2016英文班内科学心力衰竭课件.ppt

,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,单击此处编辑母版标题样式,*,Heart Failure(HF),Heart failure(HF),Conception:,heart failure is a final common pathway for many cardiac disorders of diverse etiology and pathogenic mechanisms.It is a clinical syndrome,manifested as a result of the inability of the heart to match its output to the metabolic needs of the body even though the filling pressure of the heart is adequate.,Categories of HF,1.left,right and whole,2.acute and chronic,3.systolic and diastolic,New York Heart Association Functional Classification,Class,No limitation of physical activity,No sympotoms with ordinary exertion,Class,Slight limitation of physical activity,Ordinary activity causes symptoms,Class,Marked limitation of physical activity,Less than ordinary activity causes symptoms,Asymptomatic at rest,Class,Inability to carry out any physical activity without,discomfort,Sympotoms at rest,Stage and Class of HF,心衰分期是,NYHA,分级的补充，但不能,替代,NYHA,分级,NYHA,分级,在具体病人,可上下变动,(,对治疗的反应和,/,或疾病进程不同,),分期,随心脏重构加重,只能进展,6-min walk distance,mild degree,：,450m,moderate degree,：,150-450m,severe degree,：,150m,Evaluation of,chronic HF,cardiac function,Fundamental causes,primary myocardial disease,increased burdens to the heart,Fundamental causes,2.,increased burdens to the heart,increased afterload(pressure load):,hypertension,aortic stenosis,pulmonary stenosis,pulmonary hypertension,Pathogenesis and pathophysiology,1.Compensate heart failure,2.Ventricular remodeling,3.About diastolic insufficiency,4.Humoral factors change,1.Compensate heart failure,Frank-Starling principle,neurohumoral activation,myocardial hypertrophy,1.Compensate heart failure,cardiac dilatation,by way of the Frank-Starling principle,contractile force increases.,1,正常静息,2,正常活动,3,心衰活动,3,心衰静息,心肌收缩性,B,A,D,C,左室舒张末容量,图,321,正常和心力衰竭时对机体活动时的代偿情况,最大活动,活动,静息,左室作功,呼吸困难,肺水肿,E,4,静息,致死性心肌受损,1.Compensate heart failure,neurohumoral activation,a.Increase in sympathetic nervous activity,b.RAAS activated(rennin angiotension aldosterone system),心肌细胞死亡,心力衰竭,心肌细胞死亡,+,+,心肌能量消耗,后负荷,血管收缩,心排血量,神经体液兴奋,RAS,SAS,InSP,3,循环,心肌能量消耗,胞浆,Ca,2+,cAMP InSP,3,心脏,心肌松弛性,变力效应,+,心律失常,猝死,图,322,肾素,血管紧张素和交感,肾,上腺素能系统激活时对心脏代偿功能的影响,2.RAAS in Heart Failure,2.RAAS in Heart Failure,2.Ventricular remodeling,2.Ventricular remodeling,heart failure is,the result of ventricular remodeling.,Reduce the myocardial cells,decreaseofthesystolicfunction,Increased myocardial fibrosis,decreaseofthe Ventricular compliance,Heart cavity expansion,myocardial hypertrophy,extracellular matrix,collagen fibers,Myocardial cells,Compensated stage,Decompensated stage,4.some cytofactors take part in heart failure,ANP(atrial natriuretic peptide),BNP(brain natriuretic peptide),AVP(arginine vassopressin),Endothelin(NE,angiotensin),Urine volume,peripheral vascular,sympathetic nervous,RAAS,Ventricular remodeling,Ventricular remodeling,neurohumoral activation,heart failure,Chronic heart failure,CHF,1.Left heart failure,1)dyspnea,1.exertional dyspnea,2.paroxysmal nocturnal dyspnea,3.orthopnea,4.acute pulmonary edema,1.Left heart failure,2)cough,hemoptysis,spit pink sputum,3)fatigue,dizziness,palpitation.,4)oliguria,renal dysfunction,sign,1),pulmonary basal rales,bilaterally or right-side,2)enlarged left heart,pulsus alternans,protodiastolic gallop,P2 increased,Pulmonary,edema,2.Right heart failure,symptom,abdominal discomfort,anorexia(,厌食,),nausea,vomit,exertional dyspnea,2.Right heart failure,sign,liver enlarged,ascites,distention of jugular veins,hepatojugular reflux(+),peripheral edema,most mark in dependent parts,cyanosis,protodiastolic gallop,functional murmurs,of tricuspid and,pulmonary valve,3.Whole heart failure,LHF,RHF,laboratory examination,BNP and NT-proBNP,心室扩张,心衰,张力增大,BNP,释放,呼吸困难,虚弱,运动受限等症状,(,NT-proBNP,),慢性心衰,转至心脏专科,继续下一步诊断,阳性,阴性,NT-proBNP,临床应用流程图,辅助诊断心衰,辅助判断进展期心衰患者预后,laboratory examination,CnTI,blood routine examination,routine urine examination,biochemical examination,FT3,FT4,TSH,ECG(electrocardiogram),ischemia,OMI,conduction block,arrhysmia,X-ray,Pulmonary congestion,Pleural effusion,Kerlry B,Right pulmonary artery broadening,Pulmonary hilar butterfly shape,Echocardiogram,LVEF,50%,E/A,1.2,LVEDV/LVESV,LVEDD/LVESD,ventricular wall motion,Cardiac magnetic resonance,CMR,99M,T,C,-MIBI SPECT(radionuclide),Coronary angiography,Cardiac Catheterization,Swan-Ganz PCWP,12mmHg,CI,2.5L/,（,min.m,2,）,Cardiopulmonary Exercise Testing(CPET),Chronic stable HF,Measurement of rate of oxygen uptake(VO,2,),rate of CO,2,production(VCO,2,),during,maximal,“,symptom-limited,”,exercise,Diagnosis and differential diagnosis,Diagnosis:,medical history+symptoms+signs+exam,Exam:,ECG:rarely normal in systolic HF.,x-ray:to detect cardiomegaly and pulmonary congestion.,(3),Echocardiogram:It is critical importance.,to determine the underlying causes of HF,to assess the severity of ventricular dysfunction,a.function of contraction:LVEF50%,b.function of relaxation:E/A1.2,2.Differential diagnosis,:,cardiac asthma,Bronchial asthma,History,Heart disease,allergichistory,age,older,young,time,night,spring,HF sign,yes,no,Lung sign,pulmonary basal rales,typical wheezing,x-ray,Pulmonary congestion,LV large,emphysema,alleviate symptoms of dyspnea,Diuretics,digitalis,isosorbide dinitrate,after cough out sputum,antispasmodic,2.Differential diagnosis,:,Pericardial effusion,Constrictive pericarditis:,distention of jugular veins,hepatojugular reflux(+),liver enlarged,ascites,peripheral edema,most mark in dependent parts,medical history,signs of heart and perivascular,echocardiogram,CMR,the most sensitive,specific noninvasive method,2.Differential diagnosis,:,Hepatocirrhosis with ascites and edema of lower extremity,distention of jugular veins(-)hepatojugular reflux(-),Treatment of chronic heart failure,Principle:,alleviate symptoms,improve life quality.,treatment for primary disease and precipitating causes,Antagonism of neurohumoral activation,inhibition of progressive ventricular remodeling,reduce mortality and extend life.,Treatment of chronic heart failure,General,Pharmacologic treatment,Non-medicine treatment,General,treatment,decreased,burdens,increased,systole power,Anti-,neurohumoral,activation,General,treatment,decreased,burdens,increased,systole power,Anti-,neurohumoral,activation,1.Lifestyle management,Education,Regulate weight,Dietary management:salt take,2.Rest and action,3.Treatment for primary disease and precipitating,General,treatment,decreased,burdens,increased,systole power,Anti-,neurohumoral,activation,1.Rest,2.Dietary management:salt take,3.,Diuretics,furosemide,dihydrochlorothiazide,(potassium-losing),antistone,(potassium-sparing),The main point of diuretics application,对于有症状的心衰，当液体负荷过重已表现为肺淤血或外周水肿时，,利尿剂是基本的治疗,。应用利尿剂可迅速改善呼吸困难并增加运动耐量（,I,类建议，证据级别,A,）,尚无大型随机对照试验评估这类药物对症状和生存的影响。,如能耐受，利尿剂始终应与,ACEI,和,-,受体阻滞剂一起使用。（,I,类建议，证据级别,C,）。,襻利尿剂应作为,首选,。噻嗪类仅适用于轻度液体潴留、伴高血压和肾功能正常的心衰患者,(I,类，,B,级,),。,利尿剂通常从小剂量开始,(,氢氯噻嗪,25 mg/d,，呋塞米,20 mg/d,，托塞米,10 mg/d),逐渐加量。一旦病情控制即以最小有效量长期维持。每日体重变化是最可靠检测利尿剂效果和调整利尿剂剂量的指标。,长期服用利尿剂应严密观察不良反应的出现如电解质紊乱、症状性低血压，以及肾功能不全，特别在服用剂量大和联合用药时（,类，,B,级）。,The main point of diuretics application,General,treatment,decreased,burdens,increased,systole power,Anti-,neurohumoral,activation,1.Rest,2.Dietary management:salt take,3.Diuretics,4.,Vasodilator,sodium nitroprusside(SNP),nitroglecerin,regitine(,酚妥拉明,),),The main point of,Vasodilator,application,直接血管扩张剂对于,CHF,的治疗无特殊作用。（,类,，,A,级）,血管扩张剂可用于不能耐受,ACEI,或,ARBs,的患者；伴有心绞痛或高血压可考虑应用（,类，,B,级）,禁忌证：,血容量不足，低血压、肾功能衰竭,心脏流出道或瓣膜狭窄患者,General,treatment,decreased,burdens,increased,systole power,Anti-,neurohumoral,activation,1.Digitalis,（,1,）,effection:,Positive inotropic,：,inhibit,Na,+,-K,+,-ATP,enzyme,introcellular,Na,+,、,K,+,Na,+,-,Ca,2+,exchange,introcellular,Ca,2+,myocardial systole power,introcellular,K,+,，,digitalis poisoning,General,treatment,decreased,burdens,increased,systole power,Anti-,neurohumoral,activation,1.Digitalis,（,1,）,effection:,Positive inotropic,：,Electrophysiological,Inhibit condution system,espicially atriventricular junction.,Improve the autorhythmicty of atrium,junction region and ventricle.,General,treatment,decreased,burdens,increased,systole power,Anti-,neurohumoral,activation,1.Digitalis,（,1,）,effection:,Positive inotropic,：,Electrophysiological,Parasympathetic stimulating,anti-sympathetic nerve exciting,General,treatment,decreased,burdens,increased,systole power,Anti-,neurohumoral,activation,1.Digitalis,（,1,）,effection:,Positive inotropic,：,Electrophysiological,Parasympathetic stimulating,Role in the renal tubule cells,reducing sodium reabsorption,inhibit the secretion of renin,General,treatment,decreased,burdens,increased,systole power,Anti-,neurohumoral,activation,1.Digitalis,（,2,）,application,indication:,chronic congestive heart failure,complicated by atrail flutter and,fibrillation and a rapid ventricular rate,General,treatment,decreased,burdens,increased,systole power,Anti-,neurohumoral,activation,1.Digitalis,（,2,）,application,contraindication:,WPW with AF,degree AVB,degree AVB,sick sinus syndrome(SSS),Hypertrophic cardiomyopathy(HOCM),severe mitral stenosis(SMS),acute myocardiac infarction(first 24 h,General,treatment,decreased,burdens,increased,systole power,Anti-,neurohumoral,activation,1.Digitalis,(,3)digitalis poisoning,factors,：,K,+,O,2,RF,Clincal expression:,gastric bowel reaction;,arrhythmia;,neurological and visual change,Diagnosis,：2.0 ng/ml,Arrhythmia of,digitalis poisoning,Ventricular Premature beat,Nonparoxysmal atrioventricular junctional tachycardia,Atrial Premature beat,Atrial fibrillaton,Atrioventricular block,ST-T change like fishhook,Characteristic feature,General,treatment,decreased,burdens,increased,systole power,Anti-,neurohumoral,activation,1.Digitalis,Treatment of,digitalis poisoning,drug withdrawal,tachycadia,:supply,K,+,Lidocain iv,bradicadia,：,atropin iv,not suitable for pacemaker,not suitable for isoprenaline,disable cardioerter,General,treatment,decreased,burdens,increased,systole power,Anti-,neurohumoral,activation,1,、,Digitalis,2,、,-excitant,Dopamine,：,NE precursor,2,g/kg.min,Dopamine,-R(+),expand renal artery,2-5,g/kg.min,1,2,-R(+),myocardial contractility,Vasodilate,5-10,g/kg.min,-R(+),BP,HR,Dobutamine,：,Dopamine derivatives,2,g/kg.min,10,g/kg.min,Vasodilate,HR-small effects,General,treatment,decreased,burdens,increased,systole power,Anti-,neurohumoral,activation,1,、,Digitalis,2,、,-excitant,3,、,Phosphodiesterase inhibitors,1,、,effect:,restrain activity of phosphodiesterase,，,the degradation of cAMP(-),cAMP,Ca,2+,channel activation,Ca,2+,-inflow,myocardial contractility,General,treatment,decreased,burdens,increased,systole power,Anti-,neurohumoral,activation,1,、,Digitalis,2,、,-excitant,3,、,Phosphodiesterase inhibitors,1,、,effect:,2,、,indications,：,refractory heart failure,end-stage heart failure,before,heart transplantation,General,treatment,decreased,burdens,increased,systole power,Anti-,neurohumoral,activation,1,、,Digitalis,2,、,-excitant,3,、,Phosphodiesterase inhibitors,1,、,effect:,2,、,indications,：,3,、,drugs,：,氨力农,(Amrinone),VD 5-10,g/kg.min,米力农,(Milrinone),VD 0.5,g/kg.min,General,treatment,decreased,burdens,increased,systole power,Anti-,neurohumoral,activation,1,、,Digitalis,2,、,-excitant,3,、,Phosphodiesterase inhibitors,1,、,effect:,2,、,indications,：,3,、,drugs,：,4,、,defect,：,side-effect,;mortality,AII,产生是通过多种通道,血管紧张素原,肾素,血管紧张素,I(1-10),Ang II,（,1-8,）,ACE,AT1,AT2,血管收缩,增殖,醛固酮增加,血管扩张,抗增殖,Ang1-7,Ang1-7,受体激活,血管扩张,抗增殖,ARB,General,treatment,decreased,burdens,increased,systole power,Anti-,neurohumoral,activation,1,、,RAAS inhibitor,Angiotensin Converting Enzyme Inhibitors(ACEI),dilate blood vessels,inhibit RAS,sympathetic,system,reverse the ventricular remodeling,improve artery stiffness and sensitivity,Improve endothelial function,AT,Inhibit the degradation of,bradykinin,General,treatment,decreased,burdens,increased,systole power,Anti-,neurohumoral,activation,1,、,RAAS inhibitor,Angiotensin Converting Enzyme Inhibitors(ACEI),Clinical status,symptoms,exercise tolerance,mortality,delay the progress of heart failure,reducing hospitalization rates,prevent HF after myocardial infarction,General,treatment,decreased,burdens,increased,systole power,Anti-,neurohumoral,activation,1,、,RAAS inhibitor,Angiotensin Converting Enzyme Inhibitors(ACEI),Captopril 6.25,25mg 2,3/d,Enalapril 10 mg 2/d,Cilazapril 2.5 mg/d,Benazepril 2.5,10 mg/d,Perindopril 2,4 mg/d,Fosinopril 5,10 mg/d,Ramipril 2.5 mg/d,General,treatment,decreased,burdens,increased,systole power,Anti-,neurohumoral,activation,1,、,RAAS inhibitor,Angiotensin Converting Enzyme Inhibitors(ACEI),application methods,starting with small doses,if tolerated,gradually,increase the dose,monitoring of renal function and ions,renal function change,high potassium,dry cough,angioedema,General,treatment,decreased,burdens,increased,systole power,Anti-,neurohumoral,activation,1,、,RAAS inhibitor,Angiotensin Converting Enzyme Inhibitors(ACEI),Contraindication:,anuric renal failure pregnancy and brest feeding woman allerge,Relative Contraindication:,renal artery stenosis bilaterally,Cr225 mol/l,k+5.5mmol/l,hypotension,General,treatment,decreased,burdens,increased,systole power,Anti-,neurohumoral,activation,1,、,RAAS inhibitor,Angiotensin Converting Enzyme Inhibitors(ACEI),Angiotensin II receptor antagonist(ARB),AT-AT,1,receptor,Inhibit RAS,No affecting the degradation,of,bradykinin,General,treatment,decreased,burdens,increased,systole power,Anti-,neurohumoral,activation,1,、,RAAS inhibitor,Angiotensin Converting Enzyme Inhibitors(ACEI),Angiotensin II receptor antagonist(ARB),application methods,less dry cough and angioedema,when HF,first chose ACEI,when HF,should not be combined,application,of,ACEI and ARB,Losartan 50mg/d;valsartan 80mg/d,General,treatment,decreased,burdens,increased,systole power,Anti-,neurohumoral,activation,1,、,RAAS inhibitor,Angiotensin Converting Enzyme Inhibitors(ACEI),Angiotensin II receptor antagonist(ARB),Aldosteroneantagonists,spironolactone(SPI),potassium-sparing diuretic,reverse the ventricular remodeling,improve prognosis,General,treatment,decreased,burdens,increased,systole power,Anti-,neurohumoral,activation,1,、,RAAS inhibitor,Angiotensin Converting Enzyme Inhibitors(ACEI),Angiotensin II receptor antagonist(ARB),Aldosteroneantagonists,renin inhibitor,ACEI/ARB,increasingplasmareninactivity,renininhibitiorhastheeffectof,cardiorenalprotection,not ACEI/ARB replacement therapy,General,treatment,decreased,burdens,increased,systole power,Anti-,neurohumoral,activation,RAAS inhibitor,-blocker,sympathetic activation,b,1,receptors,b,2,receptors,a,1,receptors,metoprolol,bisoprolol,arrythmia,dilate blood vessels;,the myocardial O,2,Cardiac toxicity,carvedilol,General,treatment,decreased,burdens,increased,systole power,Anti-,neurohumoral,activation,RAAS inhibitor,-blocker,Inhibition of sympathetic activation,improve prognosis,1-,blocker metoprolol,bisoprolol,1 2,-,bloker carvedilol,application methods,starting with small doses,if tolerated,gradually,increase the dose,monitoring of Bp,HR,ECG,General,treatment,decreas