HF心衰英文课件

1、HF心衰英文课件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.中国心力衰竭流行病学推算我国目前成年人中约400万心衰患者随着年龄增加，心力衰竭患病率显著上升城市农村，北方南方，与我国冠心病和高血压的地区分布一致冠心病和高血压是心力衰竭的主要病因1. 中华心血管病杂志 2007; 35(12): 1076-95. 2. 顾东风等. 中华心血管病杂志 2003; 31(1): 3-6.心力衰竭预后过去40年，心衰导致的死亡增加6倍（AHA 2005）2007年中国心衰诊疗指南指出，有临床症状的患者5年生存率与恶性肿瘤相仿25% 新发心力

3、衰竭患者在1年内死亡 (ESC 1999）心力衰竭反复入院治疗很常见，超过50% 患者半年内即再入院治疗 (Krumholz et al. 1997, Vinson et al. 1990, Burns et al. 1997)狄兰.托马斯蒋介石伊丽莎白.泰勒聂荣臻叶利钦詹姆斯.门罗詹姆斯.布朗”Two new epidemics of cardiovasculardisease are emerging: heart failure andatrial fibrillation.” Eugene BraunwaldNEJMNow 1997心力衰竭心脏疾病的最后战场 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)治疗 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 心脏功能的生理基础心排血量心肌收缩力前负荷（舒张期容量）后负荷（射血阻抗）心率房室收缩协调性心脏机械结构完整性原发性心肌损害：缺血性心肌损害 心肌炎或心肌病 心肌代谢障碍 （糖尿病性心肌病等）高血压、瓣膜狭窄（半月瓣）心脏瓣膜关闭不全、血液返流 左、右心分流或动静脉分流全身血容量增加，如贫血、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收缩性 vs 舒张性急性心梗后的心室重建开始心梗心梗持续（几小时至几天）全面重建（几天至几月）在舒张性和收缩性心力衰竭中的心室重建正常的心脏心脏肥厚（舒张性心衰）心脏扩大（收缩性心衰）高血压和心梗后的心室重构浓度水平血浆去甲肾上腺素(pg/mL)NLHF血浆肾素激活(ng/mL/h)15129630NLHF精氨酸血管加压素(pg/mL)126420NLHF心房钠尿肽(pg/mL)300250200150100500NLHF内皮素-1(pg/mL)86420NLHF6005004003002001000Adapted from Co

11、hn JN. Cardiology. 1997;88:26.neurohumoral activation累计死亡率(%)月NE 900pg/ml 10080604020001224364860总 体P50% b. function of relaxation: E / A1.2 Diagnosis and differential diagnosis2. Differential diagnosis: Bronchial asthma : young allergichistory typical wheezing (哮鸣音) 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 调整生活方式1限钠：轻度心衰患者23g/d，中到重度心衰患者2

16、 g/d。2限水：低钠血症，血钠130mg/L，液体摄入量2L/d。3营养和饮食：低脂饮食，戒烟，肥胖患者应减轻体重；心脏恶液质者，给予营养支持，如血清白蛋白。4休息和适度运动 心理和精神治疗压抑、焦虑和孤独在心衰恶化中发挥重要作用主要的死亡预后因素；情感干预；心理疏导；酌情应用抗抑郁药物。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利尿剂临床应用起始和维持：小剂量开始，如呋噻米每日20mg，氢氯噻嗪每日25mg逐渐增量直至尿量增加，体重每日减轻0.5-

18、1.0Kg。一旦病情控制(如肺部罗音消失，水肿消退，体重稳定)，以最小有效剂量长期维持。维持期间，据液体潴留情况随时调整剂量。利尿剂抵抗心衰进展和恶化时常需加大利尿剂剂量，最终再大剂量亦无反应时，即出现利尿剂抵抗。解决方案：静脉应用利尿剂如呋噻米持续静脉滴注(1040mg/h)；2种或2种以上利尿剂联合使用；应用增加肾血流的药物，如短期应用小剂量的多巴胺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)血管紧张素转换酶抑制剂(ACEI)降低心衰患者死亡率，是治疗心衰的首选药物。 越严重的心衰患者受益越大。 显著降低死亡率、因心衰住院和再梗死率。ACEI应用方法 采用

21、目标剂量或患者能耐受的最大剂量。 极小剂量开始，每隔周剂量加倍，最大耐受量可长期维持。 监测血压、血钾和肾功能。如果肌酐增高225 mol/l k+5.5mmol/l hypotensionACEI不良反应低血压。肾功能恶化。高血钾。咳嗽：干咳。血管性水肿。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 地高辛应用要点适用于已应用ACEI/ARB、受体阻滞剂和利尿剂治疗,而仍持续有症状的心衰患者。适用于伴快速心室率的房颤患者。NYHA级患者和疾病早期不主张应用。维持量疗法，0.25mg/d。70岁以上，肾功能减退者宜用0.125mg每日或隔日一次。地高辛血清浓度与疗效无关，不需用于监测剂量。地高辛不良反应主要见于大剂量时，包括：心律失常。胃肠道症状。神经精神症状。常出现于血清地高辛药物浓度2.0ng/m

23、l时，也可见于地高辛水平较低时。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受体阻滞剂应用要点无限期终身使用受体阻滞剂（禁忌证或不能耐受除外）：慢性收缩性心衰，NYHA、级病情稳定患者，以及阶段B、无症状性心衰或NYHA级的患者(LVEF40%) 。严密监护下应用：NYHA 级心衰患者。在ACEI和利尿剂基础上加用受体阻滞剂。最适剂量

25、下使用。受体阻滞剂应用要点清晨静息心率不宜低于55次/分。需监测低血压、液体潴留和心衰恶化、心动过缓、房室阻滞及无力等不良反应。从极小剂量开始，每24周剂量加倍。症状改善常在治疗23个月后才出现，即使症状不改善，亦能防止疾病的进展；不良反应一般不妨碍长期用药。 受体阻滞剂禁忌证1)支气管痉挛性疾病、心动过缓(心率60次/分)、度及以上房室阻滞(除非已安装起搏器) 。2)心衰患者伴液体潴留，利尿后再开始应用。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 + + +/- + + + + + + + + + + + 心力衰竭的药物治疗 改善血流动力学 纠正神经内分泌异常强心药利尿剂扩血管药转换酶抑制剂受体阻滞剂醛固酮抑制剂心力衰竭治疗药物 延长寿命 中性（改善症状） 缩短寿命转换酶抑制剂受体阻滞剂醛固酮抑制剂洋地黄肾上腺素能受体兴奋剂磷酸二酯酶抑制剂利尿剂 Acute cardiac insufficiency Underlying and precipitating causes 1. tight mitral stenosis ,especially in presence of