深度和节律的改变Dyspneaoneertion劳力性呼吸困难Orthopnea端课件

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 小型水库(shuk) 1000m3 中型水库 1000 m3 大型水库 100,000 000m3 龙泉驿水库 蓄水约 330万立方米第一页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难Orthopnea端

2、 Concept 概念(ginin) Pathogenesis 发病机制 Effect（important）and mechanisms 影响及机制 Outline大纲(dgng) 第二页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难Orthopnea端 Background 背景 Definition and explaining the definition 定义(dngy) pathogenesis 机制 Content 内容(nirng)第三页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难Orthopnea端 心为君主之官

3、，脏腑百骸，惟所是命，聪明智慧(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 第四页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难Orthopnea端Heart failure 心衰-Background Cats look down on us. Dogs look up to us. Pigs treat us as equa

4、ls第五页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难Orthopnea端Heart failure 心衰-Background 第六页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难Orthopnea端What kill us?Background第七页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难Orthopnea端 2010年中国(zhn u)心血管病报告 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第八页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难Orthopnea端 hypertension 高血压 2亿人 myocardial infarction 心肌(xnj)

6、梗 200万人 pulmonary heart disease 肺心病 500万人 rheumatic heart disease 风心病 250万人 congenital heart disease 先心病 200万人 heart failure 心衰竭 420万人2010年中国(zhn u)心血管病报告the report of cardiovascular disease in china 2010Background第九页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难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第十页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难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 %第十一页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难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 第十二页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难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第十三页，共四十五页。

12、深度和节律的改变Dyspneaonexertion劳力性呼吸困难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)渐进式发展心功不全 insufficiency第十四页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难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 分级(fn j): The New York Heart Association Functional Class (NYHA-FC)第十五页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难Orthopnea端 心肌收缩(shu su)力因各种病因减弱（原发或继发），不能将静脉回心血量等量搏出，因而使心输出量绝对或相对减少，使体循环和/或肺循环静脉系统淤血，动脉系统

15、供血不足，不能满足人体在静息状态或一般活动时代谢的的需要，从而出现一系列的心脏循环障碍的症状和体征。大循环(xnhun) 心功 临床第十六页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难Orthopnea端 心肌(xnj)衰竭：原发性心肌病变，如心肌炎，心肌梗塞 Myocardial failure： primary myocardial lesions ，myocarditiis 心力衰竭：不仅仅是心脏问题，如缩窄性心包炎Heart failure：not only heart problem，contractive pericarditis 充血性心衰： 慢

16、性经过，血容量增加，出现水肿 Congestive heart failure：chronic，blood，edema 心肌(xnj)收缩力因各种病因减弱（原发或继发） Expounding Myocardial contractility is impaired by various causes （primary or secondary).第十七页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难Orthopnea端fibrinous pericarditis心肌收缩(shu su)力因各种病因减弱（原发或继发） Expounding 第十八页，共四十五页。深

17、度和节律的改变Dyspneaonexertion劳力性呼吸困难Orthopnea端 The factors influence CO Basic causesExample Contractility 收缩性（力)Myocardial abnormalitiescoronary heart diseaseload负荷OverloadValvular stenosis, valvular insufficiencySynergy 协同性 Disharmony Rhythm 节律Arrhythmia Underlying Causes of HF 心衰的基本(jbn)病因第十九页，共四十五页。深度

18、和节律的改变Dyspneaonexertion劳力性呼吸困难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 心衰的常见病因第二十页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难Orthopnea端诱因(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 第二十一页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难Orthopnea端Expounding 心输出量绝对或相对(xingdu)降低AV瘘 贫血 甲亢 脚气病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,第二十二页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难Orthopnea端dermatophytosis barbiers = beriberipanneur

21、itis epidemica dietetic neuritis endemic neuritis脚气(jioq)与脚气(jioq)病香港脚 Hong Kong foot 运动员脚 athlete footburning, itching，cracking第二十三页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难Orthopnea端糖代谢脱羧酶的辅酶(f mi)Coenzyme of decarboxylase in Sugar metabolism参与-酮酸的氧化脱羧Participate in - keto acid oxidative decarboxyla

22、tion VitB1(thiamin 硫胺素) ：第二十四页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难Orthopnea端葡萄糖 glucose 酵解glycolysis 乳酸(r sun)Lactic acid丙酮酸 pyruvic acidTCA循环(xnhun)乙酰辅酶(f mi)A丙酮酸NADHNAD+NADHNAD+发酵 ferment呼吸链递氢NADHNAD+VitB1丙酮酸脱氢酶系参与-酮酸的氧化脱羧 丙酮酸 乳酸堆积CO2, H+第二十五页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难Orthopnea端Ber

23、iberi： comes from aSinhalesephrase Meaning： “weak, weak” or “I can not, I can not”,第二十六页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难Orthopnea端备急千金要方考诸经方往往有脚弱之论，而古人(grn)少有此疾。自永嘉南渡，衣缨士人，多有遭者。风毒中人，随处皆得，作病何偏着于脚也？答曰夫人有五脏，心肺二脏，经络所起在手十指；肝肾与脾三脏，经络所起在足十趾。夫风毒之气，皆起于地。地之寒暑风湿皆作蒸气，足常履之，所以风毒之中人也必先中脚；久而不瘥，遍及四肢腹背头项也；微时不觉

24、，痼滞乃知。经云次传、间传是也。 东晋(DngJn)、六朝时叫脚弱孙思邈称为风毒脚气内经诸病源(bn yun)候论脚气病治法总要 第二十七页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难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 第二十八页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难Orthopnea端Expounding 心

26、功下降(xijing)，静脉淤血，动脉缺血 Causes Cardiac function impairment 代 偿 Cardiac output Venous congestion引起病理性损害，出现临床(ln chun)症状和体征Arterials ischemiavenous system congestion arterial system insufficient blood supply第二十九页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难Orthopnea端Cardiac outputIschemia and Hypoxia heart Ra

27、te sympathetic stroke sympathetic Frank-Starling law hypertrophy- remodeling Blood redistribution neurohumoral (NE, RAAS) 心衰时机体的适应(shyng)和代偿 adaption and compensationCardiac output CO =stroke/min X heart Rate第三十页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难Orthopnea端Cardiac（ventricular） remodeling 心肌(xnj)

28、重塑（构）心肌受损，代偿与适应 出现结构、代谢和功能改变(gibin) 生物学：心肌细胞，非心肌细胞、细胞外基质 基因表达 ？几何学：心肌肥大，心室扩大等第三十一页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难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第三十二页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难Orthopnea端 significant myofibre disarray and interstitial fibrosis in HCM.第三十三页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难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第三十四页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难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.第三十五页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难Orthopnea端Expounding 4：症状(zhngzhung)和体征 signs and symptomsCardiac output Arterials perfusion Venous stagnation renal FatigueCardiac shock Sudden death liver-gut l

34、ung skin Edema Dyspnea Cyanosis第三十六页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难Orthopnea端Dyspnea 呼吸困难(h x kn nn)Respiratory become labored 呼吸费力 Respiratory frequency depth and rhythm 呼吸频率、深度和节律(jil)的改变 第三十七页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难Orthopnea端Dyspnea on exertion 劳力(lol)性呼吸困难Orthopnea 端坐呼吸Pa

35、roxysmal nocturnal dyspnea 夜间阵发性呼吸困难Dyspnea 呼吸困难(h x kn nn)第三十八页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难Orthopnea端 Fatigue Activities limited Chest congestion Edema or ankle swelling Shortness of breathThe Major signs and symptoms of CHF?Think FACES. 疲乏 活动受限 胸闷 水肿或脚踝(jio hui)肿胀 气促第三十九页，共四十五页。深度和节律的改变Dyspneaonexertion劳力性呼吸困难Orthopnea端“Evolution” of Our Understanding of CHF慢性(mn xng)心衰的认识演变 cardio-renal model 心肾模型 Na-water retention Hemodynamic disorder 血流动力学紊乱(wnlun) reduced cardiac output and excessive vasoconstriction Neurohormonal model 神经体液模型第四十页，共四十五页。深度和节律的改变Dyspneaonexertion劳力