内科学-心力衰竭-范维琥课件

内科学心力衰竭-范维琥56、死去何所道，托体同山阿。57、春秋多佳日，登高赋新诗。58、种豆南山下，草盛豆苗稀。晨兴理荒秽，带月荷锄归。道狭草木长，夕露沾我衣。衣沾不足惜，但使愿无违。59、相见无杂言，但道桑麻长。60、迢迢新秋夕，亭亭月将圆。内科学心力衰竭-范维琥内科学心力衰竭-范维琥56、死去何所道，托体同山阿。57、春秋多佳日，登高赋新诗。58、种豆南山下，草盛豆苗稀。晨兴理荒秽，带月荷锄归。道狭草木长，夕露沾我衣。衣沾不足惜，但使愿无违。59、相见无杂言，但道桑麻长。60、迢迢新秋夕，亭亭月将圆。Heartfailure2 DEFINITIONHEARTFAILUREAclinicalsyndromeinwhichanabnormalityofcardiacstructureorfunctionisresponsiblefortheinabilityofthehearttoejectorfillwithbloodataratecommensuratewiththerequirementsofthemetabolizingtissues.Heartfailureresultsinaconstellationofclinicalmanifestations,includingcirculatorycongestion,dyspnea,fatigue,andweakness.3PRECIPITATINGFACTORS

InfectionArrhythmiasPhysical,dietary,fluid,environmental,andemotionalexcessesMyocardialinfarctionPulmonaryembolismAnemiaThyrotoxicosisandpregnancyAggravationofhypertensionRheumatic,viral,andotherformsofmyocarditisInfectiveendocarditis6PATHOGENESISChronichemodynamicoverload→eccentricventricularhypertrophyChronicpressureoverload→concentricventricularhypertrophyVentr.hypertrophy→ventr.DilatationRemodelingofventricle→HFActivationofendogenousneurohormonalsystemandcytokines7

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CLINICALMANIFESTATIONOFHF

Primary

SymptomsDyspneaOrthopneaParoxysmal(nocturnal)dyspneaAcutepumnonaryedema9CLINICALMANIFESTATIONOFHFOthersymptomsFatigueandweaknessAbdominalsymptomsCerebralsymptoms10PHYSICALFINDINGSOFHFGeneralfindings↓Pulsepressure（severeHF)↓SBPwithcool,diaphoreticextremities,andCheyne-StokesrespirationCyanosis,sinustachycardia11PHYSICALFINDINGSOFHFCardiovascularfindingsS3and

S4CardiomegalyMurmursPulsusalternansDistentionofjv.(↑systemicv.p)12PHYSICALFINDINGSOFHFPulmonaryralesCardiacedemaSymmetricanddependentinthelegsMostprominetineveningHydrothoraxandascitesCongestivehepatomegaly.13LABORATORYEXAMINATIONN-terminal-pro-BNPandBNPTwo-dimensioanlechocardiographywithDopplerflowstudiesChestroentgenogramECG14Echocardiogram

2DechowithDoplertechniqueforsystolicanddiastolicfunctionofLVLVDdandLVDs（DdandDs）LVEF15DIAGNOSISOFHFCombinationoftheclinicalmanifestationofHF,togetherwiththefindingscharacteristicofoneoftheunderlyingformsofheartdisease.16DIFF.DIAGNOSISOFHFPulmonarydiseasePulmonaryembolismAnkleedemaEnlargementoftheliverandascites17TREATMENTOFHFCorrectionoftheunderlyingcauseRemovaloftheprecipitatingcausePreventionofdeteriorationofcardiacfunctionControlofthecongestiveHFstate18

GENERALMEASURES

TreatingcoronaryriskfactorsModeratedietaryNarestrictionDailymeasurementofweightPreventrespiratoryinfection

Aviodingexcessivealcohol,temperatureextremes,andtiringtripsTREATMENTOFHFControlofexcessivefluidDietDiureticsThiazidediureticsMetolazoneFrusemideBumetanidetorsemidePotassium-sparingdiuretics20TREATMENTOFHFBlockadeofrenin-angiotensin-aldosteroneandadrenergicsystemACEinhibitorsAngiotensinreceptorblockersBeta-adrenoceptorblockersAldosteroneantagonist21TREATMENTOFHFEnhancementofmyocardialcontractilityDigitalisSympathomimeticaminesPhosphodiesteraseinhibitors22TREATMENTOFHFVasodilatorsNitratesNitroglycerineIsosorbide

dinitrateMononitratesNitroprussidenesiritide23TREATMENTOFHFVentricularresynchronizationManagementofarrhythmiaAnticoagulantsRefractoryheartHFAssistedcirculation/cardiactransplant.24STAGEAAthighriskforHFbutwithoutstructuralheartdiseaseorsymptomsofHF.TreathypertensionEncouragesmokingcessationTreatlipiddisordersEncourageregularexerciseDiscouragealcoholintake,illicitdruguseControlmetabolicsyndromeACEIorARBinappropriatepatientsforvasculardiseaseordiabetes25STAGEBStructuralheartdiseasebutwithoutsignsorsymptomsofHFAllmeasuresunderStageAACEIorARBinappropriatepatientsBeta-blockersinappropriatepatients26STAGECStructuralheartdiseasewithpriororcurrentsymptomsofHF.AllmeasuresunderStagesAandBDietarysaltrestrictionDRUGSFORROUTINEUSEDiureticsforfluidretentionACEIBeta-blockersDRUGSINSELECTEDPATIENTSAldosteroneantagonistARBsDigitalisHydralazine/nitratesDEVICESINSELECTEDPATIENTSBiventricularpacingImplantabledefibrillators27STAGEDRefractoryHFrequiringspecializedinterventions.AppropriatemeasuresunderStagesA,B,CDecisionre:appropriatelevelofcareOPTIONSCompassionateend–of-lifecare/hospiceExtraordinarymeasureshearttransplantchronicinotropespermanentmechanicalsupportexperimentalsurgeryordrugs28PROGNOSISOFHFDependonNatureoftheunderlyingheartdiseasePr