardialsystolepowerintrocellularK+，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:WPWwithAFdegreeAVB,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：NEprecursor2g/kg.minDopamine-R(+)expandrenalartery2-5g/kg.min12-R(+)myocardialcontractility,Vasodilate5-10g/kg.min-R(+)BP,HRDobutamine：Dopaminederivatives2g/kg.min10g/kg.minVasodilate,HR-smalleffects,Generaltreatment,decreasedburdens,increasedsystolepower,Anti-neurohumoralactivation,1、Digitalis2、-excitant3、Phosphodiesteraseinhibitors,1、effect:restrainactivityofphosphodiesterase，thedegradationofcAMP(-)cAMPCa2+channelactivationCa2+-inflowmyocardialcontractility,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)VD5-10g/kg.min米力农(Milrinone)VD0.5g/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,exercisetolerancemortalitydelaytheprogressofheartfailurereducinghospitalizationratespreventHFaftermyocardialinfarction,Generaltreatment,decreasedburdens,increasedsystolepower,Anti-neurohumoralactivation,1、RAASinhibitor,AngiotensinConvertingEnzymeInhibitors(ACEI),Captopril6.2525mg23/dEnalapril10mg2/dCilazapril2.5mg/dBenazepril2.510mg/dPerindopril24mg/dFosinopril510mg/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:anuricrenalfailurepregnancyandbrestfeedingwomanallerge,RelativeContraindication:renalarterystenosisbilaterallyCr225mol/lk+5.5mmol/lhypotension,Generaltreatment,decreasedburdens,increasedsystolepower,Anti-neurohumoralactivation,1、RAASinhibitor,AngiotensinConvertingEnzymeInhibitors(ACEI)AngiotensinIIreceptorantagonist(ARB),AT-AT1receptorInhibitRASNoaffectingthedegradationofbradykinin,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,bisoprolol12-blokercarvedilol,applicationmethodsstartingwithsmalldosesiftolerated,graduallyincreasethedosemonitoringofBp,HR,ECG,Generaltreatment,decreasedburdens,increasedsystolepower,Anti-neurohumoralactivation,RAASinhibitor-blocker,Contraindication:bronchospasmseverebradycardia。atrioventricularblocksevereperipheralvasculardiseaseacuteheartfailure,Treatmentofchronicheartfailure,TherecentadvancesaboutthetreatmentofHF,Micturitionrestrainthesympatheticnervoussystemdilatebloodvessels,rhBNP,levosimendan,IncreasetheCa2+sensitivitymyocardialcontractilityMediateATP-K+channeldilatebloodvessels,ivabradine,InhibiteSANIfcurrent,tolvaptan,CombineV2receptorH2O2reabsoption,Treatmentofchronicheartfailure,Non-medicinetreatment,CardiacResynchronizationTherapy(CRT),LeftVentricularAssistDevice（LAVD）,TransitedtreatmentforhearttransplantationAdjuvanttherapyforacuteHF,Treatmentofchronicheartfailure,Non-medicinetreatment,hearttransplantationcellreplacementtherapy-SCT(stemcelltransplantation),Acuteheartfailure,AHF,CategoriesofAHF,1.Acuteleftheartfailure2.Acuterightheartfailure3.non-cardiacacuteheartfailure,CategoriesofAHF,Acuteleftheartfailuredecreasedmyocardialcontractilityincreasedburdensto