内科学课件心力衰竭讲课

HEARTFAILURE(心力衰竭)DepartmentofCardiology,JinanCentralHospitalDEFINITIONOFTHEHEARTFAILURE(心力衰竭概念)

Aclinicalsyndromeinwhichallkindofheartdiseasesleadtocardiacinsufficiency（是各种心脏疾病导致心功能不全的一种综合征）

Inmostcasestheheartisunabletopumpasufficientamountofbloodtomeettheneedsofthebodytissuesandorgansduetoadefectinmyocardialcontraction,meanwhilemanifestssymptomsandsignsofpulmonaryand/orsystemicvascularcongestion.(SystolicHF)（绝大多数情况下是指心肌收缩力下降使心排血量不能满足机体代谢的需要,器官、组织血液灌注不足，同时出现肺循环和（或）体循环淤血的表现）DEFINITIONOFTHEHEARTFAILURE(心力衰竭概念)Inasmallnumberofcasesthemyocardialcontractioncanmaintainthecardiacoutputnormal,butbecausetheabnormallyincreasedleftventricularfillingpressure,pulmonaryvenousbloodrefluxisinhibited,leadingtopulmonarycongestion(DiastolicHF).少数情况下心肌收缩力尚可使心排血量维持正常，但由于异常增高的左心室充盈压，使肺静脉回流受阻，而导致肺循环淤血。DEFINITIONOFTHEHEARTFAILURE(心力衰竭概念)Congestiveheartfailure(充血性心力衰竭）

Bothpulmonaryandsystemiccirculationarepassivelycongestedduringheartfailure（心力衰竭时通常伴有体循环和（或）肺循环的被动性充血）Cardiacinsufficiency（心功能不全）Suggestsastateinwhichthecardiacsystolicand/ordiastolicfunctionisabnormalbyusinginstrumentssuchasechocardiographytoexaminetheheart,butthereisnoclinicalsymptomswithhearfailure(常用以表明经器械检查如UCG等提示心脏收缩或舒张功能已不正常，而尚未出现临床症状的状态）CAUSESOFTHEHEARTFAILURE(心力衰竭病因)Underlyingcauses(基本病因）1,Primarymyocardialimpairment(原发性心肌损害(1)Ischemicmyocardialimpairment(缺血性心肌损害)(2)MyocarditisandCardiomyopathy(心肌炎和心肌病)(3)Myocardialmetabolicdisorders(心肌代谢障碍性疾病）:Diabeticcardiomyopathy(糖尿病性心肌病),beriberiheartdisease(维生素B1缺乏),myocardialamyloidosis(心肌淀粉样变性)CAUSESOFTHEHEARTFAILURE(心力衰竭病因)2,Cardiacoverload(心脏负荷过重）Pre-Load(volume-load)前负荷（容量负荷）

Increaseinend-diastolicpressure(highfillingpressure)，cardiacvalveincompetence(心脏瓣膜关闭不全）,congenitalheartdisease（先心病）,anemia（贫血）,thyroidism（甲状腺功能亢进症）Post-Load(pressure-load)后负荷（压力负荷）

Theforcetheventriclemustexertduringsystoletoejectstrokevolume，hypertension（高血压）,aorticvalvestenosis（主动脉瓣狭窄）,pulmonaryhypertension（肺动脉高压）,pulmonaryvalvestenosis（肺动脉瓣狭窄）PRECIPITATINGFACTORS

(心力衰竭诱因)1,Infections（感染）:respiratorytractinfectioniscommon（呼吸道感染常见）2,Arrhythmias(心律失常）:atrialfibrillation（心房颤动）

andothertachyarrhythmias（快速性心律失常）3,Bloodvolumeincreased(血容量增加）：dietaryexcessesofsalt(摄入钠盐过多）,venousinfusionoverdoseandrapid（静脉输液过多过快）4,Exertionandemotionalcrisis(劳累和情绪激动）5,Inappropriatetherapy(治疗不当）6,Accelerationofprimaryheartdiseaseordevelopasecondformofdisease(原有心脏病变加重或并发其他疾病）PathophysiologyofHeartFailureCompensatorymechanisms(代偿机制）1.Frank-Starlingmechanism:anincreasedpreloadhelpstosustaincardiacperformanceandincreasebloodtoreturnheart,thendiastolicvolumeincreasedwithhighcardiacoutput.2,myocardialhypertrophy(心肌肥厚）：AmajorcompensatorymechanismforafterloadPathophysiologyofHeartFailureNeurohumoralmechanism(神经体液机制）1，Increasedsympatheticactivity（交感神经兴奋性增强）：releaseofnorepinephrine(NE),(1)effectontheBreceptor,augmentmyocardialcontractionandincreaseheartrateandCO.(2)peripheralvascularcontractionleadtoaugmentafterloadandincreasemyocardialoxygenconsumption,(3)NEhasdirecttoxiceffectonmyocardium,cancausecardiaccellsapotosis(细胞凋亡）,participatinginthepathologicalprocessofcardiacremodelling（心脏重塑）PathophysiologyofHeartFailure2，Renin-angiotensinsystemactivated(肾素-血管紧张素系统激活）AugumentmyocardialcontractilityMaintainbloodpressure,regulatebloodredistribution,ensurebloodsupplyforthevitalorganssuchasbrain,heartandkidneysInducealdosteronesecretion,leadtowaterandsodiumretensionPathophysiologyofHeartFailureAngiotensinIIMakethemyocytes,vascularsmoothcells(VSMC)andintimacellschanged,causecellandtissueremodelling(引起心肌细胞、血管平滑肌细胞和内皮细胞改变，导致细胞和组织重塑）Cardiaccellshypertrophyandfibroblastshyperplasia,leadtomyocardialfibrosis（心肌细胞肥大和成纤维细胞增生，导致心肌纤维化）VSMChyperplasiacancausevascularstenosis,reducingtheabilityforitssecretingNO（血管平滑肌细胞增生可引起血管狭窄，降低其分泌NO的能力）PathophysiologyofHeartFailureHormonalfactorschanged(体液因子的改变）1，Atrialnatriureticpeptide(ANP)andbrainnatriureticpeptide(BNP)（心钠肽和脑钠肽）ANPisstoredmainlyintherightatriumandreleasedinresponsetoanincreaseinatrialdistendingpressure.(ANP主要储存于心房，心房压力增高，房壁受牵张时分泌增加）Causevasodilation,natriuresisandcounteractthewater-retainingeffectsoftheepinephrine,RASandAVPsystems.(具有扩张血管、利钠、对抗肾上腺素、RAS、AVP等的水、钠潴留效应）PathophysiologyofHeartFailureBNPisstoredmainlyinventricularmyocardiumandmayberesponsetochangesinventricularfillingpressure.（BNP主要储存于心室肌，其分泌受心室充盈压的影响）TherewerestudiesdemonstratethatneutralendopeptidaseinhibitorscaninhibitANPdegradation,infusionofcandoxatrilatcanmimicANPandexertitsbeneficialeffectsforpatientswithheartfailure.（有研究表明中性内肽酶抑制剂可抑制ANP降解，心衰患者输注candoxatrilat可发挥类似ANP的有益效应）PathophysiologyofHeartFailure2，Argininevasopressin(AVP)（精氨酸加压素）Secreatedbypituitarium,regulatedbytheatrialstretchreceptors,whichsensitivityisreducedinheartfailure,andthereleaseofAVPcannotbeinhibited,causeplasmaAVPincreased,itssideeffectsinduceHFworsen.Antiureticeffect（抗利尿作用）Peripheralvascularcontraction（周围血管收缩）Maintainplasmaosmolality（维持血浆渗透压）PathophysiologyofHeartFailureEndothelin(内皮素）Apotentpeptidevasoconstrictor(强力血管收缩肽)Releasedbyendothelialcells(由内皮细胞分泌)Threeendothelinpeptides(1,2,3)havebeenidentified(已发现三种内皮素)Thereleaseofendothelincanbeenhancedbyseveralvasoactiveagents(eg.NE,AII,thrombin)andcytokines(eg.transforminggrowthfactor-B,interleukin-B)(血管活性药物和细胞因子可增加其分泌)PathophysiologyofHeartFailurePlasmaendothelincontentcorrelatesdirectlywithpulmonaryarterypressureandKillipgrades(血浆内皮素浓度与肺动脉压和心功能Killip分级直接相关)Endothelinreceptorantagonistbosentancanreducecardiachypertrophy,improvetheshort-termandlong-termprognosisofanimalswithchronicHF(内皮素受体拮抗剂bosentan能减轻心肌肥厚,改善慢性心衰动物的近期和远期预后)PathophysiologyofHeartFailureAboutdiastolicdysfunction(关于舒张功能不全)Activediastolicfunctiondisorder,theCa2+cannotbereabsorbedbysarcoplasmicreticulum,suchasCHD(主动舒张功能障碍,肌浆网不能重吸收Ca2+,如CHD)Reducedcomplianceduetoreplacementfibrosis,suchashypertensionandhypertrophiccardiomyopathy(替代性心肌纤维化引起心肌顺应性降低,如高血压和肥厚性心肌病)PathophysiologyofHeartFailureMyocardialimpairmentandventricularremodelling(心肌损害和心室重构)1,Primarymyocardialimpairmentandheartoverload----cardiacdysfunction---ventricularenlargementorhypertrophy(cardiacmyocytes,extracellularmatrixandcollagenfiberschanged)---remodelling---HF2,Energysupplytomyocytesreduced---myocytenecrosis---contractileabilityreduced---HFRemodeling

Progressiveventriculardilation(进行性心室扩张)Hypertrophy(肥厚)Myocytedeath(心肌细胞死亡)Progressivefibrosis(进行性纤维化)InjurytoheartSympatheticDiseaseprogressionNeurohormonalactivationReninangiotensinaldosteroneNeurohormonalactivation

inheartfailureCATEGORIESOFHEARTFAILUREAcuteHeartFailure(急性心衰)ChronicHeartFailure(慢性心衰)(LeftHeart&RightHeartFailure)SystolicFailure(收缩性心衰)DiastolicFailure(舒张性心衰)NYHAClassificationofHeartFailure

ClassIFullyfunctional(体力活动不受限制)ClassIISlightlimitationbyshortnessofbreath/fatigue(体力活动轻度受限)ClassIIISymptomswithminimalexertion;interferewithdailyactivities(体力活动明显受限)ClassIVSymptomsatrest(休息时有症状)AHAClassificationofHeartFailure

Agrade:noobjectivetestimonyofcardiovasculardisease(无心血管疾病的客观证据)Bgrade:objectiveexaminationshowedmildcardiovasculardisease(客观检查示有轻度心血管疾病)Cgrade:objectiveexaminationshowedmoderatecardiovasculardisease(客观检查示有中度心血管疾病)Dgrade:objectiveexaminationshowedseverecardiovasculardisease(客观检查示有严重心血管疾病)The6-minutewalktest

(6分钟步行试验)AsimpleandconvenienttestthatcanevaluatetheexercisecapabilityforpatientswithHF.(评估心衰病人运动耐力的一种简单、安全、方便的试验）Thepatientisaskedtowalkinalevelcorridorasfarashe/shecanin6minutes,andthenmeasurethedistancewalkedonlevelground.（病人在水平走廊行走6分钟，然后测量距离）<150m,severecardiacinsufficiency（严重心功能不全）150-425m,moderatecardiacinsufficiency（中度）426-550m,mildcardiacinsufficiency（轻度）ChronicHeartFailure慢性心力衰竭EpidemiologyofHeartFailure

(流行病学)Approximately5millionAmericanshaveCHF(maletofemaleratio1:1)550,000newcasesannuallyIncidenceof10/1000>65yearsofageHospitaldischarges1,000,000(2001)Accountsfor12millionofficevisits/yearSinglelargestexpenseforMedicareFive-yearmortalityrateashighas50%CLINICALMANIFESTATIONSLeftHeartFailuresymptoms1,Dyspnea(呼吸困难)Exertionaldyspnea(劳力性呼吸困难)Orthopnea(端坐呼吸)ParoxysmalNocturnalDyspnea(夜间阵发性呼吸困难) “CardiacAsthma”(心源性哮喘)Acutepulmonaryedema(急性肺水肿)CLINICALMANIFESTATIONSMechanismsofParoxysmalnocturnaldyspnea(夜间阵发性呼吸困难的机制)1,Pulmonarybloodincreased(肺血增加）2,Nocturnalvagalnervestressactivated（夜间迷走神经兴奋性增加）3,Bronchiolecontraction（小支气管收缩）4,Diaphragmriseandlungvitalcapacityreduced（横膈高位，肺活量减少）CLINICALMANIFESTATIONS2,cough,sputum,hemoptysis(咳嗽、咳痰、咯血）3,weakness,fatigue,dizzinessandpalpitation（乏力、疲倦、头晕、心慌）4,oliguriaandsymptomsofrenalfunctionimpairment（少尿及肾功能损害症状）CLINICALMANIFESTATIONSLeftheartfailureSigns1,pulmonarymoistrales(肺部湿性罗音）:canfromthelungbasestoalllungs,moistralesresultfromthetransudationintothealveolioffluidwhichthenmovesintotheairwayswiththedevelopmentofHF.2,Cardiacsigns（心脏体征）:cardiacenlargement(cardiomegaly，心脏扩大),diastolicgallopsounds（舒张期奔马律）,accentuationofP2（肺动脉瓣第二心音亢进）CLINICALMANIFESTATIONSRightheartfailureSymptoms1,digestivetractsymptoms（消化道症状）:fullnessofabdomen（腹胀）,anorexia（厌食）,nausea（恶心）,vomting（呕吐）2,exertionaldyspnea（劳力性呼吸困难）Signs1,edema（水肿）:usuallysymmetrical,pittingandgenerallyoccursfirstinthedependentportionsofthebody.hydrothorax(pleuraleffusion，胸腔积液):usuallybilateral,butwhenunilateralitisusuallyconfinedtotherightsideoftheheart.

CLINICALMANIFESTATIONSRightheartfailure2,jugularvein’ssigns(颈静脉征）:jugularveinpulsationenhanced（颈静脉搏动增强）,engorgement（怒张）,hepatojugularrefluxpositive（肝颈静脉反流征阳性）3,hepatomegaly（肝脏肿大）:tender（压痛）,persistentchronicHFcancausecardiaccirrhosis（心源性肝硬化）,jaundice（黄疸）,liverfunctionimpairment（肝功能受损）andalargeamountofascites（大量腹水）.4,cardiacsigns（心脏体征）:tricuspidvalveregurgitationsecondarytorightventriculardilatation,manifestsystolicmurmurs.（右心室扩大而出现三尖瓣关闭不全的反流性杂音）CLINICALMANIFESTATIONSAllheartfailureManifestthesymptomsandsignsofbothleftandrightfailureLaboratoryfindingsThechestroentgenogram（X线检查）Thesizeandshapeofthecardiacsilhouetteprovideimportantinformationconcerningtheprecisenatureoftheunderlyingheartdisease.（心脏轮廓的大小和形状为诊断基础心脏疾病提供了重要信息）Earlypulmonaryvenouspressureincreased,pulmonaryvesselsinthelowerlobesequaltoevenmorethanthesizeoftheupperlobes---latelyinterstitialpulmonaryedema（间质肺水肿）---producingKerley’sBline---alveolaredema（肺泡水肿）---cloudlikeappearance（云雾状）

andconcentrationofthefluidaroundthehiliina“butterfly”pattern.（蝴蝶状）AnEchocardiogramisthemostusefulinitialtestintheevaluationofapatientwithsuspectedheartfailureEcho:whatdoyouget?Systolicfunction-preservedornot?DiastolicFunctionValveFunctionPreviousInfarctionRadiologicalnuclearexamination放射性核素检查Cardiopulmonaryexercisetesting

(心-肺吸氧运动试验）MeasuretheexercisetoleranceofHFpatients（测量心衰患者对运动的耐受量）SuitforthepatientswithchronicstableHF（适应于慢性稳定性心衰病人）Thereare2dataneedtoevaluateincardiopulmonaryexercisetesting（有两个数据资料）1,VO2max(ml/min.kg)（最大耗氧量）:theproductofmaximalarterialvenousoxygendifferenceandcardiacoutput.Normal:>20Mild-moderate:16-20Moderate:10-15Moresevere:<10Cardiopulmonaryexercisetesting

(心-肺吸氧运动试验）2,Anaerobicthreshold（无氧阈值）Atheoreticalpointduringdynamicexercisewhenmuscletissueswitchesovertoanaerobicmetabolismasanadditionalenergysource.（运动时无氧代谢出现时氧耗量的代表值）Thelowertheanaerobicthreshold,theworsethecardiacfunction.（无氧阈值愈低，心功能愈差）Invasivehemodynamicexaminaation

(有创性血流动力学检查）Nowdays,balloonflotationcathetersarecommonusedatbedside.（目前，球囊漂浮导管常在床边进行）Thistechniquecanobtainrightheartpressure（右心压力）

,oxygencontent（氧含量）,cardiacindex(CI)（心脏指数）,pulmonarycapillarywedgepressure(PCWP)（肺小动脉楔压）Normal:CI>2.5l/min.m2PCWP<12mmHgDiagnosisofCHF

（慢性心衰的诊断）Determinedbythecauses,illnesshistory,symptoms,signsandobjectiveexamination（通过病因、病史、症状、体征和客观检查确定诊断）Firstdemonstratethedefiniteorganheartdisease（首先确定有器质性心脏病）ThesymptomsandsignsarebothimportantbasisfordiagnosingCHF（症状和体征是诊断慢性心衰的基础）DiagnosisofCHF

（慢性心衰的诊断）FraminghamcriteriaforcongestiveHF(1971)Majorcriteria1,paroxysmalnocturnaldyspneaororthopnea2,neck-veindistension3,rales4,cardiomegaly5,acutepulmonaryedema6,S3gallop7,increasedvenouspressure>16cmH2O8,circulationtime>25sec9,hepatojugularrefluxDiagnosisofCHF

（慢性心衰的诊断）Minorcriteria1,ankleedema2,nightcough3,dyspneaonexertion4,hepatomegaly5,pleuraleffusion6,vitalcapacitydecrease1/3frommarimum7,tachycardia(rateof>120beats/min)DiagnosisofCHF

（慢性心衰的诊断）MajororminorcriterionWeightloss>4.5kgin5daysinresponsetotreatmentDifferentialDiagnosisofCHF

（慢性心衰的鉴别诊断）Bronchialasthma(支气管哮喘）Pericardialeffusion（心包积液）Constrictivepericarditis（缩窄性心包炎）Cirrhoticascites（肝硬化腹水）ThetreatmentofHFTherapeuticprinciplesandgoals(治疗原则和目的)Therapeuticprinciples(治疗原则)Removalorameliorationoftheunderlyingcauses(祛除或缓解基本病因)Removaloftheprecipitatingfactors(祛除诱因)ControloftheHFstate(控制心衰):regulatethecompensorymechanismofHF(调节心衰代偿机制),reduceitssideeffectsofhumoralfactors(减少体液因子的负面效应)ThetreatmentofHFTherapeuticgoals(治疗目标)Increaseexercisetoleranceandimprovequalityoflife(提高运动耐量,改善生活质量)Preventordelayventricularremodellingandprogressivemyocardialimpairment(阻止或延缓心室重塑防止心肌损害进一步加重)Reducemortality(降低死亡率)ThetreatmentofHFTherapeuticmethods(治疗方法)Treatmentofthecauses(病因治疗)Treatmentoftheunderlyingcauses(治疗基本病因)Removaloftheprecipitatingfactors(祛除诱因)Generaltherapy(一般治疗)Rest(休息):controlphysicalactivity,avoidpsychiologicalstimulation,reducecardiacloadControlnatriumuptake(控制钠盐摄入)ThetreatmentofHFDrugtherapy药物治疗DrugtherapyofHFDiuretics(利尿剂)Reducethecardiacvolumeloadbyremovingsaltandwater,alleviatecongestivesymptoms,reduceedema.(通过排钠排水降低心脏容量负荷,缓解淤血症状,减轻水肿)Inprinciple,weshouldlong-termusediuretics,andwhenedemadisappear,weshoulduselowdosediureticsindefinitely.(原则上,应长期维持,水肿消失后,应以最小剂量无限期使用)Sideeffects(副作用):electrolytedisorders(电解质紊乱),hyponatremia(低钠血症),hypokalemia(低钾血症),hyperkalemia(高钾血症)Diuretics(利尿剂)Thiazidediuretics(噻嗪类利尿剂)Hydrochlorothiazide(氢氯噻嗪):anmoderate-effectivediuretics(中效利尿剂),effectondistalconvultedtubule,inhibitNa+reabsoption(作用于远曲小管,抑制钠重吸收)MildHF:25mg,2times/week,orqodSevereHF:100mg/dDiuretics(利尿剂)Loopdiuretics(袢利尿剂)Fluosemide(速尿):anhigh-effectivediuretics(高效利尿剂),effectonthethickascendinglimboftheloopofHenle,excreteNa+andK+(作用于Henle的升支,排钠排钾)20—100mg,bidDiuretics(利尿剂)Potassium-sparingdiuretics(保钾利尿剂)Spironolactone(安体舒通):effectonrenaldistalconvolutedtubule,interferewiththeeffectofaldosterone,increaseK+reabsorptionandexcreteNa+(作用于肾远曲小管,干扰醛固酮作用,增加K+重吸收,排钠),20mg,tid氨苯喋定:50-100mgbidAmiloride(阿米洛利):5-10mgbidACEInhibitorsInhibitRAS(抑制RAS)Inhibitbradykinindegradation(抑制缓激肽降解)

ReducesmortalityinALLclassesofCHF(降低所有CHF患者的死亡率)Reducessymptomsandhospitaladmissions(减少症状和住院率)Benefitsustainedtoatleast4years(效益至少持续4年)Magnitudeofbenefitgreatestwiththeworstheartfailure(最差心衰可获最大效益)ACEInhibitorsSideeffects(副作用):hypotension(低血压),hyperkalemia(高钾血症),drycoughandrenalfunctionworsentemporarily(干咳及肾功能一过性恶化)Contraindications(禁忌症):renalfailurewithnourine(无尿性肾功能衰竭),pregnancywomen(孕妇),allergytoACEI(对ACEI过敏),angioedema(血管性水肿),bilateralrenalarterystenosis(双侧肾动脉狭窄),plasmacreatineincreasedsignificantly(血肌酐水平明显升高)(>225umol/l),hyperkalemia(高钾血症)(>5.5mmol/l)ARBUnabletolerancetotheACEinhibitors,canchooseARB(对ACEI不能耐受者可选用ARB)Losartan(氯沙坦)Valsartan(缬沙坦)PositiveinotropicdrugsDigitalisPharmacologicaleffects(药理学作用)1,Positiveinotropiceffects(正性变力作用):inhibitNa+,k+-ATPase,induceNa+contentincreased,K+reduced,Na+-Ca2+interchange---Ca2+increased2,electrophysiologicalactions(电生理作用）:decreaseautomaticityandconductionsystem(降低自律性,抑制传导系统),highdosecanincreaseatrial,conjunctionalandventricularautomaticity,inducetachycardia(大剂量可提高心房\交界区和心室的自律性,引起快速性心律失常)3,increasevagalactivity(兴奋迷走神经)PositiveinotropicdrugsDigoxin(地高辛):0.25mgqd,half-life(半衰期)1.5day,intheabsenceoflodingdose,steady-statebloodlevelsareachievedabout1week,thedoseshouldbereducedformorethan70yearsoldandrenalfunctioninsufficiencypatients.(在无负荷量情况下,1周可达稳态水平,对70岁以上和肾功能不全病人宜减量)LanatosideC(毛花苷丙):0.2-0.4mg,iv,0.8-1.2mg/24h,suitforacuteHForworsenperiodofCHF,particularlyHFwithrapidAF(适用于急性心衰或CHF加重期,特别是心衰伴快速房颤者)StrophanthinK(毒毛花苷):0.25mg,iv,0.5-0.75mg/24h,suitforacuteHF(适应于急性心衰)PositiveinotropicdrugsIndications(适应症):HFMosteffective(效果好):CHFwithAFNotwell(效果欠佳):high-outputHF(高排血量心衰)(suchasanemia(贫血),hyperthyroidism(甲亢),beriberiheartdisease(脚气病),cardiomyocarditis(心肌炎),cardiomyopathy(心肌病)Carefullyuse(慎用)d:pulmonaryheartdisease(肺心病)Contraindications(禁忌症):hypertrophiccardiomyopathy(肥厚性心肌病)PositiveinotropicdrugsDigitalisintoxication(洋地黄中毒)Causes(原因):overdose(洋地黄过量),ischemia(缺血),hypoxia(缺氧)electrolytedisordersparticularlyhypokalemia(电解质紊乱特别是低钾血症),renalfunctionreduced(肾功能降低),otherdrugssuchasamiodarone,verapamilandaspirin(合用其他药物如可达龙、维拉帕米、阿司匹林）Manifestations（表现）:arrhythmias（心律失常）,gastrointestinaltractreaction（胃肠道反应）:nausea（恶心）,vomting（呕吐）

,centralnervoussystemsymptoms（中枢神经系统症状）:fatigue（疲乏）,yellowvision（黄视）,greenvision（绿视）Treatment（治疗）:stopdrugsimmediately（立即停药）,potassiumsupplement（补钾）,lidocanine（利多卡因）

orphenytoin（苯妥英钠）

applying,atropine（阿托品）

forbradycardia（心动过缓）Non-digitalisinotropicdrugs1,Adrenergicagonists（肾上腺素能受体兴奋剂）Dopamine（多巴胺）Dobutamine（多巴酚丁胺）:5-10ug/kg.min2,Phosphodiesteraseinhibitors（磷酸二酯酶抑制剂）Amrinone（氨力农）Milrinone（米力农）:50ug/kg,iv,continuewith0.375-0.75ug/kginfusionLong-termusecanincreasemortality（长期应用可增加死亡率）B-blocker(B受体阻滞剂）Metaprolol（美托洛尔）:beginwith12.5mg/dCarvedilol（卡维地洛）:beginwith3.125mg2times/dBisoprolol（比索洛尔）:beginwith1.25mg/dContraindications（禁忌症）:Bronchialspasmdisease（支气管痉挛性疾病）Bradycardia（心动过缓）TwoandmorethantwogradeAVB（二度及二度以上房室传导阻滞）AldosteroneantagonistAngiotensinogenAngiotensinIAngiotensinIIRenalrenin

LungACEInactivepeptidesActivepeptides,

AngIII,AngIV,AngI-VIILiverAldosteroneRoleofSpironolactoneinHeartFailureRALESTrial

Pittetal.NewEnglJMed1999;341:709-171663patientswithsevereheartfailureRandomizedtospironolactone25mgqdorplaceboStoppedprematurely30%reductionindeathwithspironolactoneHyperkalemiaveryrare;10%incidenceofgynecomastiaHydralazineandNitratesHydralazine(肼苯达嗪）:notusedNitrates（硝酸酯类）:Nitroglycerin（硝酸甘油）Isosorbidedinitrate（二硝酸异山梨酯）Isosorbidemononitrate（单硝酸异山梨酯）ConclusionofthetreatmentofCHF（慢性心衰治疗小结）AccordingtoNYHAgradeIgrade:controlriskfactors(控制危险因素）,ACEIIIgrade:ACEI,diuretics,B-blocker,withorwithdigoxinIIIgrade:ACEI,diuretics,B-blocker,digoxinIVgrade:ACEI,diuretics,digoxin,aldosteronereceptorantagonist,carefullyuseB-blockerafterillnessstableSystolicHeartFailureAssessVolumeStatusVolumeOverloadEuvolumicDiureticsStartACEI–TitrateUpwardAddßBlockersSpironolactone(ClassIV)DigoxinARBifeitherNotToleratedSUMMARYHeartfailure

‘New’therapeuticapproachesEndothelinantagonistsAVPantagonistsVasopeptidaseinhibitorsNesirotide(BNPanalogue)ImidazolineI1-receptorantagonists(moxonidine)AngiotensinIIantagonistsPDEVinhibitors(sildenafil)NewdigoxinanaloguesCytokineantagonists(etanercept)AdenosineagonistsCalciumsensitisers(levosimendan)MatrixmetalloproteinaseinhibitorsThetreatmentofdiastolicHF

（舒张性心衰的治疗）DifferentfromsystolicHF,DHFisduetoventriculardiastolicdisorderwhichinducesLVEDPincreasedandcausespulmonarycongestion.(不同于收缩性心衰，舒张性心衰是由于心室舒张功能异常引起左室舒张末压升高而导致肺淤血）Itiscommonforhypertension,CHDandhypertrophiccardiomyopathy.（常见于高血压、冠心病和肥厚性心肌病）ThetreatmentofdiastolicHF

（舒张性心衰的治疗1，B-blocker2,Calciumantagonists3,ACEI4,maintenanceofnormalheartrateandrhythm,andkeepsynchronizedatrioventricularsequentialpacing,ensureaugmentationofventricularfilling（维持正常心率、律，保持房室顺序收缩，保证心室充盈）5,nitrateordiureticscanbeusedappropriatelyforseverepulmonarycongestion（对严重肺淤血病人可适当应用硝酸酯类或利尿剂）6,inotropicdrugsareprohibitedundernosystolicdysfunction（无收缩功能异常，正性肌力药禁用）RefractoryHF（顽固性心衰）HFisnotrecovered,butworseneddespitetherapywithallkindsofdrugs.butnotdemonstratethispatientcometotheterminalperiodoflife.（经各种治疗，心衰不见好转，甚至还有进展，但并非指心脏情况已至终末期不可逆转者）weshoulddoourbesttofindlatentcauses,suchasrheumaticactivity,infectiveendocarditis,anemia,hyperthyroidism,digilisoverdose,smallarea’spulmonaryembolismfrequently,orotherunrelateddiseasesuchasneoplasm.（我们应努力寻找潜在的原因，并设法纠正，如风湿活动、感染性心内膜炎、贫血、甲状腺功能亢进、电解质紊乱、洋地黄过量、反复发生的小面积肺栓塞等）RefractoryHF（顽固性心衰）Attentiontotheabovementionedfactors(注意上述提到的因素)Intensifytoregulatethedrugtherapy(强化调节药物治疗)Ultrafiltrationforrefractoryedema(对顽固性水肿者采用血液超滤)ImpantthreecavitypacemakerforfirstgradeAVBorLBBBpatients(对一度AVB或LBBB患者植入三腔起搏器)Cardiactransplantation(心脏移植)Ventricularassistpump(心室辅助泵)ACUTEHEARTFAILURE

(急性心力衰竭)Anacutecongestivesyndromewhichinducesamarkedsuddenreductionofcardiacoutputwithsymptomsofinadequatetissueandorganperfusionduetoacuteheartdisease.(是指由于急性心脏病变引起心排血量显著、急骤降低导致组织器官灌注不足和急性淤血综合征.AcuterightHF(急性右心衰竭):acutepulmonaryheartdisease(急性肺源性心脏病)---massivepulmonaryinfarction(大块肺梗死)AcuteleftHF(急性左心衰竭):pulmonaryedema(肺水肿)orcardiogenicshock(心源性休克)ACUTEHEARTFAILURE

(急性心力衰竭)Causes（病因）1,CHD（冠心病）:AMI,papillarymusclesdisruption乳头肌断裂）,ventricularseptalperforation（室间隔穿孔）2,infectiveendocarditisin