舒张性心力衰竭的超声心动图评价及其诊治现状课件

1、舒张性心力衰竭的超声心动图评价及其诊治现状卫生部北京医院心内科 汪芳Mortality in DHF Owan TE et al. N Engl J Med. 2006; 355: 251-259; Bhatia RS et al. N Engl J Med. 2006; 355: 260-269. 1 year mortality293222.225.5舒张性心力衰竭（diastolic heart failure, DHF）有充血性心力衰竭典型的表现（肺循环和体循环淤血） 非心脏瓣膜病 静息时伴异常的舒张性功能不全 收缩功能正常或仅有轻微减低诊 断 要 点DHF的主要病因和诱发因素 老年人

2、，女性 心房颤动 高血压伴左心室肥厚 肺部感染 糖尿病 肾功能不全 冠心病心肌缺血 贫血 肥胖 限制性和浸润性心肌病参数SHFDHF病史冠心病高血压糖尿病瓣膜性心脏病阵发性呼吸困难+ + + + + + + + + + + + + + + +体格检查心界扩大心音低钝S3 奔马律S4 奔马律高血压瓣膜返流啰音水肿颈静脉充盈+ + + + + + + + + + + + + + + + + + + + + +胸部X线(X-ray)心脏扩大肺淤血+ + + + + + + + + + + + + + +收缩性HF(SHF)与DHF: 症状与体征Givertz MM et al. In: Braunw

3、ald E, Zipes DP, Libby P, eds. Heart Disease, 7th edition. Philadelphia, Pa: WB Saunders. 2001;534-561.中国舒张性心力衰竭诊断标准 （2007指南）有典型心衰的症状和体征；LVEF正常（45%），左心腔大小正常；UCG有左室舒张功能异常的证据；UCG检查无瓣膜病，心包疾病及肥厚或限制型心肌病。舒张性心力衰竭的诊断标准 主要标准1. 临床 心衰证据 弗莱明翰标准 (2个主要或1个主要2个次要标准) 波士顿标准 (5-7分:可能HF; 8-12分: 确诊HF) 血浆BNP升高 (400 pg/ml

4、3) 或胸部X-线示肺淤血 心肺运动试验示肺功能减弱2.LVEF及心腔大小正常3. 左心室舒张、充盈异常，舒张期僵硬明确证据1. 左心室肥厚或向心性重构2. 左房扩大(无房颤)3. 多普勒超声心动图或导管检查有舒张功能不全的证据Yturralde RF and Gaasch WH. Prog Cardiovasc Dis 2005;47:314-319. Korenstein D et al. BMC Emerg Med 2007;7:6超声心动图诊断要点Mitral inflowPulm venous flowTDIColour M-mode flow propagation velocit

5、y LA size, LA volumeLV ejection fractionLV hypertrophy2DDoppler正常人 23 6 ml/m2 松弛异常 25 8 ml/m2 假性正常 31 8 ml/m2 （34ml/m2 ）限制性充盈 48 12 ml/m2 J Am Coll Cardiol, 2005; 45:87-92左心房容量指数（LA容量/体表面积）与舒张功能异常呈正比 NormalSystolicHeart FailureDiastolicHeart FailureAurigemma, Zile, GaaschCirculation 2005Phases of ca

6、rdiac cycleEEAAEAEAa reversalSDSDnormalabnormalMitral A durationPV a durationMitral inflowPV flowDOPPLER FLOW VELOCITY彩色多普勒M型（CMM）Normal VpSlow VpFlow propagation velocity of mitral inflow by colour M-modeNormalAbnormalrelaxationPseudo-normalizedEmAmSmAmSmEm彩色多普勒M型（CMM）normal diastolic diastolic sys

7、tolic dysfunction heart failure heart failuresmsmsmEmsmEmEmEmAmAmAmAmmmmmTDI of mitral annulus velocity, E / Em is also useful to detect impaired LV relaxation in patient with atrial fibrillationDae-Won Sohn, et al JASE 1999Estimation of LV filling pressure using E / Em SR Ommen, RA Nishimura et al

8、Circulation 2000 S.F Nagueh et alCirculation 1999Exception :in pts with constrictive pericarditis E / E is inversely proportional to PCWP Jong-Won Ha, Jae Oh et al Circulation 2001S. F NaguehCirculation 1999E / VpFor estimation of filling pressureGrade E/ADT S/D Pva A-a dur Vp Tau(ms) (cm/s) (ms) (c

9、m/s)Normal 1-2 150-200 1 35 45 NMild 200 1 35 20 45 Mild-mod 200 1 35 20 45Moderate 1-2 150-200 0.5- 35 20 2 150 35 20 45Indices of diastolic dysfunctionParameters to identify patients with elevated LV filling pressureEnlarged LADT 35 cm/sE / A 2E / Em 15E / Vp 2S fraction of PV flow 40% or S50% DMi

10、tral A duration PV a reversal durationEstimation of LV filling pressuredeceleration time (DT) 20 mmHgprovided that LVEF is abnormal eg. 15 indicates PCWP 20 mmHguseful even in AF, sinus tachycardiabut not accurate in constrictive pericarditisVentricular relaxationDiastolic suctionErectile coronary e

11、ffectViscoelastic forces of myocardiumPericardial restraintVentricular interactionAtrial contributionFactors influencing LV filling during diastoleLoad dependenceChamber complianceNon-uniformity of relaxationHeart rateloading conditionmitral regurgitationAginghypertrophic cardiomyopathy constrictive

12、 pericardiatistechnical limitations etcLimitations舒张性心力衰竭治疗原则 建 议 分类 证据级别* 医师应当根据发表的指南控制收缩期和舒张期高血压 I A* 医师应当控制心房颤动患者的心室率 I C* 医师应当使用利尿剂控制肺充血和周围性水肿 I C* 冠状动脉疾病患者有症状性或可证实的心肌缺血对心 脏舒张功能有不利影响时，最好行冠状动脉重建治疗 IIa C* 心房颤动患者恢复并维持窦性心律可能有助于改善症状 IIb C* 高血压患者应用受体阻滞剂、ACEI、ARB或 钙拮抗剂，可能有助于最大程度缓解症状 IIb C* 应用洋地黄来最大程度减轻

13、心力衰竭症状的价值尚不清楚 IIb C 06年AHA/ACC对舒张性心力衰竭患者的治疗建议DHF治疗推荐Heart Failure Society of America Practice Guideline (2006) 低钠饮食 C 容量过度负荷患者使用噻嗪类或襻利尿剂 C 使用ARBs或ACEIs ARBs :B, ACEI :C 合并冠心病或糖尿病患者使用ACEIs或ARBs C 使用阻滞剂 心肌梗死史 A 高血压 B 需要控制心室率的心房颤动 B 使用CCB diltilzem或verapamil用于阻滞剂不能耐受的心房颤动 C 心绞痛症状 A 高血压 CAdams KF, et al

14、. J Card Fail 2006;12:10-38总 结DHF诊断步骤(ESC共识,2007) HF的症状或体征LVEF 50% 且 左心室舒张末期容积指数(LVED VI) 12 mmHg或左心室舒张末压16 mmHg组织多普勒NT proBNP 220 pg/mlBNP 200 pg/mlE/E 1515 E/E 8超声血流多普勒 :. E/A DT. 肺静脉血流. 左房扩大 . 左心室肥厚. 房颤NT proBNP 220 pg/mlor BNP 200 pg/mlDHF组织多普勒E / E 8 From Paulus. Eur Heart J. 2007Treatment of d

15、iastolic heart failureImprove acute symptom of pulmonary congestionTreat underlying / precipitating causediuretics, nitratesHypertensionIschemiaAtrial arrhythmia: diuretics, ACE I, ARB, b-blockers, Ca-blockers: b-blockers, nitrates, Ca-blockers, revascularization: rate control, rhythm control, warfarin谢谢！Invasive cardiac catherization , relaxation abnormality is assessed byintracardiac pressures negative peak dP/dt time constant of relaxatio