心力衰竭-知識(shí)

心力衰竭--知識(shí)第1頁(yè)/共40頁(yè)HeartFailure

(心力衰竭)DepartmentofPathophysiology

臨床醫(yī)學(xué)（本）、醫(yī)學(xué)檢驗(yàn)（本）、醫(yī)學(xué)影像學(xué)（本）適用第2頁(yè)/共40頁(yè)Clinton第3頁(yè)/共40頁(yè)第4頁(yè)/共40頁(yè)Concept(概念)Heartfailure(pumpfailure)maybedefinedastheconditioninwhichtheheartisnolongerabletopumpanadequatesupplyofbloodforthemetabolicneedsofthebody,providedthereisadequateveneousblood.第5頁(yè)/共40頁(yè)Concept(概念)Myocardialfailure(心肌衰竭)referstotheheartfailurewhichiscausedbyadefectinmyocardiumitself.Congestiveheartfailure(充血性心衰)hasachroniccoursewithanabnormalaccumulationoffluid,whichresultsintheexpansionofintravascularbloodvolumeCardiacinsufficiency(心功能不全)

第6頁(yè)/共40頁(yè)CausesofHeartFailure(心衰的病因)Dysfunctionofmyocardium(心肌結(jié)構(gòu)破壞)

diffusemyocardialdamage:myocardialinfarction;cardiopathies;myocarditi;myocardialischemiaandhypoxia:

coronaryheartdisease;severeanemia;hypotension;shock;myocardialhypertrophy;vitaminB1deficiency

第7頁(yè)/共40頁(yè)CausesofHeartfailure(心衰的病因)Overloadformyocardium(心臟負(fù)荷過(guò)重)

Pressureoverload(afterload):systemichypertension;pulmonaryhypertension;aorticstenosis;pulmonarystenosis;Volumeoverload(preload):mitralandaorticregurgitationforleftventricles;tricuspidandpulmonaryregurgitationforrightventricles第8頁(yè)/共40頁(yè)Causesofheartfailure(心衰的病因)Conditionsthatrestrictventricularfilling(心室充盈受限)

mitralstenosis,constrictivepericarditis,restrictivecardiomyopathy

第9頁(yè)/共40頁(yè)P(yáng)recipitatingfactors(誘因)Infectionarrhythmiaspulmonaryembolismpregnancywater,eletrolytesdisturbancesacid-basedisturbancesemotion第10頁(yè)/共40頁(yè)InfectionfevertachycardiahypoxiatoxinemiaIncreaseddemands第11頁(yè)/共40頁(yè)Arrhythmias(心律失常)Reducethetimeperiodavailableforventricularfillingandcoronaryperfusionincreasethedemandformyocardialoxygenthedissociationbetweenatrialandventricularcontractions第12頁(yè)/共40頁(yè)Acidosisandheartfailure(酸中毒和心力衰竭)CompetewithCa2+forcombinationoftroponinInfluencetheCa2+triggermechanism-reducethesensitivityofthesarcoplasmicreticulumtothelocalconcentrationsofCa2+;resultinareducedreleaseofCa2+fromtheSR第13頁(yè)/共40頁(yè)Compensatorymechanisminheartfailure(心衰的代償機(jī)制)1.TheFrank-starlingmechanism(tonogenicdilatation)2.Increasedreleaseofcatecholamines3.Myocardialhypertrophy4.Increaseofbloodvolumeandredistributionofbloodflow

第14頁(yè)/共40頁(yè)1.TheFrank-starlingmechanismSarcomerelength(micron)Tension2.2Relationshipbetweenmyofilamentlengthandtensiondevelopmentincardiacmuscle

3.65第15頁(yè)/共40頁(yè)2.Increasedreleaseofcatecholamines(兒茶酚胺釋放增加)Augmentmyocardialcontractility(thepositiveinotropiceffect)increaseheartrate(thepositivechrotropiceffect)elevatetheperipheralvascularresistancepressurereceptor,volumereceptor,chemicalreceptor

第16頁(yè)/共40頁(yè)3.Myocardialhypertrophy(心肌肥大)VolumeoverloadeccentrichypertrophyPressureoverloadconcentrichypertrophy第17頁(yè)/共40頁(yè)Myocardialhypertyophy

heartfailureIncreasedformationofamyosinisozyme,V3uptakeandreleaseofCa2+bySRmaybeimparieddiminishedactivityofsympatheticnervoussystemproliferationofmitochondriaandcapillariesmyofilamentproliferationincreasedcollageninhypertrophicmyocardiumcanleadtoareducedventricularcomplianceandinterferewiththefillingofventricles?第18頁(yè)/共40頁(yè)4.increaseofbloodvolumeandredistributionofbloodflow(血容量增加和血流重分布)WaterandsodiumretensionRedistributionofbloodflow第19頁(yè)/共40頁(yè)Classificationofheartfailure(心力衰竭的分類)Right-sidedversusleft-sidedheartfailureacuteversuschronicheartfailurehigh-outputversuslow-outputheartfailurehighout-putheartfailure:hyperthyrodism,anemia,arterioveneousfistulasandberiberi(anyotherfactorsthatdecreasethetotalresistancechronicallywillalsoincreasethecardiacoutput)第20頁(yè)/共40頁(yè)beriberiLackofthisvitamincausesdiminishedabilityofthetissuestoutilizecellularneutrients,whichinturncausesmarkedperipheralvasodilation.Thetotalperipheralresistancedecreasessometimestoaslittleasone-halfnormal.consequently,thelongtimelevelofcardiacoutputalsoincreasestoasmuchas2timesnormal.第21頁(yè)/共40頁(yè)P(yáng)athogenesisofheartfailure(心力衰竭的發(fā)生機(jī)制)SarcomereThickfilamentThinfilamentMyosinActinTropomyosinTroponinBasicstructureofsarcomere第22頁(yè)/共40頁(yè)TnCTnITnTMyosinTroponinActinTropomyosinMyocardialfilamentsliding第23頁(yè)/共40頁(yè)P(yáng)athogenesisofheartfailure(心力衰竭的發(fā)生機(jī)制)Depressedmyocardialcontractilityaltereddiastolicpropertiesofventriclesasymmetryandasynchronisminventricularcontractionandrelaxation第24頁(yè)/共40頁(yè)1.Depressedmyocardialcontractility(心肌收縮功能降低)MyocardialcellularinjuriesMyocardialmetabolicdysfunctionDysfunctionofexcitation-contractioncouplingAlterationsoftheadrenergicnervoussysteminthefailingmyocardium第25頁(yè)/共40頁(yè)TherelationshipbetweenventriculardysfunctionandprognosisMyocardialinfartedsizeCardiacindexMortality5-10%Normal2%10-20%Slightlydecreased10%20-40%Decreased22%>40%Markedlydecreased60%第26頁(yè)/共40頁(yè)Energyliberation(ischemia)

energystorageenergyutilization(hypertrophy)第27頁(yè)/共40頁(yè)Myocardialmetabolicdysfunction(心肌代謝障礙)Disordersinliberationofenergy

ischemicheartdisease;shock;severeanemia;hypoxiaDisordersinutilizationofenergy

myocardialhypertrophy第28頁(yè)/共40頁(yè)Dysfunctionofexcitation-contractioncoupling(興奮和收縮偶聯(lián)障礙)ReduceduptakeandreleaseofCa2+bysarcoplasmicreticulum(SR)MitochondriaCa2+isgreatlyincreasedExtracellularCa2+inwardmovementDiturbedcombinationwithtroponin第29頁(yè)/共40頁(yè)Alterationsoftheadrenergicnervoussysteminthefailingmyocadium(交感神經(jīng)系統(tǒng)變化)NorepinephrinedepletionDowmregulationofbelta1-receptorsUncouplingofbelta2-receptors

Receptor-operatedchannels第30頁(yè)/共40頁(yè)2.Altereddiastolicpropertiesofventricles(舒張功能改變)Dysfunctionofventricularrelaxation--increasedcytosolCa2+concentration;lowlevelsofATPReducedventricularcompliance--Myocardialhypertrophy;inflammation;edema;fiberosis第31頁(yè)/共40頁(yè)3.Asymmetryandasynchronisminventricularcontractionandrelaxation(心肌收縮舒張不協(xié)調(diào))Hypokinesisorakinesisdyskinesisasynchronism第32頁(yè)/共40頁(yè)Functionalandmetabolicalterationsinheartfailure(功能代謝變化)1.Alterationsincardiacfunction2.Bloodpressurechange3.Respiratorydistress第33頁(yè)/共40頁(yè)Alterationsincardiacfunction1.Decreasedcardiacoutputandcardiacindex(CI)2.Decreasedejectionfraction(EF):strokevolume/enddiastolicvolume3.Increasedintracardiacpressure:LVEDP-PCWP;RVEDP-CVP4.Alterationsinmyocardialcontractilityanditsdiastolicproperties:Vmaxanddp/dtmax5.Bloodpressurechange

第34頁(yè)/共40頁(yè)Respiratorydistress(呼吸困難)Dyspnea-exertionaldyspneaOrthopnea-reducedpoolingoffluidintheextremitiesandabdomen;elevationofdiaphragmParoxysmalnocturnaldyspnea-reducedadrenergicdrivetotheleftventricleduringsleep;elevationofthracicbloodvolumeduringrecunbency;normalnocturnaldepressionoftherespiratorycenter;elevationofdiaphragm第35頁(yè)/共40頁(yè)病例

患者，女，36歲。主訴心慌，氣悶，浮腫，腹脹三月余?；颊哂酗L(fēng)濕性心臟病十年病史。近三月來(lái)又出現(xiàn)心慌氣悶加重，不能平臥而住院治療。檢查：重病容，半臥位，頸