深度和節(jié)律的改變Dyspneaoneertion勞力性呼吸困難Orthopnea端課件

1、Heart Failure 心衰 approx. 100,000 heartbeats/day approx. 2,760,000,000 heartbeats/lifetime approx. 4,000 gallons (15,000 liters) blood pumped/day appox，3，832，500，000 liters/lifetime 小型水庫(shuk) 1000m3 中型水庫 1000 m3 大型水庫 100,000 000m3 龍泉驛水庫 蓄水約 330萬立方米第一頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端

2、 Concept 概念(ginin) Pathogenesis 發(fā)病機制 Effect（important）and mechanisms 影響及機制 Outline大綱(dgng) 第二頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端 Background 背景 Definition and explaining the definition 定義(dngy) pathogenesis 機制 Content 內(nèi)容(nirng)第三頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端 心為君主之官

3、，臟腑百骸，惟所是命，聰明智慧(cng mng zh hu)，莫不由之 The heart is more deceitful than anything. It is incurable who can know it? Jeremiah 17:9-10 Heart failure 心衰-Background 第四頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端Heart failure 心衰-Background Cats look down on us. Dogs look up to us. Pigs treat us as equa

4、ls第五頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端Heart failure 心衰-Background 第六頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端What kill us?Background第七頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端 2010年中國(zhn u)心血管病報告 1/5 adults suffer from cardiovascular disease 3 million die from card

5、iovascular disease account for 41% of death number China death 1/11.6s America death 1/34.0s equivalent to once Wen chuan big earthquake Backgroundthe report of cardiovascular disease in china 2010第八頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端 hypertension 高血壓 2億人 myocardial infarction 心肌(xnj)

6、梗 200萬人 pulmonary heart disease 肺心病 500萬人 rheumatic heart disease 風心病 250萬人 congenital heart disease 先心病 200萬人 heart failure 心衰竭 420萬人2010年中國(zhn u)心血管病報告the report of cardiovascular disease in china 2010Background第九頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端We Face an epidemic of HF Affectin

7、g 0.4-2% of total population， 8-10% of elderly The global HF patients have up to 2250 million， increasing at 200 million per year The prognosis of HF similar to cancer or even worse The 20% patients with HF readmission after discharged from hospital in 30 days Less than 50% patients survival 5 years

8、 from the diagnosis of heart failure Average survival time is 16 month ， in hospital only 25% survival 5 years Background第十頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端020406080100Heart diseaseCerebrovascular malignancyaccidentalrespiratory gastrointestinalcommunicableUrinary system Neuropsycho

9、sis EndocrinosisLife styleBiogentics Environmental factorsHealth careTop 10 cause of death in China and the main risk factors %第十一頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端Forecasting the future of cardiovascular disease in the United States Circulation 2011;123(8):933-944Estimated direct an

10、d indirect cost of major cordial disease In united state in 2010The Economic Burden Of Cardiovascular DiseasesCoronary heart disease Hypertensive disease Stroke Heart failure$53.9$34.4 Cost in billion $105.9 $93.5 第十二頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端Clinical intervention 生 死Low risk

11、stateDangerous state Early changeDifferent prognosisClinicdiseaseSub-clinic symptoms Prevent interventionHypertension hyperlipidmia smoking diabetes obey hereditary psychological intervention National standard life style drug operation physics Backgroundheath sub-health sub-clinic disease第十三頁，共四十五頁。

12、深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端Risk FactorsEndothelial DysfunctionAtherosclerosisCoronary artery disease Myocardial IschemiaCoronary ThrombosisMyocardial InfarctionArrhythmia & Loss of MuscleRemodelingVentricular DilationCongestive Heart FailureEnd stage Heart Disease The Progressive Deve

13、lopment of Chronic Cardiovascular Disease 慢性心血管疾病(jbng)漸進式發(fā)展心功不全 insufficiency第十四頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端Heart functionPhysicalActivitylimitationSymptoms at rest DescriptionINono almost as normal personII Mild Slight noCan withstand heavier physical activityIIImoderateobvio

14、usnoCan with lighter physical activityIVsevereobviousyesLose labor ability completely Life-threating 分級(fn j): The New York Heart Association Functional Class (NYHA-FC)第十五頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端 心肌收縮(shu su)力因各種病因減弱（原發(fā)或繼發(fā)），不能將靜脈回心血量等量搏出，因而使心輸出量絕對或相對減少，使體循環(huán)和/或肺循環(huán)靜脈系統(tǒng)淤血，動脈系統(tǒng)

15、供血不足，不能滿足人體在靜息狀態(tài)或一般活動時代謝的的需要，從而出現(xiàn)一系列的心臟循環(huán)障礙的癥狀和體征。大循環(huán)(xnhun) 心功 臨床第十六頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端 心肌(xnj)衰竭：原發(fā)性心肌病變，如心肌炎，心肌梗塞 Myocardial failure： primary myocardial lesions ，myocarditiis 心力衰竭：不僅僅是心臟問題，如縮窄性心包炎Heart failure：not only heart problem，contractive pericarditis 充血性心衰： 慢

16、性經(jīng)過，血容量增加，出現(xiàn)水腫 Congestive heart failure：chronic，blood，edema 心肌(xnj)收縮力因各種病因減弱（原發(fā)或繼發(fā)） Expounding Myocardial contractility is impaired by various causes （primary or secondary).第十七頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端fibrinous pericarditis心肌收縮(shu su)力因各種病因減弱（原發(fā)或繼發(fā)） Expounding 第十八頁，共四十五頁。深

17、度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端 The factors influence CO Basic causesExample Contractility 收縮性（力)Myocardial abnormalitiescoronary heart diseaseload負荷OverloadValvular stenosis, valvular insufficiencySynergy 協(xié)同性 Disharmony Rhythm 節(jié)律Arrhythmia Underlying Causes of HF 心衰的基本(jbn)病因第十九頁，共四十五頁。深度

18、和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端 CAD the commonest 2/3Hypertension in 4%Toxic injury in 2%-4%Valve diseases in 4%Unknown in 20% Common Causes of HF 心衰的常見病因第二十頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端誘因(yuyn) precipitation cause （Aggravating Factors） Infections Arrhythmias (AF) Pregn

19、ancy and childbirth be heated with passion too fast to transfusion any factor that increase cordial load or injure heart precipitation is not always precipitation Attention 第二十一頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端Expounding 心輸出量絕對或相對(xingdu)降低AV瘺 貧血 甲亢 腳氣病Hyperdynamic status Increased

20、ventricular preloadATP consumption increased and production decreased high cardiac output HF（1%） low cardiac output HF notes：other classification self-study cardiac output reduce absolutely or relatively,第二十二頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端dermatophytosis barbiers = beriberipanneur

21、itis epidemica dietetic neuritis endemic neuritis腳氣(jioq)與腳氣(jioq)病香港腳 Hong Kong foot 運動員腳 athlete footburning, itching，cracking第二十三頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端糖代謝脫羧酶的輔酶(f mi)Coenzyme of decarboxylase in Sugar metabolism參與-酮酸的氧化脫羧Participate in - keto acid oxidative decarboxyla

22、tion VitB1(thiamin 硫胺素) ：第二十四頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端葡萄糖 glucose 酵解glycolysis 乳酸(r sun)Lactic acid丙酮酸 pyruvic acidTCA循環(huán)(xnhun)乙酰輔酶(f mi)A丙酮酸NADHNAD+NADHNAD+發(fā)酵 ferment呼吸鏈遞氫NADHNAD+VitB1丙酮酸脫氫酶系參與-酮酸的氧化脫羧 丙酮酸 乳酸堆積CO2, H+第二十五頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端Ber

23、iberi： comes from aSinhalesephrase Meaning： “weak, weak” or “I can not, I can not”,第二十六頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端備急千金要方考諸經(jīng)方往往有腳弱之論，而古人(grn)少有此疾。自永嘉南渡，衣纓士人，多有遭者。風毒中人，隨處皆得，作病何偏著于腳也？答曰夫人有五臟，心肺二臟，經(jīng)絡(luò)所起在手十指；肝腎與脾三臟，經(jīng)絡(luò)所起在足十趾。夫風毒之氣，皆起于地。地之寒暑風濕皆作蒸氣，足常履之，所以風毒之中人也必先中腳；久而不瘥，遍及四肢腹背頭項也；微時不覺

24、，痼滯乃知。經(jīng)云次傳、間傳是也。 東晉(DngJn)、六朝時叫腳弱孫思邈稱為風毒腳氣內(nèi)經(jīng)諸病源(bn yun)候論腳氣病治法總要 第二十七頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端Dry beriberiWaste beriberiDifficulty in walkingPeripheral edemaTingling or numbnessIncreased heart rateparalysis of the lower legsDyspnea on exertionMental confusion/speech difficul

25、tiesParoxysmal nocturnal dyspneanystagmusVasodilation leading to increased arteriovenous shuntPeripheral or center lesion Cardiovascular system infant beriberi crying, but not loudly and without tears. Maybe fatal . Types of beriberi 第二十八頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端Expounding 心

26、功下降(xijing)，靜脈淤血，動脈缺血 Causes Cardiac function impairment 代 償 Cardiac output Venous congestion引起病理性損害，出現(xiàn)臨床(ln chun)癥狀和體征Arterials ischemiavenous system congestion arterial system insufficient blood supply第二十九頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端Cardiac outputIschemia and Hypoxia heart Ra

27、te sympathetic stroke sympathetic Frank-Starling law hypertrophy- remodeling Blood redistribution neurohumoral (NE, RAAS) 心衰時機體的適應(shyng)和代償 adaption and compensationCardiac output CO =stroke/min X heart Rate第三十頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端Cardiac（ventricular） remodeling 心肌(xnj)

28、重塑（構(gòu)）心肌受損，代償與適應 出現(xiàn)結(jié)構(gòu)、代謝和功能改變(gibin) 生物學：心肌細胞，非心肌細胞、細胞外基質(zhì) 基因表達 ？幾何學：心肌肥大，心室擴大等第三十一頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端 Normal Centripetal Centrifugal Load postload preload Myofibers hyperplasia parallel tandem Ventricular Wall thickness thickening slight thickening Heart Chamber expansi

29、on no obvious obvious Myocardial hypertrophy第三十二頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端 significant myofibre disarray and interstitial fibrosis in HCM.第三十三頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端 Heart Rate 180 Scarometers 2.2 Excessive hypertrophy organ interstitium tissue cap,

30、 sympathetic density cell surface area, mitochondria molecular V3imbalance growth and increase Limitation of myocardial compensation第三十四頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端AbstractIt has been difficult to establish whether we are limited to the heart muscle cells we are born with or if

31、 cardiomyocytes are generated also later in life. We have taken advantage of the integration of 14C, generated by nuclear bomb tests during the Cold War, into DNA to establish the age of cardiomyocytes in humans. We report that cardiomyocytes renew, with a gradual decrease from1% turning over annual

32、ly at the age of 20 to 0.3% at the age of 75. Less than 50% of cardiomyocytes are exchanged during a normal lifespan. The capacity to generate cardiomyocytes in the adult human heart suggests that it may be rational to work towards the development of therapeutic strategies aiming to stimulate this p

33、rocess in cardiac pathologies. were myocardial cells post-mitotic cells?Science 324: 98, 2009.第三十五頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端Expounding 4：癥狀(zhngzhung)和體征 signs and symptomsCardiac output Arterials perfusion Venous stagnation renal FatigueCardiac shock Sudden death liver-gut l

34、ung skin Edema Dyspnea Cyanosis第三十六頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端Dyspnea 呼吸困難(h x kn nn)Respiratory become labored 呼吸費力 Respiratory frequency depth and rhythm 呼吸頻率、深度和節(jié)律(jil)的改變 第三十七頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端Dyspnea on exertion 勞力(lol)性呼吸困難Orthopnea 端坐呼吸Pa

35、roxysmal nocturnal dyspnea 夜間陣發(fā)性呼吸困難Dyspnea 呼吸困難(h x kn nn)第三十八頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端 Fatigue Activities limited Chest congestion Edema or ankle swelling Shortness of breathThe Major signs and symptoms of CHF?Think FACES. 疲乏 活動受限 胸悶 水腫或腳踝(jio hui)腫脹 氣促第三十九頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力性呼吸困難Orthopnea端“Evolution” of Our Understanding of CHF慢性(mn xng)心衰的認識演變 cardio-renal model 心腎模型 Na-water retention Hemodynamic disorder 血流動力學紊亂(wnlun) reduced cardiac output and excessive vasoconstriction Neurohormonal model 神經(jīng)體液模型第四十頁，共四十五頁。深度和節(jié)律的改變Dyspneaonexertion勞力