内科学教学课件：心功能不全

1、Heart Failure Definition of Heart Failure HF is a complex clinical syndrome, in which patients have typical symptoms (e.g. breathlessness呼吸急促呼吸急促, ankle swlling and fatigue疲劳疲劳) and signs (e.g. elevated jugular venous pressure, pulmonary crackles) resulting from an abnormality of cardiac structure o

2、r function. General Considerations Systolic function of the heart is governed by four major determinants: Contractile state of the myocardium Preload of the ventricle Afterload applied to the ventricles Heart rate Underlining Causes of Heart failure -from a clinical viewpoint (1) Underlying causes,

3、comprising the structural abnormalitiescongenital or acquiredthat affect the peripheral and coronary vessels, myocardium, or cardiac valves and lead to the increased hemodynamic burden, increased myocardial stress, or coronary insufficiency responsible for heart failure. Underlining Causes of Heart

4、failure -from a clinical viewpoint (1) Underlying causes: Systemic hypertension Coronary artery disease Cardiomyopathy Valvular heart disease Diabetes Beriberi Underlining Causes of Heart failure -from a clinical viewpoint (2) Precipitating causes, including the specific caused or incidents that pre

5、cipitate worsening heart failure in 50 to 90 percent of episodes of clinical heart failure. Precipitating Causes of Heart failure Infection, especially pulmonary infections. Arrhythmias, most commonly atrial fibrillation, marked bradycardia. Myocardial ischemia or infarction Pulmonary embolism Preci

6、pitating Causes of Heart failure Physical and emotional stress Inappropriate reduction of therapy Administration of myocardial depressant or salt-retaining drugs Clinical Classification 1Acute Versus Chronic Heart Failure 2Right-Sided Versus Left-Sided Failure 3Systolic Versus Diastolic Heart Failur

7、e Chronic Heart Failure Causes of HF in Western World For a substantial proportion of patients, causes are: 1. Coronary artery disease 2. Hypertension 3. Dilated cardiomyopathy Clinical Manifestations Left-sided heart failure New York Heart Association Functional Classification Class I Patients with

8、 cardiac disease but without resulting limitations of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain. New York Heart Association Functional Classification Class II Patients with cardiac disease resulting in slight limitation of physi

9、cal activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain. New York Heart Association Functional Classification Class III Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at

10、rest. Less than ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain. New York Heart Association Functional Classification Class IV Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of cardiac insuffici

11、ency of of the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased. Stages of Heart Failure At Risk for Heart Failure: STAGE A High risk for developing HF STAGE B Asymptomatic LV dysfunction Heart Failure: STAGE C Past or current symptoms of

12、HF STAGE D End-stage HF Stages of Heart Failure COMPLEMENT, DO NOT REPLACE NYHA CLASSES NYHA Classes - shift back/forth in individual patient (in response to Rx and/or progression of disease) Stages - progress in one direction due to cardiac remodeling Respiratory Distress NYHA Classes, as discussed

13、 above. Orthopnea, develops in the recumbent position and is relieved by elevation of the head with pillows. Respiratory Distress Paroxysmal nocturnal dyspnea： dyspnea usually occurs at night. The patient awakens, often quite suddenly and with a feeling of severe anxiety and suffocation, sits bolt u

14、pright, and gasps for breathe. Other Symptoms Cough may be caused by pulmonary congestion. Fatigue and weakness Urinary symptoms includes nocturia and oliguria. Physical Findings with left-sided heart failure Pulmonary rales. Moist rales heard over the lung bases are characteristic of left ventricul

15、ar failure. Gallop sounds. Physical Findings with left-sided heart failure Pulsus alternans. This sign is characterized by a regular rhythm with alternating strong and weak beats. Right-sided heart failure Symptoms of predominant right-sided heart failure Breathlessness is not as prominent in isolat

16、ed right ventricular failure because pulmonary congestion is usually absent. Congestive hepatomegaly may produce discomfort in the right upper quadrant. Symptoms of predominant right-sided heart failure Other gastrointestinal symptoms, including anorexia（食欲减退）（食欲减退）, nausea, bloating（饱胀）（饱胀）, a sens

17、e of fullness after meals, and constipation（便秘）（便秘）, are due to congestion of the liver and gastrointestinal tract. Physical Findings with right-sided heart failure Hepatojugular reflux. A positive test is expansion of jugular veins while the right upper quadrant is compressed. Physical Findings wit

18、h right-sided heart failure Congestive hepatomegaly. Edema. Pleural effusion. Ascites. Laboratory findings Brain natriuretic peptide (BNP) and N- terminal pro-BNP Echocardiogram Systolic dysfunction: ejection fraction(EF) 40% Diastolic dysfunction: E/A ratio (1.2) Laboratory findings Chest x-ray Siz

19、e and shape of the cardiac silhouette Kerler lines (i.e., sharp, linear densities of interlobular interstitial edema) “Butterfly” pattern (a cloud-like appearance and concentration of the fluid around the hili) Treatment Goals of Drugs in the Treatment of Heart Failure Treatment of chronic stable HF

20、 Enhance survival Minimize symptoms and disability Improve functional capacity Delay disease progression Classes of Drugs Used to treat Heart Failure Drugs Class Diuretics “Loop” diuretics Thiazides Vasodilators Nitrovasodilators Natriuretic peptides (nesiritide) Classes of Drugs Used to treat Heart

21、 Failure Drugs Class Positive Inotropic Agents Digitalis derivatives Beta-adrenergic receptor agonists Phosphodiesterase inhibitors Classes of Drugs Used to treat Heart Failure Neurohormonal Inhibitors Angiotensin-converting enzyme inhibitors (ACEIs) Angiotensin receptor blockers (ARBs) Beta-adrener

22、gic receptor blocking compounds Class I Benefit Risk Procedure/ Treatment SHOULD be performed/ administered Class IIa Benefit Risk Additional studies with focused objectives needed IT IS REASONABLE to perform procedure/administer treatment Class IIb Benefit Risk Additional studies with broad objecti

23、ves needed; Additional registry data would be helpful Procedure/Treatment MAY BE CONSIDERED Class III Risk Benefit No additional studies needed Procedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL should is recommended is indicated is useful/effective/

24、beneficial is reasonable can be useful/effective/ beneficial is probably recommended or indicated may/might be considered may/might be reasonable usefulness/effectiveness is unknown /unclear/uncertain or not well established is not recommended is not indicated should not is not useful/effective/bene

25、ficial may be harmful Applying Classification of Recommendations and Level of Evidence Level A Multiple (3-5) population risk strata evaluated General consistency of direction and magnitude of effect Class I Recommen- dation that procedure or treatment is useful/ effective Sufficient evidence from m

26、ultiple randomized trials or meta- analyses Class IIa Recommen- dation in favor of treatment or procedure being useful/ effective Some conflicting evidence from multiple randomized trials or meta- analyses Class IIb Recommen- dations usefulness/ efficacy less well established Greater conflicting evi

27、dence from multiple randomized trials or meta- analyses Class III Recommen- dation that procedure or treatment not useful/effectiv e and may be harmful Sufficient evidence from multiple randomized trials or meta- analyses Applying Classification of Recommendations and Level of Evidence Level B Limit

28、ed (2-3) population risk strata evaluated Class I Recommen- dation that procedure or treatment is useful/effecti ve Limited evidence from single randomized trial or non- randomized studies Class IIa Recommen- dation in favor of treatment or procedure being useful/ effective Some conflicting evidence

29、 from single randomized trial or non- randomized studies Class IIb Recommen- dations usefulness/ efficacy less well established Greater conflicting evidence from single randomized trial or non- randomized studies Class III Recommen- dation that procedure or treatment not useful/effectiv e and may be

30、 harmful Limited evidence from single randomized trial or non- randomized studies Applying Classification of Recommendations and Level of Evidence Applying Classification of Recommendations and Level of Evidence Level C Very limited (1- 2) population risk strata evaluated Class I Recommen- dation th

31、at procedure or treatment is useful/ effective Only expert opinion, case studies, or standard-of- care Class IIa Recommen- dation in favor of treatment or procedure being useful/effectiv e Only diverging expert opinion, case studies, or standard-of- care Class IIb Recommen- dations usefulness/ effic

32、acy less well established Only diverging expert opinion, case studies, or standard-of- care Class III Recommend- ation that procedure or treatment not useful/effectiv e and may be harmful Only expert opinion, case studies, or standard-of- care Pharmacological treatments An An ACEIACEI is recommended

33、, in addition to beta- is recommended, in addition to beta- blocker, for all patients with blocker, for all patients with EFEF40%40% to reduce to reduce the the risk of HF hospitalization and the risk of risk of HF hospitalization and the risk of prmature death.prmature death. IA A beta-blocker is r

34、ecommended, in addtion to an ACEI (or ARB if AECI not tolerated), for all patients with an EF40% to reduce the to reduce the risk of HF risk of HF hospitalization and the risk of prmature death.hospitalization and the risk of prmature death. IA An MRA is recommended for all patients with persisting syptoms（NYHA IIIV）and anEF35%, despite treatment with an ACEI (or ARB if AECI not tolerated) and a beta-blocker, to to reduce the reduce the risk of HF hospitalization and the risk of risk of HF hospitalization and the risk of prmature death.prmature death. IA Pharmacological treatme