范维琥-心力衰竭.ppt

1,Heartfailure,2,DEFINITION,HEARTFAILUREthepathophysiologicalstateinwhichtheheartisunabletopumpbloodataratecommensuratewiththerequirementofthemetabolizingtissuesorcandosoonlyfromanelevatedfillingpressure.Usuallycausedbyadefectinmyocardialcontraction(myocardialfailure).,3,DEFINITION,CONGESTIVEHEARTFAILUREClinicalmanifestedasPulmonarycongestionSystemiccongestionInadequatetissurebloodperfusionHEMODYNAMICALLYheartfailure(cardiacdysfunction)isdiagnosedwhenLVEDP18mmHgorRVEDP10mmHg,4,UNDERLYINGCAUSES,Primarymyocardialdysfunction(systolicand/ordiastolic)CardiomyopathyPrimaryorsecondarymetabolicdisturbancesofmyocardiumOverloadingofheartPressureoverloadingVolumeoverloadinglimiteddiastolicfunction,5,UNDERLYINGCAUSES,Age70.310.1yr.CausesCHD65.8%Hypertension36.0%Dila.Cardiomy.11.9%With2DM14.9%ShanghaiOPD,ChinJCardiol2001;29:644,6,Precipitatingfactors,infectionarrhythmiasPulmonaryembolismoverfatiguePregnancyanddeliveryAnemiaandhemorrhageothers,7,Pathophysiology,Frank-StarlingmechanismActivationofneurohormonalpathway(SASandRAS)MyocardialdamageandremodelingDiasatolicheartfailure,8,“,9,CLINICALCLASSIFICATION,Acutevs.chronicheartfailureRight-sidedvs.left-sidedHeartfailureLow-outputvshigh-outputheartfailureSystolicvsdiastolicheartfailureAsymptomaticvscongestiveheartfailure,10,Chronicleft-sidedHF：symptoms,RespiratorydistressExertionaldyspneaParoxysmalnocturnaldyspneaOrthopneaAcutepumnonaryedemaCough(nonproductive),andhemoptysisReducedexercisecapacityFatigueandweaknessUrinarysymptoms,11,Chron.left-sidedHF：Physi.findings,GeneralappearanceDyspneticCyanosis,icterus,malarflush,diminishedpulsepressure,reducedSBP,rapid,weakandthreadypulseinsevereHFEvidenceofadrenergicactivityPeripheralvasoconstriction(pallor,coldnessofextremitiesandcyanosisofthedigits).Diaphoresiswithsinustachycardia,12,Chron.left-sidedHF：Physi.finding,CardiacfindingsCardiomegalyS3gallopsAccentuationofP2SystolicmurmurPulsusalternans,PulmonaryralesMoistralesoverthelungbasesRhonchiwheezesBS,13,Chron.right-sidedHF：symptoms,GastrointestinalsymptomsSymtomsofurinarysystemDullacheinrightupperquadrant.dyspnea,14,Chron.right-sidedHF：Physi.finding,CardiacfindingsHepatojugularrefluxCongetivehepatomegalyortendernessEdemaHydrothoraxandascitesOthers(cyanosis,andetc.),15,ChronicHF：labolarotyfindings,Routinelab.Andserumelectrolytes&liverfunctiontestsECGEchocardiographyChestRoentgenogram,16,ECG,SuggestingbasicpresenceofbasicheartdiseasesAtrialandventricularhypertrophy,myocardialischemiaorinfarction,arrhythmiaV1ptf0.03mms，indicatingleftatrialoverloading.,17,Echocardiogram,Mmode,2DechoandDoplertechniqueforsystolicanddiastolicfunctionofLVLVDdandLVDs（DdandDs）LVfractionofshortening（D（Dd-Ds）Dd100）mVCF（Dd-Ds）DdLVETSVLVEF,18,ChestXray,Left-sidedheartfailurecardiomegaly(cardiothoraxratio50%)minentbronchovascularmarkingsInterstitialedema,Kerley.sBline,alveolaredema,pleuraleffusionwhenPCWP2530mmHg.Right-sidedHFCardiomegaly,19,20,Invasivehemodynamicmonitoring,UsingSwan-GanzcatherandthermodilutionmethodformeasurementofIntracardiacandvascularpressureCardiacoutputtoassescardiacfunction,21,Invasivehemodynamicmonitoring,CVP（中心静脉压）612cmH2OPAP（肺动脉压）1230/4l3mmHgPCWP（肺毛细血管楔嵌压）612mmHgSV（心搏量）6070mlSI（心搏指数）4l51ml/m2CO（心排血量）56L/minCI（心排指数）2.64.0L/min.m2EF（射血分数）0.50.6,22,ChronicHF：diagnosis,causesanatomypathologyarrhythmiaFunctionalclassification,23,Functionalclassification（NYHA),ClassI-Nolimitation:Ordinaryphysicalactivitydoesnotcauseunduefatigue,dyspnea,orpalpitationClassII-slightlimitationofphysicalactivity:Suchpatientsarecomfortableatrest.Ordinaryphysicalactivityresultsinfatigue,palpitation,dyspnea,orangina.ClassIII-markedlimitationofphysicalactivity:althoughpatientsarecomfortableatrest,lessthanordinaryactivitywillleadtosymptoms.ClassIV-inabilitytocarryonanyphysicalactivitywithoutdiscomfort:symptomsofcongestivefailurearepresentevenatrest.Withanyphysicalactivity,increaseddiscomfortisexperience.,24,ChronicHF：diff.diagnosis,Left-sidedHFWithpulmonarydyspnea:COPD,asthmaMetabolicacidosisCardiacneurosisRight-sidedHFPricarditisHepatic,renaledema.,25,Functionalclassification（NYHA),ClassI-Nolimitation:Ordinaryphysicalactivitydoesnotcauseunduefatigue,dyspnea,orpalpitationClassII-slightlimitationofphysicalactivity:Suchpatientsarecomfortableatrest.Ordinaryphysicalactivityresultsinfatigue,palpitation,dyspnea,orangina.ClassIII-markedlimitationofphysicalactivity:althoughpatientsarecomfortableatrest,lessthanordinaryactivitywillleadtosymptoms.ClassIV-inabilitytocarryonanyphysicalactivitywithoutdiscomfort:symptomsofcongestivefailurearepresentevenatrest.Withanyphysicalactivity,increaseddiscomfortisexperience.,26,ChronicHF：diff.diagnosis,Left-sidedHFWithpulmonarydyspnea:COPD,asthmaMetabolicacidosisCardiacneurosisRight-sidedHFPricarditisHepatic,renaledema.,SurvivalMorbidityExercisecapacityQualityoflifeNeurohormonalchangesProgressionofCHFSymptoms,TREATMENTOBJECTIVES,28,ChronicHF:treatment,ReducingloadRestandtranquilizerControlsaltintakeWaterintakediureticsVasodilators,ImproveCOdigitalisnon-digitalispositiveinotropicagentsaldost.antagonist-bloker,correctingPFandcauseofHF,diastolicHFdificultHFcases,29,Diuretics,ThiazidesHydrochlorothiazidePotassium-spari