循环系统诊断常见症征课件

SignsandsymptomsofsomecommonheartdiseasesWeiMengShanghaisixthpeople’shospitalShanghaijiaotonguniversityContentsMitralstenosis(MS)Mitralregurgitation(MR)Aorticstenosis(AS)Aorticregurgitation(AR)PericardialeffusionHeartfailure(HF)MitralstenosisConditionscausingleftventricularinflowobstructionCongenitalAcquiredValvularmitralstenosisValvularmitralstenosisCortriatriatumAtrialmyxomaSubvalvularringThrombusPulmonaryveinstenosisNeoplasmInfectivevegetationProstheticvalvedisfunctionMitralstenosisCauseofMSrequiringintervention(n=1050)CauseNumberpercentageRheumaticfever56253.5Rheumaticequivalent13913.2Scarletfever11110.6Infectiveendocarditis353.3Degenerative282.7Congenital131.2Others16215.5PathophysiologyofMitralstenosisLVinflowobstructionLeftatrialpressureLungcongestionO2supplyshortagepulmonaryA&Vhypertension(RHF

hemoptysisleftatrialenlargementAtrialfibrillationthrombosis&embolismhoarsenessCommonSymptomsofMitralstenosisAsymptomaticsExertionaldyspnea,paroxysmalnocturnaldyspnea,orthopneaPalpitationduetoarhythmiaMiscellaneousHemoptysis,blood-tingesputum,pinkfrothysputum,chestpain,mitralfacies,Cough,hoarseness,dysphagiaRelationbetweendyspneaandMVA

ClassMVA(cm2)manifestationminimal>2.5noneMild1.4~2.5MinimaldyspneawithmarkedexertionModerate1.0-1.4Dyspnea,orthopnea,paroxysmalnocturnaldyspnea,pulmonaryedemaSevere<1.0RestingdyspneaSignsofMitralstenosisInspectionMitralfacies,increasedimpulseatprecardialarea&/orwithlocalelevationofthethoraciccavity,thoseduetorightheartfailurePalpationApicalimpulseisnormalordecreasedRightventricularheaveispresentifwithpulmonaryhypertensionApicaldiastolicthrillmaybepresentSymptomsofMitralstenosisPercussionDullnessareaoftheheartshiftstowardtheleftatwaistoftheheartaswellastowardtherightifmarkedenlargementofrightheartAuscultationLouds1OpeningsnapDiastolicrumble,nearapexLoudP2withorwithoutsplitGrahamsteelmurmurMurmurofTRIrregularrhythmSymptomsofMitralstenosisSymptomsduetochronicHFEdema,Effusion,Hepatomegaly,Jaundice,WetRalesCachexiaMitralregurgitationEtiologyofMR(1)OrganicMRRheumaticheartdiseaseMyxomatouschanges(mitralvalveprolapse)InfectiousendocarditisChordalraptureordysfunctionofpapillarymusclesCollagenvasculardiseaseTrauma:pentratingornonpeneratingMitralregurgitationEtiologyofMR(2)FunctionalMRCoronaryheartdiseaseHypertrophiccardiomyopathyDilatedcardiomyopathyLeftatrialdilatationPathophysiologyofMRPreloadincreasecausedbybloodreturntotheleftventriclefromLAIncreasedleftatrialvolume&pressureDiastolicvolumeaugmentationVentricularcontractionincreasecompensately(Frank-Starlingmechanism)Ventricularremodelingprogressively(heartfailureeventually)SymptomsofMRAsymptomaticDyspneaonexertion,cough,progressingparoxysmalnocturnaldyspnea,orthopneaultimately,evenacutepulmonaryedema(lessthanMS)FatiguePalpitationduetoarhythmiaAtypicalchestpain,inappropriatesympatheticnervesystemactivation,panicattack(ofteninvalveprolaps)SignsofMR(1)InspectionSomehavingincreasedimpulseoftheapexPalpationEnhancedapicalimpulseistotheleftlowerPercussionDullnessareaoftheheartshiftstowardtheleftlowerSymptomsofMR(2)Auscultation(1)NormalormuffledS1,P2ifpulmonarypressurehighS3iscommon,notalwaysindicatingHFHolosytolicmurmurisclassicalattheapex,radiatingtotheaxillaeventheback,thebaseoftheheart.MurmuratlatesystoliccanbeheardatthevalveprolapseoratmildMRSymptomsofMR(3)Auscultation(2)Music-likemurmurcanbeheardatsevereMR,atthevalveprolapseMidsystolicclickwithorwithoutmurmurpresentsatthevalveprolapseOccasionallydiastolicrumblingcanbeheardatsevereMRbecauseofrelativeMSNomurmurcanbeheardatmildevenmoderateMRsometimeAorticstenosisEtiologyCongenitalBicuspidvalve(verycommon)Fusionofthevalveleaflet(rare)DegenerationRheumaticfeverOthersSLE,ochronosis,severefamilialhyper-cholesterolemiaPathophysiologyofASAfterloadofleftventricleincreasedLVhypertrophy,ischemiaCompliance,LAlarge&pressurehighLowcardiacoutputInsufficientbloodsupplytoheart,brain,kidney,etcSymptomsofAS(1)AsymptomaticAnginawithorwithoutcoronaryarterystenosisTypicalchestpainlikeeffortanginaAtypicalchestpainSyncope,usuallyoneffortHeartfailure,diastoliccommon,ComplaintrelatedtoLow(output)BPsignsofAS(1)InspectionPale,carotidpulsationweakenApicalimpulseincreasedOccasionalimpulsecausedbyS4canbeseenPalpationCarotidupstrokelowinvolumeanddelayedForcefulandsustainedapexbeatOccasionaloscillationcausedbyS4ThrillintheaorticareaPercussiondullnessareaoftheheartshiftingleftlowerSymptomsofAS(2)AuscultationReducedandeveninaudibleA2,paradoxicsplittingP2increasedinpulmonaryhypertensionEjectionmurmurradiatingtothecarotidarterieswithorwithoutthrillintheaorticareaS4causedbyatrialkickagainstthestiffventricleS3inadvancedstageDifferentiationofsystolicmurmurFlowTRASMR/VSDMVPHOCMinspiration-or____Stand___Squat___ValsalvaHandgrip__postpvcEtiologyofAR(1)AorticcupsabnormalitiesRheumaticfeverInfectiousendocarditisNon-specificinflammation:SLE,rheumatoidarthritis,Behcet’ssyndromeDegenerative:myxomatouschange,calcificationOthers:trauma,postaorticvalvularplasty,dietdrugvalvulopthyEtiologyofAR(2)AorticrootabnormalitiesTherootdilatationMarfan’s,syndrome,syphilis,ankylosingspondylitis,relapsingpolychondritis,idiopathicaortitis,annuloaorticectasia,cysticmedialnecrosis,Ehlers-danlossyndromeLossofcommissuralsupportAorticdissection,trauma,ventricularseptaldefectEtiologyofAR(3)IncreasedafterloadHypertensionSupravalvularaorticstenosiPathophysiologyofARPreloadincreasecausedbybloodreturntoLVfromAOIncreasedLVvolume&pressureVentricularcontractionincreasecompensately(Frank-Starlingmechanism)Ventricularremodelingprogressively(heartfailureeventually)SymptomesofARAsymptomaticPalpitationduetoforcefulbeatingorarhythmiaChestpain,typicaloratypicalDyspneaonexertion,cough,orthopnea,paroxysmalnocturnaldyspneaSignsofAR(1)InspectionVisiblecardiacimpulseenhancedtowardleftlowerPalpationTheapicalimpulseisincreasedanddisplacedcaudallyandlaterallyAuscultation(1)A2maybedecreased,S4isoftenpresent,S3isaudiblewhenHFoccursSignsofAR(2)Auscultation(2)Soft,high-pitchedidastolicdecrescendomurmurisheardbestat3rdintercostalspacealongtheleftsternalborderatendexpirationwiththepatientsittingandleaningforward,maybebestattherightofthesternalinthepresenceofaorticarootdilatationMurmurradiatingtotheleftlowersternumandtheapexSignsofAR(3)Auscultation(3)AsystolicejectionmurmurmaybepresentattheaorticareaAdiastolicmurmurmaybeheardattheapex(Austinflintmurmur)PeripheralsingsPulsepressureisincreased,othersignsOtherperipheralsignsofARCrrigan’spulse(locomotivepulse)RapidandforcefuldistensionofarterialpulsewithquickcollapseDe-Msset’ssignToandfroheadbobingMuller’ssignVisiblepulsationofuvulaQuincke’ssignCapilarypulsationseenonlightcompressionofnailbedTraube’ssignSystolicanddiastolicsounds(pistolshots)overthefemoralarteryDurosier’ssignBruitsheardoverthefemoralarteryonlightcompressionbystethoscopeHill’ssignPoplitealcuffpressureexeedingbrachialpressureby60mmHgorgreaterPericardialeffusionEtiology(1)Infection:virus,bacterium,tuberculosis,AIDSMalignancyIatrogeniccauseSurgeryrelatedsyndromeTraumaRadiation

therapyConnectivetissuedisordersPericardialeffusionEtiology(2)MyocardialinfarctionAcutephasein1stweekDressler’ssyndrome(postmyocardialinfarctionsyndrome)1-6weeklaterUremiaHypothyroidismDrug-relatedProcainamide,hydralazine,methydopa,etcPathophysiology

ofpericardialeffusionPericardialpressureincreasedObstructionofvenousflowreturnFillingvolumeofLVinsufficientCardiacoutputdecreasedPericardialeffusionClassificationAcutepericardialeffusion(pericarditis)ChronicpericardialeffusionCardiacpamponadeConstrictivepericarditisEffusive-constrictivepericarditisPericardialeffusionSymptomedependsontheeffusivevolumeandtherapidityofaccumulationCommonseenAsymptomaticChestdiscomfort,dyspnea,cough,dysphagia,hoarseness,hiccup,nausea,abdominalfullness,evencardiactamponadeSignsofprimarydiseasesPericardialeffusionSigns(1)InspectionWeakenpulsationofapex,PalpationApexbeatweakenornotpalpable,ifpalpableithasadistancetothedullnessborderPericardialeffusionSigns(2)PercussionDullnessareaoftheheartisenlargedtobothsidesandtheshapechangeswithbodypositionAuscultationTachycardia,muffuledheartsound,pericardialrubandpericardialknockareinfrequentPericardialeffusionOthermanifestationsPulsepressurenarrowingwithorwithoutBPPulseparadoxus:Pulseweakenordisappearsatinspiratoryphase.inspiratoryfallofsystolicBP>10mmHg.Ewartsignleftlowerlobelungbecomenullnessengorgementofjugularvein,positivesignofhepatojugularrefluxPericardialtaponadeCirculationcollapseorshockcausedbyrapidorlargevolumefluidaccumulationHR,BPdecreased,pulsusparadoxus,jugularveinpressureExtremitiesarecoldandwetDyspnea,restlessness,diminishedresponse,unconsciousnessPulsepressurediminishedHeartfailureAcomplexclinicalsyndromeinwhichtheheartisincapableofmaintainingacardiacoutputadequatetoaccommodatemetabolicrequirementsandthevenousreturn.EtiologyofHeartFailureWhatcausesheartfailure?Thelossofacriticalquantityoffunctioningmyocardialcellsafterinjurytotheheartdueto:IschemicHeartDiseaseHypertensionIdiopathicCardiomyopathyInfections(e.g.,viralmyocarditis,Chagas’disease)Toxins(e.g.,alcoholorcytotoxicdrugs)ValvularDiseaseProlongedArrhythmiasVolumeOverloadPressureOverloadLossofMyocardiumImpairedContractilityLVDysfunctionEF<40%Cardiac

OutputHypoperfusionEndSystolicVolumeEndDiastolicVolumePulmonaryCongestion

LeftVentricularDysfunction30%70%DiastolicDysfunctionSystolicDysfunction(EF<40%)(EF>40%)LeftVentricularDysfunctionSystolic:Impairedcontractility/ejectionApproximatelytwo-thirdsofheartfailurepatientshavesystolicdysfunction1Diastolic:Impairedfilling/relaxation1Lilly,L.PathophysiologyofHeartDisease.SecondEditionp200HemodynamicBasisfor

HeartFailureSymptomsLVEDPLeftAtrialPressurePulmonaryCapillaryPressurePulmonaryCongestionLeftVentricularDysfunction

SystolicandDiastolicSymptomsDyspneaonExertionParoxysmalNocturnalDyspneaTachycardiaCoughHemoptysisPhysicalSignsBasilarRalesPulmonaryEdemaS3GallopPleuralEffusionCheyne-StokesRespirationRightVentricularFailure

SystolicandDiastolicSymptomsAbdominalPainAnorexiaNauseaBloatingSwellingPhysicalSignsPeripheralEdemaJugularVenousDistentionAbdominal-JugularRefluxHepatomegaly

NewYorkHeartAssociation

FunctionalClassificationClassI:

NosymptomswithordinaryactivityClassII:

Slightlimitationofphysicalactivity.Comfortableatrest,

butordinaryphysicalactivityresultsinfatigue,

palpitation,dyspnea,oranginaClassIII:

Markedlimitationofphysicalactivity.Comfortableat

rest,butlessthanordinaryphysicalactivityresultsin

fatigue,palpitation,dyspnea,oranginalpainClassIV:

Unabletocarryoutanyphysicalactivitywithout

discomfort.Symptomsofcardiacinsufficiencymaybe

presentevenatrestHFClassification:Evolutionand

DiseaseProgressionFourStagesofHF(ACC/AHAGuidelines):StageA:PatientathighriskfordevelopingHFwithnostructuraldisorderoftheheartStageB:PatientwithstructuraldisorderwithoutsymptomsofHFStageC:PatientwithpastorcurrentsymptomsofHFassociatedwithunderlyingstructuralheartdiseaseStageD:Patientwithend-stagediseasewhorequiresspecializedtreatmentstrategiesHunt,SA,etalACC/AHAGuidelinesfortheEvaluationandManagementofChronicHeartFailureintheAdult,2001Thanks树立质量法制观念、提高全员质量意识。7月-237月-23Thursday,July27,2023人生得意须尽欢，莫使金樽空对月。11:43:0811:43:0811:43