心力衰竭-英文版課件

1、Objective :1.Mastering clinical manifestation ,diagnosis and management of heart failure2.Grasping causes,pathophysiology of heart failure3.Understanding classification and investigation of heart failure 1.general concept 1)causes of heart failure 2)precipitating/aggravating factors 3)pathophysiolog

2、y 4)type of heart failure2.chronic and acute heart failure 1)clinical manifestation 2)investigation 3)diagnosis and differential diagnosis 4)management Content Heart failure is an imprecise term used to describe the state that develops when the heart cannot maintain an adequate cardiac output or can

3、 do so only at the expense of an elevated filling pressure. Definition pulmonary congestion, systemic venous congestion , tissue perfusion deficiency due to low cardiac output . Clinical Features left ventricular end-diastolic pressure18mmHg, right ventricular end-diastolic pressure10mmHg, heart fai

4、lure = cardiac insuffiency.Hemodynamic FeaturesCauses of heart failure1.Reduced ventricular contractility a. Cardiomyopathy, myocardial infarction. b. Metabolic dysfunction 2.ventricular overload a. pressure overload- hypertension , aortic stenosis, pulmonary hypertension, pulmonary valve stenosis.

5、b. volume overload - mitral regurgitation, aortic regurgitation , atrial septal defect, ventricular sepals defect , hyperthyroidism, artery-venous fistula. c. ventricular inflow obstruction-hypertrophy , mitral stenosis, tricuspid stenosis, restrictive cardiomyopathy, constrictive pericarditis .endo

6、cardial fibrosis and other disorders that cause a stiff myocardium. Precipitating / aggravating factors myocardial ischemia or infarction infection arrhythmia pulmonary embolism exertion pregnancy and parturition anemia intravenous fluid overload, electrolyte disturbance, acid-base imbalancePathophy

7、siology1. Frank-Starlings Law of the heart a. The cardiac output is a function of the preload, the afterload, and myocardial contractility. b.Preload: the volume and pressure of blood in the ventricle at the end of diastole. c. Afterload :the arterial resistance.1 正常靜息2 正?；顒? 心衰活動3 心衰靜息心肌收縮性BADC左室舒張

8、末容量圖321 正常和心力衰竭時對機體活動時的代償情況最大活動活動靜息左室作功呼吸困難肺水腫E4 靜息 致死性心肌受損心肌細胞死亡心力衰竭心肌細胞死亡+心肌能量消耗后負荷血管收縮心排血量神經(jīng)體液興奮RASSASInSP3循環(huán)心肌能量消耗胞漿Ca2+cAMP InSP3 心臟心肌松弛性變力效應(yīng)+心律失常猝死圖322 腎素血管緊張素和交感腎上腺素能系統(tǒng)激活時對心臟代償功能的影響 2. RAAS in Heart Failure 2. RAAS in Heart Failure 3.myocardium impaired and remodelinginitial myocardium impair

9、edventricular overloadmyocardium infarctioninflammationdisease progressheart failurecomplicationdeathchamber enlargementmyocardial hypertrophyembryo gene phenotypeextracellular matrix changesecondary conductfactorsympathetic nervoussystemRAASendothelinsTNF- ,IL-6mechanical stressoxidative stress4.Di

10、astolic heart failure Heart failure may develop as a result of poor ventricular filling and high filling pressure caused by abnormal ventricular relaxation 順應(yīng)性順應(yīng)性正常壓 力圖324 心室舒張末期壓力和容積的關(guān)系舒張性心力衰竭時，心室順應(yīng)性降低，心室壓力容積曲線向左上方移位，即在任何特定的舒張末期壓時，心室末期容量小于正常人。容 積sarcoplasmic reticulum intake Ca2+ free Ca2+ in myocy

11、te degrade slowly b. In CHD with obvious ischemia ,before contractility dysfunction, have occurred relaxation dysfunctionc. In hypertrophy and hypertrophic cardiomyopathy, left ventricular end-diastolic filling pressure pulmonary hypertension ,pulmonary congestion diastolic heart failure relaxation

12、dysfunction Type of heart failure Heart failure can be described or classified in several ways.1.Acute and chronic heart failure 2.Left ,right and biventricular heart failure 3.High and low output heart failure 4.Diastolic and systolic dysfunction5.Asymptomatic and congestive heart failureLow output

13、 heart failure: Clinical manifestation of abnormal peripheral circulation: vasoconstriction in system , cold, pale, extremities cyanosis, in the late period,output per minute decrease and lead to difference of pulse pressure decrease, the above manifestation occur in the majority of CHF.High output

14、heart failure: Extremities warm,flush, difference of pulse pressure increase,seen in hyperthyroidism,anemia,pregnancy Systolic dysfunction Heart failure may develop as a result of impaired myocardial contraction . Diastolic dysfunction Heart failure can also be due to poor ventricular filling pressu

15、re caused by abnormal ventricular relaxation ,which is commonly found in patients with left ventricular hypertrophy, hypertension and ischemic heart disease.1 Chronic heart failureDefinition same meaning as congestive heart failureclinical manifestation1.left ventricular heart failuremainly manifest

16、ed with pulmonary congestion and reduction of cardiac output A symptom1.dyspnea1)breathlessness2) paroxysmal nocturnal dyspnea:often with wheeze sound in both lung cardiogenic asthma3)Orthopnea: in decubitus,blood volume flow to heart increase elevated enddiastolic filling pressure pulmonary venous

17、and capillary pressure increase interstitial pulmonary edema pulmonary compliance decrease respiratory resistance4)acute pulmonary edema2. cough and hemoptysis pink-tinged or brownish sputum3. fatigue on exertion 4. urinary system symptom in early period ,nocturia increase in later period, oliguria

18、B. Sign1.general sign dyspnea after activity,also cyanosis, jaundice , difference of pulse pressure decrease,SBp decrease, rapid heart rate , peripheral vasoconstriction ,extremities cyanosis, cold,sinus tachycardia.2.Heart sign diffuse and laterally displaced apical impulse gallop in early diastoli

19、c period , accentuated p2 systolic murmur at cardiac apex pulses alternans occur when left ventricular ejective impedance increase3.Lung sign moist rales in the base of lung CHF patients occur pleural fluid2.Right ventricular Failure systemic circulation congestionSymptom1)gastrointestinal tract sym

20、ptom: anorexia, distention ,nausea ,vomiting ,constipation2)kidney symptom kidney congestion renal function decrease3)hepatic region pain: congestion , cardiac cirrhosis4)dyspnea Sign1.heart sign heart dilate when right heart failure is obvious,strong impulse occur in the systolic period at the left

21、 sternal border, obvious beat occur infraxiphoid diastolic gallop relative tricupid incompetence2.hepatic cervical reflux3.congestive liver and tenderness occur before edema Acute : jaundice , ALT increase Long term: cardiac cirrhosis4.edema occur after cervical filling and liver large, is typical s

22、ign of right heart failure. at first occur in foot, ankle , anterior tibia. In the early period,edema occur in the morning, worse in the evening ,disappear after sleeping. In the late time,systemic , symmetric, pitting edema If complicated with malnutrition or hepatic dysfunction , face edema occur,

23、 prognosis is poor.5.pleural fluid and ascites 3.biventricular heart failure have clinical manifestation of left and right heart failure. Conditions with normal systolic function and decreased diastolic function include: (1) systemic arterial hypertension (2) myocarditis (3) hyretrophic cardiomyopat

24、hy (4) congestive cardiomyopathy In the setting of left ventricular dysfunction,which of following neurohormonal factors would be activated? (1)Norepinephrine (2)Endothelin (3)Arginie vasopreein (4)Endothelial-derived relaxing factor Investigation 1.routine examination blood, urine, renal function,

25、electrolyte, liver function 2.ECG a.no specific findings . b.Abnormalities may provide etiological clue(ventricular hypertrophy,AMI,bundle branch block) c.V1ptf25-30mmHg(3.3-4KPa) interstitial edema occur.參 數(shù)正常值臨床意義中心靜脈壓（CVP）612cmH2O（0.591.18KPa）說明血容量過多或右心衰竭肺動脈壓（PAP）1230/413mmHg（1.64.0/0.531.73KPa）說

26、明肺動脈高壓、左心衰竭肺毛細血管楔嵌壓（PCWP）612mmHg（0.81.6KPa）說明肺淤血、左心衰竭心搏量（SV）6070ml可由于前負荷不足、心包填塞、心肌收縮力下降，心排阻力上升心搏指數(shù)（SI）4151ml/m2同上心排血量（CO）56L/min可由于正性肌力藥物作用，說明有心力衰竭心排指數(shù)（CI）2.64.0L/（minm2）說明收縮力減低或心力衰竭射血分數(shù)（EF）0.50.6說明心室收縮功能減低左室每搏作功（LVSW）60123左室每搏作功指數(shù)（LVSWI）5062體循環(huán)血管阻力（SVR）7701500dyness/ cm5見于缺血、血管擴張劑，高血壓、血管活性藥物體循環(huán)血管阻力

27、指數(shù)（SVRI）19702390dyness（cm5m2）同上肺血管阻力（PVR）37250 dyness/ cm5毛細血管前肺小動脈收縮、肺栓塞、慢性肺疾病、肺間質(zhì)水腫、肺小血管阻塞性病變、二尖瓣狹窄肺血管阻力指數(shù)（PVRI）69177 dyness（cm5m2）同上增高 降低 Invasive homodynamic monitoringDiagnosis and differential diagnosis Clinical diagnosis include : etiology(basic cause and induce cause), pathoanatomy, pathophy

28、siology, heart rhythm cardiac function NYHA classification no activity limit , daily activity dont lead to inertia, dyspnea, palpitation. slight activity limit , no symptom at rest ,daily activity lead to inertia, dyspnea, palpitation or angina pectoris. obvious activity limit , no symptom at rest ,

29、 daily activity lead to inertia, dyspnea, palpitation or angina pectoris. cannot do any activity , have symptom at rest.typeCI(L/minm2）PCWP（mmHg）Clinical manifestation2.218（2.4）No peripheral perfusion deficiency and pulmonary congestion ,no symptom and sign of heart failure 2.218（2.4）No peripheral p

30、erfusion deficiency ,pulmonary congestion ,no obvious clinical manifestation 2.218（2.4） peripheral perfusion deficiency, no pulmonary congestion ,seen in right ventricular infarction and blood volume deficiency 2.218（2.4） peripheral perfusion deficiency and pulmonary congestion ,severe typeForrester

31、 classificationKillip classification no heart failure symptom, no moist rales, PCWP may elevate slight to moderate heart failure, 50%lung field moist rales, may occur lung edema cardiac shock, Bp90mmHg, oliguria 18mmHg, pulmonary congestion2.clinical manifestation of peripheral circulatory perfusion

32、 deficiency CI2.2L/min.m23.valve insufficiency, ventricular septal defect pulmonary hypertension,valve regurgitation with cardiac dysfunction If blood volume deficiency ,should fluid replacement at first,then use vasodilator drugs.藥物機制前負荷后負荷常用劑量作用時間開始高峰持續(xù)硝酸鹽血管擴張劑硝酸甘油NO供者+0.210g/（kgmin） iv56mg 經(jīng)皮2min

33、515min10ug/Kg.min activate -receptor, vasoconstrict Dobutamine 2-7.5ug/Kg.min 2.Phosphodiesterase inhibitor Inhibit cAMP degrade increase intracellular cAMP Ca2+ increase cardiac contraction increase Amrinone Milrione 3.Aldosterone antagonist Protect aldosterone escape.4.-adrenocepter antagonists Re

34、cent clinic trials have shown ,when given in very small doses under carefully monitored conditions , they can increase ejection fraction, improve symptoms and reduce the frequency of hospitalization in patient with chronic heart failure. . Relieve toxiation of catecholamine . On the base of using AC

35、E-I, diuretics , digitalis, using bloker. . Given in very small incremental doses Bisoprool 1.25mg metoprolol 6.25mg 5.diastolic heart failure treatment treat primary disease relax myocardium revert myocardial hypertrophy decrease preload control tachycardia calcium channel blocker,and blocker can b

36、e useful.6.Refractory heart failure 1)Have the etiology and precipitating causes been established? 2)Are drug dose optimal? 3)Is the patient adhering to an adequate low-salt diet? 4)Need another cardiac transplantation. 7.Acute pulmonary edemaEmergency treatment1)position:Dont keep patient in a supine position2)Maintain oxygenation:high concentrations of O2 should be given by mask or nasal cannula.3)Morphine sulfate 3