深和节律的改变Dyspneaonexertion劳力性呼吸困难Orthopnea端

HeartFailure

心衰Concept概念

Pathogenesis发病机制

Effect（important）andmechanisms影响及机制

Outline大纲

Background背景

Definitionandexplainingthedefinition定义

pathogenesis机制Content内容

心为君主之官，脏腑百骸，惟所是命，聪明智慧，莫不由之"

Theheartismoredeceitfulthananything.Itisincurable—whocanknowit?

Jeremiah17:9-10

Heartfailure心衰----BackgroundHeartfailure心衰----Background

Catslookdownonus.Dogslookuptous.PigstreatusasequalsHeartfailure心衰----BackgroundWhatkillus?Background

《2010年中国心血管病报告》

1/5adultssufferfromcardiovasculardisease

3milliondiefromcardiovasculardiseaseaccountfor41%ofdeathnumberChinadeath1/11.6sAmericadeath1/34.0sequivalenttoonceWenchuanbigearthquakeBackground《thereportofcardiovasculardiseaseinchina2010》hypertension高血压2亿人

myocardialinfarction心肌梗200万人

pulmonaryheartdisease肺心病500万人

rheumaticheartdisease风心病250万人

congenitalheartdisease先心病200万人

heartfailure心衰竭420万人《2010年中国心血管病报告》《thereportofcardiovasculardiseaseinchina2010》BackgroundWeFaceanepidemicofHF

Affecting

0.4-2%

oftotalpopulation，8-10%ofelderly

TheglobalHFpatientshaveupto2250million，

increasingat200millionperyear

TheprognosisofHFsimilartocancerorevenworse

The20%patientswithHFreadmissionafterdischargedfromhospitalin30days

Lessthan50%patientssurvival5yearsfromthediagnosisofheartfailure

Averagesurvivaltimeis16month，inhospitalonly25%survival5years

Background020406080100HeartdiseaseCerebrovascularmalignancyaccidentalrespiratorygastrointestinalcommunicableUrinarysystemNeuropsychosis

EndocrinosisLifestyleBiogenticsEnvironmentalfactorsHealthcareTop10causeofdeathinChinaandthemainriskfactors%ForecastingthefutureofcardiovasculardiseaseintheUnitedStatesCirculation2011;123(8):933-944EstimateddirectandindirectcostofmajorcordialdiseaseInunitedstatein2010TheEconomicBurdenOfCardiovascularDiseasesCoronaryheartdiseaseHypertensivediseaseStrokeHeartfailure$53.9$34.4Costinbillion$105.9$93.5Clinicalintervention

生

死LowriskstateDangerousstateEarlychangeDifferentprognosisClinicdiseaseSub-clinicsymptomsPreventinterventionHypertensionhyperlipidmiasmokingdiabetesobeyhereditary

psychologicalintervention

NationalstandardlifestyledrugoperationphysicsBackgroundheathsub-healthsub-clinicdiseaseRiskFactorsEndothelialDysfunctionAtherosclerosisCoronaryarterydiseaseMyocardialIschemiaCoronaryThrombosisMyocardialInfarctionArrhythmia&LossofMuscleRemodelingVentricularDilationCongestiveHeartFailureEndstageHeartDisease

TheProgressiveDevelopmentofChronicCardiovascularDisease

慢性心血管疾病渐进式发展心功不全insufficiencyHeartfunctionPhysicalActivitylimitationSymptomsatrestDescriptionINonoalmostasnormalpersonIIMildSlightnoCanwithstandheavierphysicalactivityIIImoderateobviousnoCanwithlighterphysicalactivityIVsevereobviousyesLoselaborabilitycompletelyLife-threating分级:TheNewYorkHeartAssociationFunctionalClass

(NYHA-FC)

心肌收缩力因各种①病因减弱（原发或继发），不能将静脉回心血量等量搏出，因而使②心输出量绝对或相对减少，③使体循环和/或肺循环静脉系统淤血，动脉系统供血不足，不能满足人体在静息状态或一般活动时代谢的的需要，从而出现一系列的心脏循环障碍的④症状和体征。大循环—心功—临床

心肌衰竭：原发性心肌病变，如心肌炎，心肌梗塞Myocardialfailure：primarymyocardiallesions，myocarditiis

心力衰竭：不仅仅是心脏问题，如缩窄性心包炎Heartfailure：notonlyheartproblem，contractivepericarditis

充血性心衰：慢性经过，血容量增加，出现水肿Congestiveheartfailure：chronic，blood，edema心肌收缩力因各种①病因减弱（原发或继发）ExpoundingMyocardialcontractilityisimpairedbyvariouscauses（primaryorsecondary).fibrinouspericarditis心肌收缩力因各种①病因减弱（原发或继发）ExpoundingThefactorsinfluenceCOBasiccausesExampleContractility收缩性（力)Myocardialabnormalitiescoronaryheartdiseaseload负荷OverloadValvularstenosis,valvularinsufficiencySynergy

协同性DisharmonyRhythm

节律ArrhythmiaUnderlyingCausesofHF心衰的基本病因

CADthecommonest2/3Hypertensionin4%

Toxicinjuryin2%-4%

Valvediseasesin4%

Unknownin20%CommonCausesofHF心衰的常见病因诱因precipitationcause（AggravatingFactors）InfectionsArrhythmias(AF)Pregnancyandchildbirthbeheatedwithpassiontoofasttotransfusion…………anyfactorthatincreasecordialloadorinjureheartprecipitationisnotalwaysprecipitationAttentionExpounding

②心输出量绝对或相对降低AV瘘

贫血

甲亢

脚气病HyperdynamicstatusIncreasedventricularpreloadATPconsumptionincreasedandproductiondecreased

highcardiacoutputHF（1%）

lowcardiacoutputHF

notes：otherclassificationself-study

②cardiacoutputreduceabsolutelyorrelatively,dermatophytosisbarbiers=beriberipanneuritisepidemicadieteticneuritisendemicneuritis脚气与脚气病香港脚HongKongfoot运动员脚athletefootburning,itching，cracking……糖代谢脱羧酶的辅酶—Coenzymeofdecarboxylasein

Sugarmetabolism参与-酮酸的氧化脱羧Participatein-ketoacidoxidativedecarboxylation

VitB1(thiamin硫胺素)：葡萄糖glucose酵解glycolysis

乳酸Lacticacid丙酮酸pyruvicacidTCA循环乙酰辅酶A丙酮酸NADHNAD+NADHNAD+发酵ferment呼吸链递氢NADHNAD+VitB1丙酮酸脱氢酶系参与-酮酸的氧化脱羧丙酮酸乳酸堆积CO2,H+Beriberi：comesfroma

Sinhalese

phraseMeaning：“weak,weak”or“Icannot,Icannot”,《备急千金要方》考诸经方往往有脚弱之论，而古人少有此疾。自永嘉南渡，衣缨士人，多有遭者。风毒中人，随处皆得，作病何偏着于脚也？答曰∶夫人有五脏，心肺二脏，经络所起在手十指；肝肾与脾三脏，经络所起在足十趾。夫风毒之气，皆起于地。地之寒暑风湿皆作蒸气，足常履之，所以风毒之中人也必先中脚；久而不瘥，遍及四肢腹背头项也；微时不觉，痼滞乃知。经云∶次传、间传是也。东晋、六朝时叫脚弱孙思邈称为风毒脚气《内经》《诸病源候论》《脚气病治法总要》DryberiberiWasteberiberiDifficultyinwalkingPeripheraledemaTinglingornumbnessIncreasedheartrateparalysisofthelowerlegsDyspneaonexertionMentalconfusion/speechdifficultiesParoxysmalnocturnaldyspneanystagmusVasodilationleadingtoincreasedarteriovenousshuntPeripheralorcenterlesionCardiovascularsystem

infantberibericrying,butnotloudlyandwithouttears.Maybefatal.TypesofberiberiExpounding

③心功下降，静脉淤血，动脉缺血CausesCardiacfunctionimpairment

代偿

Cardiacoutput↓

Venouscongestion引起病理性损害，出现临床症状和体征Arterialsischemia③venoussystemcongestionarterialsysteminsufficientbloodsupplyCardiacoutputIschemiaandHypoxiaheartRatesympatheticstrokesympatheticFrank-Starlinglawhypertrophy-remodelingBloodredistributionneurohumoral(NE,RAAS)

心衰时机体的适应和代偿adaptionandcompensationCardiacoutputCO=stroke/minXheartRateCardiac（ventricular）remodeling心肌重塑（构）心肌受损，代偿与适应出现结构、代谢和功能改变

生物学：心肌细胞，非心肌细胞、细胞外基质基因表达？？？几何学：心肌肥大，心室扩大等

NormalCentripetalCentrifugal

Loadpostload↑preload↑MyofibershyperplasiaparalleltandemVentricularWallthicknessthickeningslightthickeningHeartChamberexpansionnoobviousobviousMyocardialhypertrophysignificantmyofibredisarrayandinterstitialfibrosisinHCM.HeartRate>180Scarometers>2.2Excessivehypertrophyorganinterstitium

＞

tissuecap,sympatheticdensity↓

cellsurfacearea,mitochondria↓molecularV3imbalancegrowthandincreaseLimitationofmyocardialcompensationAbstractIthasbeendifficulttoestablishwhetherwearelimitedtotheheartmusclecellswearebornwithorifcardiomyocytesaregeneratedalsolaterinlife.Wehavetakenadvantageoftheintegrationof14C,generatedbynuclearbombtestsduringtheColdWar,intoDNAtoestablishtheageofcardiomyocytesinhumans.Wereportthatcardiomyocytesrenew,withagradualdecreasefrom1%turningoverannuallyattheageof20

to0.3%attheageof75.Lessthan50%ofcardiomyocytesareexchangedduringanormallifespan.Thecapacitytogeneratecardiomyocytesintheadulthumanheartsuggeststhatitmayberationaltoworktowardsthedevelopmentoftherapeuticstrategiesaimingtostimulatethisprocessincardiacpathologies.weremyocardialcellspost-mitoticcells?Science324:98,2009.Expounding4：症状和体征signsandsymptomsCardiacoutput↓Arterialsperfusion↓VenousstagnationrenalFatigueCardiacshockSuddendeathliver-gutlungskin

EdemaDyspneaCyanosisDyspnea呼吸困难Respiratorybecomelabored呼吸费力Respiratoryfrequencydepthandrhythm呼吸频率、深度和节律的改变Dyspneaonexertion劳力性呼吸困难Orthopnea

端坐呼吸Paroxysmalnocturnaldyspnea

夜间阵发性呼吸困难Dyspnea呼吸困难Fatigue

Activitieslimited

Chestcongestion

Edemaorankleswelling

ShortnessofbreathTheMajorsignsandsymptomsofCHF?ThinkFACES...

疲乏

活动受限

胸闷

水肿或脚踝肿胀

气促“Evolution”ofOurUnderstandingofCHF慢性心衰的认识演变

cardio-renalmodel心肾模型

Na-waterretention

Hemodynamicdisorder血流动力学紊乱