HF心衰英文課件

1、HF心衰英文課件Heart failure (HF) Meaning of HF1.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 b

2、ody even though the filling pressure of the heart is adequate.中國心力衰竭流行病學推算我國目前成年人中約400萬心衰患者隨著年齡增加，心力衰竭患病率顯著上升城市農村，北方南方，與我國冠心病和高血壓的地區(qū)分布一致冠心病和高血壓是心力衰竭的主要病因1. 中華心血管病雜志 2007; 35(12): 1076-95. 2. 顧東風等. 中華心血管病雜志 2003; 31(1): 3-6.心力衰竭預后過去40年，心衰導致的死亡增加6倍（AHA 2005）2007年中國心衰診療指南指出，有臨床癥狀的患者5年生存率與惡性腫瘤相仿25% 新發(fā)心力

3、衰竭患者在1年內死亡 (ESC 1999）心力衰竭反復入院治療很常見，超過50% 患者半年內即再入院治療 (Krumholz et al. 1997, Vinson et al. 1990, Burns et al. 1997)狄蘭.托馬斯蔣介石伊麗莎白.泰勒聶榮臻葉利欽詹姆斯.門羅詹姆斯.布朗”Two new epidemics of cardiovasculardisease are emerging: heart failure andatrial fibrillation.” Eugene BraunwaldNEJMNow 1997心力衰竭心臟疾病的最后戰(zhàn)場 E Braunwald A

4、CC 20032.HF=systolic HF and/or diastolic HF3.HF and cardiac dysfunction (1) cardiac dysfunction = systolic dysfunction or diastolic dysfunction via instrumental examination without signs (2)HF= cardiac dysfunction +signsThe Donkey Analogy Ventricular dysfunction limits a patients ability to perform

5、the routine activities of daily living Lets compare our heart to this donkey, and our body to the wagon that this donkey has to pullevery day. Fundamental causes1. primary decreased myocardial contractility such as coronar heart disease (hungry)myocarditis ,cardiomyopathy. (injury)治療 Fundamental cau

6、ses2. increased burdens to the heart increased afterload (pressure load): hypertension aortic stenosis pulmonary stenosis pulmonary hypertension . Fundamental causes increased preload (volume load): mitral incompetence aortic incompetence tricuspid incompetence atrial septal defect (ASD) ventricular

7、 septal defect (VSD) (PDA) hyperthyroidism anemia 心臟功能的生理基礎心排血量心肌收縮力前負荷（舒張期容量）后負荷（射血阻抗）心率房室收縮協(xié)調性心臟機械結構完整性原發(fā)性心肌損害：缺血性心肌損害 心肌炎或心肌病 心肌代謝障礙 （糖尿病性心肌病等）高血壓、瓣膜狹窄（半月瓣）心臟瓣膜關閉不全、血液返流 左、右心分流或動靜脈分流全身血容量增加，如貧血、甲亢心力衰竭的基本病因 Precipitating causes 1. infection ,especially respiratory infection 2.arrhythmias 3.physica

8、l or emotional excesses e.g. pregnancy and delivery 4.rapid intravenous infusion ,excessive salt taking 5.electrolyte imbalance 6.primary disease deterioration or a new disease happens Pathogenesis and pathophysiology1.Compensate heart failure 2.some cytofactors take part in heart failure3.about dia

9、stolic insufficiency4.ventricular remodeling1.Compensate heart failurecardiac dilatation, by way of the Frank-Starling principle ,contractile force increases.cardiac hypertrophyneurohumoral activation a. Increase in sympathetic nervous activity b. RAAS activated (rennin angiotension aldosterone syst

10、em)N Engl J Med 2003;348:2007-18收縮性 vs 舒張性急性心梗后的心室重建開始心梗心梗持續(xù)（幾小時至幾天）全面重建（幾天至幾月）在舒張性和收縮性心力衰竭中的心室重建正常的心臟心臟肥厚（舒張性心衰）心臟擴大（收縮性心衰）高血壓和心梗后的心室重構濃度水平血漿去甲腎上腺素(pg/mL)NLHF血漿腎素激活(ng/mL/h)15129630NLHF精氨酸血管加壓素(pg/mL)126420NLHF心房鈉尿肽(pg/mL)300250200150100500NLHF內皮素-1(pg/mL)86420NLHF6005004003002001000Adapted from Co

11、hn JN. Cardiology. 1997;88:26.neurohumoral activation累計死亡率(%)月NE 900pg/ml 10080604020001224364860總 體P50% b. function of relaxation: E / A1.2 Diagnosis and differential diagnosis2. Differential diagnosis: Bronchial asthma : young allergichistory typical wheezing (哮鳴音) alleviate symptoms of dyspnea af

12、ter cough out sputum Diagnosis and differential diagnosis Pericardial effusion, Constrictive pericarditis: medical history signs of heart and perivascular echocardiogram the most sensitive and specific noninvasive method Diagnosis and differential diagnosis Hepatocirrhosis with ascites and edema of

13、lower extremity distention of jugular veins hepatojugular reflux(+).Treatment of chronic heart failure Principle: alleviate symptoms ,improve life quality. inhibition of progressive ventricular remodeling. reduce mortality and extend life.Treatment of chronic heart failuretreatment of the underlying

14、 causes and precipitating causes2. rest and restriction of salt take(1.5-2.5g/d)3. pharmacologic treatment Non-pharmacological managementA strong relationship between healthcare professionals and patients as well as sufficient social support from an active social network has been shown to improve ad

15、herence to treatment. It is recommended that family members be invited to participate in education programmes and decisions regarding treatment and careSabate E. Adherence to Long-term Therapies. Evidence for Action. Geneva: WHO;2003.People involved in careThe Players 調整生活方式1限鈉：輕度心衰患者23g/d，中到重度心衰患者2

16、 g/d。2限水：低鈉血癥，血鈉130mg/L，液體攝入量2L/d。3營養(yǎng)和飲食：低脂飲食，戒煙，肥胖患者應減輕體重；心臟惡液質者，給予營養(yǎng)支持，如血清白蛋白。4休息和適度運動 心理和精神治療壓抑、焦慮和孤獨在心衰惡化中發(fā)揮重要作用主要的死亡預后因素；情感干預；心理疏導；酌情應用抗抑郁藥物。Pharmacological therapyMoity:rPrbidognosis:Reduce mortalityImprove quality of life Prevention:Reduce hospitalizationTreatment of chronic heart failure1)Di

17、uretics: furosemide , dihydrochlorothiazide ( potassium-losing) antistone (potassium-sparing)DiureticsDiuretics are recommended in patients with HF and clinical signs or symptoms of congestion.Class of recommendation I, level of evidence B利尿劑臨床應用起始和維持：小劑量開始，如呋噻米每日20mg，氫氯噻嗪每日25mg逐漸增量直至尿量增加，體重每日減輕0.5-

18、1.0Kg。一旦病情控制(如肺部羅音消失，水腫消退，體重穩(wěn)定)，以最小有效劑量長期維持。維持期間，據液體潴留情況隨時調整劑量。利尿劑抵抗心衰進展和惡化時常需加大利尿劑劑量，最終再大劑量亦無反應時，即出現(xiàn)利尿劑抵抗。解決方案：靜脈應用利尿劑如呋噻米持續(xù)靜脈滴注(1040mg/h)；2種或2種以上利尿劑聯(lián)合使用；應用增加腎血流的藥物，如短期應用小劑量的多巴胺150250g/min。 Treatment of chronic heart failure2)Angiotensin Converting Enzyme Inhibitors(ACEI) -improve prognosis long-te

19、rm use of ACEI has significant effects, such as captopril , benazeprilACE inhibitorsUnless contraindicated or not tolerated, an ACEI should be used in all patients with symptomatic HF and a LVEF 40%.Treatment with an ACEI improves ventricular function and patient well-being, reduces hospital admissi

20、on for worsening HF, and increases survival.In hospitalized patients, treatment with an ACEI should be initiated before discharge.Class of recommendation I, level of evidence ACONSENSUS(1987) and SOLVD-Treatment(1991)血管緊張素轉換酶抑制劑(ACEI)降低心衰患者死亡率，是治療心衰的首選藥物。 越嚴重的心衰患者受益越大。 顯著降低死亡率、因心衰住院和再梗死率。ACEI應用方法 采用

21、目標劑量或患者能耐受的最大劑量。 極小劑量開始，每隔周劑量加倍，最大耐受量可長期維持。 監(jiān)測血壓、血鉀和腎功能。如果肌酐增高225 mol/l k+5.5mmol/l hypotensionACEI不良反應低血壓。腎功能惡化。高血鉀?？人裕焊煽?。血管性水腫。Treatment of chronic heart failure3) the agent of improving myocardial contractility digitalis:Digoxin(0.125mg qd po) , Cedilanid(0.2-0.4mg st iv) indication: chronic cong

22、estive heart failure complicated by atrail flutter and fibrillation and a rapid ventricular rate 地高辛應用要點適用于已應用ACEI/ARB、受體阻滯劑和利尿劑治療,而仍持續(xù)有癥狀的心衰患者。適用于伴快速心室率的房顫患者。NYHA級患者和疾病早期不主張應用。維持量療法，0.25mg/d。70歲以上，腎功能減退者宜用0.125mg每日或隔日一次。地高辛血清濃度與療效無關，不需用于監(jiān)測劑量。地高辛不良反應主要見于大劑量時，包括：心律失常。胃腸道癥狀。神經精神癥狀。常出現(xiàn)于血清地高辛藥物濃度2.0ng/m

23、l時，也可見于地高辛水平較低時。Treatment of chronic heart failurecontraindication:1)WPW with AF2) degree AVB , degree AVB3) sick sinus syndrome(SSS)4) hypertrophic obstructive cardiomyopathy (HOCM)5)severe mitral stenosis(SMS)6)acute myocardiac infarction(first 24 h) (AMI) adrenegic receptors activators a.Dopamine

24、 :2-5g/kgmin myocardial contractility vascular dilatation HR- Phosphodiesterase inhibitors a.Amrinone b.Milrinone4) Beta blocker: -improve prognosis metaprolol carvedilol受體阻滯劑應用要點無限期終身使用受體阻滯劑（禁忌證或不能耐受除外）：慢性收縮性心衰，NYHA、級病情穩(wěn)定患者，以及階段B、無癥狀性心衰或NYHA級的患者(LVEF40%) 。嚴密監(jiān)護下應用：NYHA 級心衰患者。在ACEI和利尿劑基礎上加用受體阻滯劑。最適劑量

25、下使用。受體阻滯劑應用要點清晨靜息心率不宜低于55次/分。需監(jiān)測低血壓、液體潴留和心衰惡化、心動過緩、房室阻滯及無力等不良反應。從極小劑量開始，每24周劑量加倍。癥狀改善常在治療23個月后才出現(xiàn)，即使癥狀不改善，亦能防止疾病的進展；不良反應一般不妨礙長期用藥。 受體阻滯劑禁忌證1)支氣管痙攣性疾病、心動過緩(心率60次/分)、度及以上房室阻滯(除非已安裝起搏器) 。2)心衰患者伴液體潴留，利尿后再開始應用。5) Aldosterone-receptors inhibitors -improve prognosis antistoneTreatment of chronic heart fail

26、urechronic heart failure-choice of pharmacologic therapy (systolic dysfunction)NYHA ACEI Diuretic Digitalis Vasodilator Beta blocker + After AMI + + +/- + + + + + + + + + + + 心力衰竭的藥物治療 改善血流動力學 糾正神經內分泌異常強心藥利尿劑擴血管藥轉換酶抑制劑受體阻滯劑醛固酮抑制劑心力衰竭治療藥物 延長壽命 中性（改善癥狀） 縮短壽命轉換酶抑制劑受體阻滯劑醛固酮抑制劑洋地黃腎上腺素能受體興奮劑磷酸二酯酶抑制劑利尿劑 Acute cardiac insufficiency Underlying and precipitating causes 1. tight mitral stenosis ,especially in presence of