心力衰竭英文课件.ppt

1、HEART FAILURE,Definition of Heart Failure,Heart failure is a pathophysiological state of heart in which, the heart cannot pump enough blood to meet the needs required by the metabolizing tissue, or to do so only from an elevated filling pressure. Classification,Etiological Causes of Heart Failure,My

2、ocardial damage: myocardial ischemia, inflammation etc. Increased cardiac load Increased preload: congenital heart diseases with left to right shunt. Increased afterload: hypertension, stenosis of cardiac valves. Disturbance of the diastolic filling: constrictive pericarditis, hypertrophic cardiomyo

3、pathy, etc.,Pathophysiology,Compensation Decompensation Adaptive mechanisms: Frank-Starling mechanism: Decreased cardiac ejection fraction increased ventricular end diastolic volume and pressure (LVEDP) elongation of the myocardial fiber increased contractility of the myocardium restoration of the e

4、jection fraction,Adjustment of neuro-endocrine systems,Sympathetic activation Increased contractility of the myocardium Elevation of norepinephrine blood level Down regulation of 1 receptor Activation of RAAS Others,神经内分泌系统的调节机制,交感神经系统、肾素-血管紧张素-醛固酮系统（RAAS）的激活:早期心输出量减少-兴奋交感神经-血中儿茶酚胺水平升高-早期代偿-心输出量增加。如

5、果病因未消除，持续过度代偿，RAAS激活-心肌代谢增加、耗氧增加，受体密度下调，心肌收缩力减弱，外周血管收缩，水钠潴留，心肌毒性等-促进心衰恶化，心室重构。 内分泌系统其他方面,Clinical Manifestation,Three aspects: 1.general manifestation 2. manifestation of Left heart failure: polypnea dyspnea , signs of pulmonary congestion etc. 3. manifestation of right heart failure :general edema,

6、 enlargement of liver, distention of jugular vein, anorexia due to congestion of stomach pleural effusion, etc.,Auxiliary Examination,1.Chest radiography: large cardiac sihouette, pulmonary venous congestion, edema 2. Echocardiography: cardiomegaly, ventricular disfunction, heart function(EF50、FS30、

7、STI；IVRT 、 E/A 1) ，ect. 3. Electrocardiogram:,Diagnosis of Heart Failure,Clinical Findings: 1.HR 2. Dyspnea, R 3. Liver Enlargement 4. Cardiac sound，Cantering rhythm 5. Dysphoria 6. Oliguresis, Edema,诊断,前四项为主要临床依据，结合临床及检查，综合分析（临床上并无严格的界定及量化标准，其辨认是根据病史、症状合体力活动耐力而定。） 心脏病心功能分级：儿童分级同成年人（根据活动情况）。婴儿分级：同样分

8、四个级，根据每次哺乳量、哺乳时间、呼吸及心率情况分级 。,Functional Classification of H.F. (By New York Heart Association),Grade I No limitation to ordinary activities II Slight limitation to ordinary activities III Marked limitation to ordinary activities IV Unable to do any activitybed ridden. Congestive heart failure denote

9、s cases with symptoms and signs of passive congestion.,儿童心功能分级：纽约心脏病学会（NYHA）心脏病心功能分级方案，根据患儿症状和活动能力分为4级。 I级：体力活动不受限制。学龄期儿童能够参加体育课，并且能和同龄儿一样活动。 II级（轻度心衰）：体力活动轻度受限。一般活动可引起疲乏、心悸活呼吸困难。学龄儿童能够参加体育课，但活动量比同龄儿童小。可能存在继发性生长障碍。 III级（中度心衰）：体力活动明显受限。少于平时活动即出现症状（如步行15分钟），学龄儿童不能参加体育活动，存在继发性生长障碍。 IV级（重度心衰）：不能从事任何体力活动

10、，休息时也有心衰症状，并在活动后加重。存在继发性生长障碍。,婴儿心功能分级：婴儿心功能评价，根据喂养情况、呼吸情况、心率、末梢灌注以及肝脏肿大程度综合评价，分为4级。 0级：无心衰的表现。 I级（轻度心衰）：特点为：每次哺乳量105ml，或时间30分钟，呼吸困难，心率 150次/分，肝肋下2cm。 II级（中度心衰）：特点为：每次哺乳量90ml，或时间40分钟，呼吸 60次/分，呼吸形式异常，心率 160次/分，肝肋下23cm，有奔马律。 III级（重度心衰）：特点为：每次哺乳量75ml，或时间40分钟，呼吸 60次/分，呼吸形式异常，心率 170次/分，肝肋下 3cm，有奔马律并有末梢灌注不

11、良。,婴儿心衰分级评分表,注：0-2分无心衰；3-6分轻度心衰；7-9分中度心衰； 10分重度心衰。,改良Rose心衰分级计分法,注：0-2分无心衰；3-6分轻度心衰；7-9分中度心衰；10-12分重度心衰。,Management of Heart Failure,Treatment Strategies: Ameliorate symptoms Maintain cardiac functional state Reduce mortality rate Reduce hospitalization,Treatment,1. The cause must be removed 2. Gene

12、ral management: bed rest, mitigate，oxygen inhalation， reduction of salt intake 3. Drug Treatment,Drug Treatment,Positive inotropic agentscardiac glycosides, phosphodiesterase inhibitors Vasodilators Diuretics Angiotensin converting enzyme inhibitors (ACEI) Beta-blockers,治疗,洋地黄类药物：正性肌力，负性传导，负性心率；直接抑制

13、过度的神经内分泌系统。 临床常用制剂：地高辛；西地兰。 常用剂量：地高辛口服化量：2岁0.05-0.06mg/kg，2岁0.03-0.05mg/kg，维持量为化量的1/5。西地兰静注化量：2岁0.03-0.04mg/kg，2岁0.02-0.03mg/kg。 新生儿用量更少，取婴儿量的1/2至2/3。,治疗-洋地黄类药物,使用方法 化量（饱和量）：适用于急性心衰或重症心衰，首次用化量的1/2量，余量分2次（1/4、1/4）， q4h-q6h或q8h。 维持量：适用于慢性心衰或轻症心衰，维持量为化量的1/5量，分2次口服；或者化量后需继续维持者，于化量后12小时开始予维持量。,治疗-洋地黄类药物,

14、注意事项：用药前了解洋地黄情况；避免用钙剂；注意纠正低血钾。 洋地黄中毒 表现：心律失常；消化道症状；神经系统症状等。 处理：停用洋地黄及利尿剂；口服补钾；必要时用抗心律失常药。,Diuretics,Relieve the congestion status by elimination of sodium and water. Indicated in pulmonary congestion with dyspnea and rales and generalized edema ,ascites Agents used: Thiazideschlorothiazide , chlotha

15、lidone Loop diureticsfurosimide, bumetanide, ethacrynic acid Potassium-sparing diureticsspirolectone, triamterene, amiloride Side effects: hypokalemia, hyperglycemia,ACE-Inhibitors,Rationales of the ACEI treatment for heart failure: Decreases peripheral circulatory resistance Decreases the blood vol

16、ume Decreases the sympathetic activity Inhibition of the remodeling process,ACE-Inhibitors,Short-term effects Symptomatic improvement: approximately 2/3 of cases with severe heart failure show diurea, improvement in dyspnea and less edema. Hemodynamic improvement: increased cardiac output by 25%-30%

17、 reduction of PCWP by 20% decreased peripheral resistance by 30% BPdrop 10%-15% Heart rateslightly reducsed N.B. 1st dose hypotension, transient elevation of BUN and creatinin,ACEI treatment of H.F.,Long-term effects : Reduction of mortality and preservation of cardiac function. SAVE study: Cases: p

18、ost acute myocardial infarction with EF40% Captopril Control P Case No. 1115 1116 Mortality rate (42months) RR21% 0.014 Development Of severe H.F. RR 37% 0.001,SOLVE study:,1) Cases of H.F.with symptoms, EF35% Enalapril Control Case No. 2111 2117 Follow up for 37.4 months Reduction of the death or d

19、evelopment of H.F. by 37% (P0.001),Conclusion of ACEI treatment of heart failure:,ACEI should be used in patients with heart failure irrespective to their underlying causes, if not contra-indicated. Early application of ACEI can postpone the development of congestive heart failure Attention should b

20、e paid to hypotension, increased blood Cr content and the side effect of cough. Agent used: Captopril, Enalapril, Perindopril, Lisinopril etc.,Beta-blocker in treatment of H.F.,Adverse effects induced by prolonged excessive sympathetic activity: Increases peripheral resistance-after-load Increases h

21、eart rate Increases excitability-arrhythmias Elevation of NE cAMP intracellular Ca+ overload precipitation of apoptosis and cell death Beta-blockers can induce negative inotropic response,Clinical Trial: US Carvedilol Heart Hailure Study,Carvedilol Placebo RR P No.of cases 696 398 Mortality rate (%)

22、 3.2 7.8 65% 0.001 Hospitalization (%) 14.1 19.6 27% 0.036 Agents proved to be effective in major clinical trails: Carvedilol, Metaprolol, Bisoprolol,Indications of Beta-blockers in CHF,Beta-blocker is indicated in CHF grade II,III and IV irrespective to its cause if not contraindicated Used on top

23、of ACEI and diuretics Preferably initiate the treatment in hospital especially for severe cases Start with a very small dose (usually 1/8 of the target dose), and increase gradually in 1-2 week interval. Watch carefully, adjust the dosage of ACEI or diuretics if necessary,Summary of management of H. F.,Treating the underlying cause and associated diseases General care daily life adjustments Drug therapy: ACEI Diuretics in case presence of congestion Beta-blockers Digoxin if necessary,Acute Left Heart FailurePulmonary edema,Etiological causes: Acute myocardial