循环系统诊断常见症征

SignsandsymptomsofsomecommonheartdiseasesWeiMengShanghaisixthpeople’shospitalShanghaijiaotonguniversity第一页，共五十二页。ContentsMitralstenosis(MS)Mitralregurgitation(MR)Aorticstenosis(AS)Aorticregurgitation(AR)PericardialeffusionHeartfailure(HF)第二页，共五十二页。MitralstenosisConditionscausingleftventricularinflowobstructionCongenitalAcquiredValvularmitralstenosisValvularmitralstenosisCortriatriatumAtrialmyxomaSubvalvularringThrombusPulmonaryveinstenosisNeoplasmInfectivevegetationProstheticvalvedisfunction第三页，共五十二页。MitralstenosisCauseofMSrequiringintervention(n=1050)CauseNumberpercentageRheumaticfever56253.5Rheumaticequivalent13913.2Scarletfever11110.6Infectiveendocarditis353.3Degenerative282.7Congenital131.2Others16215.5第四页，共五十二页。PathophysiologyofMitralstenosisLVinflowobstructionLeftatrialpressureLungcongestionO2supplyshortagepulmonaryA&Vhypertension(RHF

hemoptysisleftatrialenlargementAtrialfibrillationthrombosis&embolismhoarseness第五页，共五十二页。CommonSymptomsofMitralstenosisAsymptomaticsExertionaldyspnea,paroxysmalnocturnaldyspnea,orthopneaPalpitationduetoarhythmiaMiscellaneousHemoptysis,blood-tingesputum,pinkfrothysputum,chestpain,mitralfacies,Cough,hoarseness,dysphagia第六页，共五十二页。RelationbetweendyspneaandMVA

ClassMVA(cm2)manifestationminimal>2.5noneMild1.4~2.5MinimaldyspneawithmarkedexertionModerate1.0-1.4Dyspnea,orthopnea,paroxysmalnocturnaldyspnea,pulmonaryedemaSevere<1.0Restingdyspnea第七页，共五十二页。SignsofMitralstenosisInspectionMitralfacies,increasedimpulseatprecardialarea&/orwithlocalelevationofthethoraciccavity,thoseduetorightheartfailurePalpationApicalimpulseisnormalordecreasedRightventricularheaveispresentifwithpulmonaryhypertensionApicaldiastolicthrillmaybepresent第八页，共五十二页。SymptomsofMitralstenosisPercussionDullnessareaoftheheartshiftstowardtheleftatwaistoftheheartaswellastowardtherightifmarkedenlargementofrightheartAuscultationLouds1OpeningsnapDiastolicrumble,nearapexLoudP2withorwithoutsplitGrahamsteelmurmurMurmurofTRIrregularrhythm第九页，共五十二页。SymptomsofMitralstenosisSymptomsduetochronicHFEdema,Effusion,Hepatomegaly,Jaundice,WetRalesCachexia第十页，共五十二页。MitralregurgitationEtiologyofMR(1)OrganicMRRheumaticheartdiseaseMyxomatouschanges(mitralvalveprolapse)InfectiousendocarditisChordalraptureordysfunctionofpapillarymusclesCollagenvasculardiseaseTrauma:pentratingornonpenerating第十一页，共五十二页。MitralregurgitationEtiologyofMR(2)FunctionalMRCoronaryheartdiseaseHypertrophiccardiomyopathyDilatedcardiomyopathyLeftatrialdilatation第十二页，共五十二页。PathophysiologyofMRPreloadincreasecausedbybloodreturntotheleftventriclefromLAIncreasedleftatrialvolume&pressureDiastolicvolumeaugmentationVentricularcontractionincreasecompensately(Frank-Starlingmechanism)Ventricularremodelingprogressively(heartfailureeventually)第十三页，共五十二页。SymptomsofMRAsymptomaticDyspneaonexertion,cough,progressingparoxysmalnocturnaldyspnea,orthopneaultimately,evenacutepulmonaryedema(lessthanMS)FatiguePalpitationduetoarhythmiaAtypicalchestpain,inappropriatesympatheticnervesystemactivation,panicattack(ofteninvalveprolaps)第十四页，共五十二页。SignsofMR(1)InspectionSomehavingincreasedimpulseoftheapexPalpationEnhancedapicalimpulseistotheleftlowerPercussionDullnessareaoftheheartshiftstowardtheleftlower第十五页，共五十二页。SymptomsofMR(2)Auscultation(1)NormalormuffledS1,P2ifpulmonarypressurehighS3iscommon,notalwaysindicatingHFHolosytolicmurmurisclassicalattheapex,radiatingtotheaxillaeventheback,thebaseoftheheart.MurmuratlatesystoliccanbeheardatthevalveprolapseoratmildMR第十六页，共五十二页。SymptomsofMR(3)Auscultation(2)Music-likemurmurcanbeheardatsevereMR,atthevalveprolapseMidsystolicclickwithorwithoutmurmurpresentsatthevalveprolapseOccasionallydiastolicrumblingcanbeheardatsevereMRbecauseofrelativeMSNomurmurcanbeheardatmildevenmoderateMRsometime第十七页，共五十二页。AorticstenosisEtiologyCongenitalBicuspidvalve(verycommon)Fusionofthevalveleaflet(rare)DegenerationRheumaticfeverOthersSLE,ochronosis,severefamilialhyper-cholesterolemia第十八页，共五十二页。PathophysiologyofASAfterloadofleftventricleincreasedLVhypertrophy,ischemiaCompliance,LAlarge&pressurehighLowcardiacoutputInsufficientbloodsupplytoheart,brain,kidney,etc第十九页，共五十二页。SymptomsofAS(1)AsymptomaticAnginawithorwithoutcoronaryarterystenosisTypicalchestpainlikeeffortanginaAtypicalchestpainSyncope,usuallyoneffortHeartfailure,diastoliccommon,ComplaintrelatedtoLow(output)BP第二十页，共五十二页。signsofAS(1)InspectionPale,carotidpulsationweakenApicalimpulseincreasedOccasionalimpulsecausedbyS4canbeseenPalpationCarotidupstrokelowinvolumeanddelayedForcefulandsustainedapexbeatOccasionaloscillationcausedbyS4ThrillintheaorticareaPercussiondullnessareaoftheheartshiftingleftlower第二十一页，共五十二页。SymptomsofAS(2)AuscultationReducedandeveninaudibleA2,paradoxicsplittingP2increasedinpulmonaryhypertensionEjectionmurmurradiatingtothecarotidarterieswithorwithoutthrillintheaorticareaS4causedbyatrialkickagainstthestiffventricleS3inadvancedstage第二十二页，共五十二页。DifferentiationofsystolicmurmurFlowTRASMR/VSDMVPHOCMinspiration-or____Stand___Squat___ValsalvaHandgrip__postpvc第二十三页，共五十二页。EtiologyofAR(1)AorticcupsabnormalitiesRheumaticfeverInfectiousendocarditisNon-specificinflammation:SLE,rheumatoidarthritis,Behcet’ssyndromeDegenerative:myxomatouschange,calcificationOthers:trauma,postaorticvalvularplasty,dietdrugvalvulopthy第二十四页，共五十二页。EtiologyofAR(2)AorticrootabnormalitiesTherootdilatationMarfan’s,syndrome,syphilis,ankylosingspondylitis,relapsingpolychondritis,idiopathicaortitis,annuloaorticectasia,cysticmedialnecrosis,Ehlers-danlossyndromeLossofcommissuralsupportAorticdissection,trauma,ventricularseptaldefect第二十五页，共五十二页。EtiologyofAR(3)IncreasedafterloadHypertensionSupravalvularaorticstenosi第二十六页，共五十二页。PathophysiologyofARPreloadincreasecausedbybloodreturntoLVfromAOIncreasedLVvolume&pressureVentricularcontractionincreasecompensately(Frank-Starlingmechanism)Ventricularremodelingprogressively(heartfailureeventually)第二十七页，共五十二页。SymptomesofARAsymptomaticPalpitationduetoforcefulbeatingorarhythmiaChestpain,typicaloratypicalDyspneaonexertion,cough,orthopnea,paroxysmalnocturnaldyspnea第二十八页，共五十二页。SignsofAR(1)InspectionVisiblecardiacimpulseenhancedtowardleftlowerPalpationTheapicalimpulseisincreasedanddisplacedcaudallyandlaterallyAuscultation(1)A2maybedecreased,S4isoftenpresent,S3isaudiblewhenHFoccurs第二十九页，共五十二页。SignsofAR(2)Auscultation(2)Soft,high-pitchedidastolicdecrescendomurmurisheardbestat3rdintercostalspacealongtheleftsternalborderatendexpirationwiththepatientsittingandleaningforward,maybebestattherightofthesternalinthepresenceofaorticarootdilatationMurmurradiatingtotheleftlowersternumandtheapex第三十页，共五十二页。SignsofAR(3)Auscultation(3)AsystolicejectionmurmurmaybepresentattheaorticareaAdiastolicmurmurmaybeheardattheapex(Austinflintmurmur)PeripheralsingsPulsepressureisincreased,othersigns第三十一页，共五十二页。OtherperipheralsignsofARCrrigan’spulse(locomotivepulse)RapidandforcefuldistensionofarterialpulsewithquickcollapseDe-Msset’ssignToandfroheadbobingMuller’ssignVisiblepulsationofuvulaQuincke’ssignCapilarypulsationseenonlightcompressionofnailbedTraube’ssignSystolicanddiastolicsounds(pistolshots)overthefemoralarteryDurosier’ssignBruitsheardoverthefemoralarteryonlightcompressionbystethoscopeHill’ssignPoplitealcuffpressureexeedingbrachialpressureby60mmHgorgreater第三十二页，共五十二页。PericardialeffusionEtiology(1)Infection:virus,bacterium,tuberculosis,AIDSMalignancyIatrogeniccauseSurgeryrelatedsyndromeTraumaRadiation

therapyConnectivetissuedisorders第三十三页，共五十二页。PericardialeffusionEtiology(2)MyocardialinfarctionAcutephasein1stweekDressler’ssyndrome(postmyocardialinfarctionsyndrome)1-6weeklaterUremiaHypothyroidismDrug-relatedProcainamide,hydralazine,methydopa,etc第三十四页，共五十二页。Pathophysiology

ofpericardialeffusionPericardialpressureincreasedObstructionofvenousflowreturnFillingvolumeofLVinsufficientCardiacoutputdecreased第三十五页，共五十二页。PericardialeffusionClassificationAcutepericardialeffusion(pericarditis)ChronicpericardialeffusionCardiacpamponadeConstrictivepericarditisEffusive-constrictivepericarditis第三十六页，共五十二页。PericardialeffusionSymptomedependsontheeffusivevolumeandtherapidityofaccumulationCommonseenAsymptomaticChestdiscomfort,dyspnea,cough,dysphagia,hoarseness,hiccup,nausea,abdominalfullness,evencardiactamponadeSignsofprimarydiseases第三十七页，共五十二页。PericardialeffusionSigns(1)InspectionWeakenpulsationofapex,PalpationApexbeatweakenornotpalpable,ifpalpableithasadistancetothedullnessborder第三十八页，共五十二页。PericardialeffusionSigns(2)PercussionDullnessareaoftheheartisenlargedtobothsidesandtheshapechangeswithbodypositionAuscultationTachycardia,muffuledheartsound,pericardialrubandpericardialknockareinfrequent第三十九页，共五十二页。PericardialeffusionOthermanifestationsPulsepressurenarrowingwithorwithoutBPPulseparadoxus:Pulseweakenordisappearsatinspiratoryphase.inspiratoryfallofsystolicBP>10mmHg.Ewartsignleftlowerlobelungbecomenullnessengorgementofjugularvein,positivesignofhepatojugularreflux第四十页，共五十二页。PericardialtaponadeCirculationcollapseorshockcausedbyrapidorlargevolumefluidaccumulationHR,BPdecreased,pulsusparadoxus,jugularveinpressureExtremitiesarecoldandwetDyspnea,restlessness,diminishedresponse,unconsciousnessPulsepressurediminished第四十一页，共五十二页。HeartfailureAcomplexclinicalsyndromeinwhichtheheartisincapableofmaintainingacardiacoutputadequatetoaccommodatemetabolicrequirementsandthevenousreturn.第四十二页，共五十二页。EtiologyofHeartFailureWhatcausesheartfailure?Thelossofacriticalquantityoffunctioningmyocardialcellsafterinjurytotheheartdueto:IschemicHeartDiseaseHypertensionIdiopathicCardiomyopathyInfections(e.g.,viralmyocarditis,Chagas’disease)Toxins(e.g.,alcoholorcytotoxicdrugs)ValvularDiseaseProlongedArrhythmias第四十三页，共五十二页。VolumeOverloadPressureOverloadLossofMyocardiumImpairedContractilityLVDysfunctionEF<40%

Cardiac

OutputHypoperfusion

EndSystolicVolume

EndDiastolicVolumePulmonaryCongestion

LeftVentricularDysfunction第四十四页，共五十二页。30%70%DiastolicDysfunctionSystolicDysfunction(EF<40%)(EF>40%)LeftVentricularDysfunctionSystolic:Impairedcontractility/ejectionApproximatelytwo-thirdsofheartfailurepatientshavesystolicdysfunction1Diastolic:Impairedfilling/relaxation1Lilly,L.PathophysiologyofHeartDisease.SecondEditionp200第四十五页，共五十二页。HemodynamicBasisfor

HeartFailureSymptomsLVEDP

LeftAtrialPressure

PulmonaryCapillaryPressure

PulmonaryCongestion第四十六页，共五十二页。LeftVentricularDysfunction

SystolicandDiastolicSymptomsDyspneaonExertionParoxysmalNocturnalDyspneaTachycardiaCoughHemoptysisPhysicalSignsBasilarRalesPulmonaryEdemaS3GallopPleuralEffusionCheyne-StokesRespiration第四十七页，共五十二页。RightVentricularFailure

SystolicandDiastolicSymptomsAbdominalPainAnorexiaNauseaBloatingSwellingPhysicalSignsPeripheralEdemaJugularVenousDistentionAbdominal-JugularRefluxHepatomegaly第四十八页，共五十二页。

NewYorkHeartAssociation

FunctionalClassificationClassI:

NosymptomswithordinaryactivityClassII:

Slightlimitatio