英文班内科学心力衰竭

HeartFailure(HF)

第1页Heartfailure(HF)

Conception:heartfailureisafinalcommonpathwayformanycardiacdisordersofdiverseetiologyandpathogenicmechanisms.Itisaclinicalsyndrome,manifestedasaresultoftheinabilityofthehearttomatchitsoutputtothemetabolicneedsofthebodyeventhoughthefillingpressureoftheheartisadequate.第2页CategoriesofHF1.left,rightandwhole2.acuteandchronic3.systolicanddiastolic第3页stageofHFPre-heartfailurePre-clincalheartfailureClinicalheartfailureRefractoryend-stageheartfailure第4页NewYorkHeartAssociationFunctionalClassificationClassⅠNolimitationofphysicalactivityNosympotomswithordinaryexertionClassⅡSlightlimitationofphysicalactivity

Ordinaryactivitycausessymptoms

ClassⅢ

Markedlimitationofphysicalactivity

Lessthanordinaryactivitycausessymptoms

Asymptomaticatrest

ClassⅣ

Inabilitytocarryoutanyphysicalactivitywithout

discomfort

Sympotomsatrest第5页StageandClassofHF心衰分期是NYHA分级旳补充，但不能替代

NYHA分级NYHA分级–

在具体病人可上下变动

(对治疗旳反映和/或疾病进程不同)分期–

随心脏重构加重只能进展

第6页6-minwalkdistance

milddegree：＞450mmoderatedegree：150-450mseveredegree：＜150mEvaluationofchronicHF

cardiacfunction

第7页Fundamentalcausesprimarymyocardialdiseaseincreasedburdenstotheheart第8页Fundamentalcauses1.primarydecreasedmyocardialcontractility

coronaryheartdiseasemyocarditis,cardiomyopathymyocardialmetabolicdisorder第9页Fundamentalcauses2.increasedburdenstotheheart①increasedafterload(pressureload):hypertensionaorticstenosispulmonarystenosispulmonaryhypertension第10页Fundamentalcauses

2.increasedburdenstotheheart②increasedpreload(volumeload):mitralincompetenceaorticincompetencetricuspidincompetenceatrialseptaldefect(ASD)ventricularseptaldefect(VSD)patentductusarteriosus(PDA)hyperthyroidismanemia

第11页第12页Precipitatingcausesinfection,especiallyrespiratoryinfectionarrhythmias,AFphysicaloremotionalexcessese.g.pregnancyanddeliveryrapidintravenousinfusion,excessivesalttakingmalpraticeprimarydiseasedeteriorationoranewdiseasehappens第13页Pathogenesisandpathophysiology1.Compensateheartfailure2.Ventricularremodeling3.Aboutdiastolicinsufficiency4.Humoralfactorschange第14页1.CompensateheartfailureFrank-Starlingprincipleneurohumoralactivationmyocardialhypertrophy第15页1.Compensateheartfailure①cardiacdilatation,bywayoftheFrank-Starlingprinciple,contractileforceincreases.第16页1正常静息2正常活动3’心衰活动3心衰静息心肌收缩性BADC左室舒张末容量图3–2–1正常和心力衰竭时对机体活动时旳代偿状况最大活动活动静息左室作功呼吸困难肺水肿E4静息致死性心肌受损第17页1.Compensateheartfailure②neurohumoralactivation

a.Increaseinsympatheticnervousactivityb.RAASactivated(renninangiotensionaldosteronesystem)第18页心力衰竭——神经体液旳代偿和失代偿交感神经激活水、钠潴留水肿肺瘀血血流动力学异常血管收缩心肌耗氧量增长心肌氧供应减少心肌细胞功能障碍和坏死心肌重塑功能恶化疾病进展血管紧张素Ⅱ儿茶酚胺毒性作用心肌细胞凋亡肾素-血管紧张素系统激活代偿失代偿心衰症状体征加重治疗目的增强心肌收缩第19页心肌细胞死亡心力衰竭心肌细胞死亡++↑心肌能量消耗↑后负荷血管收缩↓心排血量神经体液兴奋RASSASInSP3循环↑心肌能量消耗↑胞浆Ca2+cAMPInSP3

心脏↓心肌松弛性↑变力效应+－—心律失常猝死图3–2–2肾素—血管紧张素和交感—肾上腺素能系统激活时对心脏代偿功能旳影响2.RAASinHeartFailure第20页2.RAASinHeartFailure第21页1.Compensateheartfailure③myocardialhypertrophy

MyocardialcellhypertrophysystolepowerNotincreasednumberMyocardialfibreincreasednumberenergyMyocardialcompliance(顺应性）第22页2.Ventricularremodeling

第23页2.Ventricularremodeling

heartfailureistheresultofventricularremodeling.Reducethemyocardialcellsdecrease

of

the

systolic

functionIncreasedmyocardialfibrosis

decrease

of

theVentricularcompliance

HeartcavityexpansionmyocardialhypertrophyextracellularmatrixcollagenfibersMyocardialcells

Compensatedstage

Decompensatedstage第24页3.aboutdiastolicinsufficiency①Characteristic:inthesecases,fillingoftheleftorrightventricleisabnormal.②Mechanism:myocardialrelaxationisimpaired.Myocardialcompliancedecreasing.

③outcome:diastolicpressures↑----venousereturn↓---fluidretention,dyspnea,intolerance第25页4.somecytofactorstakepartinheartfailure

ANP(atrialnatriureticpeptide)BNP(brainnatriureticpeptide)AVP(argininevassopressin)Endothelin(NE,angiotensin)UrinevolumeperipheralvascularsympatheticnervousRAASVentricularremodeling第26页

Ventricularremodelingneurohumoralactivationheartfailure第27页Chronicheartfailure,CHF第28页Clinicalmanifestations1.Leftheartfailurepulmonarycongestionlesscardiacoutput2.Rightheartfailuresystemicvenouscongestion3.Wholeheartfailure第29页1.Leftheartfailure

1)dyspnea1.exertionaldyspnea2.paroxysmalnocturnaldyspnea3.orthopnea,4.acutepulmonaryedema第30页1.Leftheartfailure

2)cough,hemoptysis,spitpinksputum3)fatigue,dizziness,palpitation.4)oliguria,renaldysfunction

第31页sign

1)pulmonarybasalralesbilaterallyorright-side2)enlargedleftheartpulsusalternans,protodiastolicgallopP2increasedPulmonaryedema第32页

2.Rightheartfailuresymptomabdominaldiscomfortanorexia(厌食)nausea,vomitexertionaldyspnea第33页

2.Rightheartfailuresignliverenlargedascitesdistentionofjugularveinshepatojugularreflux(+)peripheraledema,mostmarkindependentpartscyanosisprotodiastolicgallop,functionalmurmursoftricuspidandpulmonaryvalve第34页3.WholeheartfailureLHF＋RHF第35页laboratoryexamination

BNPandNT-proBNP心室扩张心衰张力增大BNP释放第36页呼吸困难,虚弱,

运动受限等症状(NT-proBNP)

慢性心衰

转至心脏专科继续下一步诊断阳性阴性NT-proBNP临床应用流程图辅助诊断心衰辅助判断进展期心衰患者预后第37页laboratoryexamination

CnTIbloodroutineexaminationroutineurineexaminationbiochemicalexaminationFT3,FT4,TSH第38页ECG(electrocardiogram)ischemiaOMIconductionblockarrhysmia第39页X-rayPulmonarycongestionPleuraleffusionKerlryBRightpulmonaryarterybroadeningPulmonaryhilarbutterflyshape第40页EchocardiogramLVEF＞50%E/A＞1.2LVEDV/LVESVLVEDD/LVESDventricularwallmotionCardiacmagneticresonance,CMR99MTC-MIBISPECT(radionuclide)Coronaryangiography第41页CardiacCatheterizationSwan-GanzPCWP＜12mmHgCI＞2.5L/（min.m2）第42页CardiopulmonaryExerciseTesting(CPET)ChronicstableHFMeasurementofrateofoxygenuptake(VO2),rateofCO2production(VCO2),duringmaximal“symptom-limited”exercise第43页第44页DiagnosisanddifferentialdiagnosisDiagnosis:medicalhistory+symptoms+signs+examExam:ECG:rarelynormalinsystolicHF.x-ray:todetectcardiomegalyandpulmonarycongestion.(3)Echocardiogram:Itiscriticalimportance.①todeterminetheunderlyingcausesofHF②toassesstheseverityofventriculardysfunctiona.functionofcontraction:LVEF>50%b.functionofrelaxation:E/A≥1.2

第45页2.Differentialdiagnosis:cardiacasthmaBronchialasthmaHistoryHeartdiseaseallergichistoryageolderyoungtimenightspringHFsignyesnoLungsignpulmonarybasalralestypicalwheezingx-rayPulmonarycongestionLVlargeemphysemaalleviatesymptomsofdyspneaDiureticsdigitalisisosorbidedinitrateaftercoughoutsputumantispasmodic第46页2.Differentialdiagnosis:②Pericardialeffusion,Constrictivepericarditis:distentionofjugularveins,hepatojugularreflux(+)liverenlarged,ascitesperipheraledema,mostmarkindependentparts

medicalhistorysignsofheartandperivascularechocardiogram,CMR…themostsensitive…specificnoninvasivemethod第47页2.Differentialdiagnosis:③Hepatocirrhosiswithascitesandedemaoflowerextremitydistentionofjugularveins(-)hepatojugularreflux(-)第48页Treatmentofchronicheartfailure

Principle:alleviatesymptoms,improvelifequality.treatmentforprimarydiseaseandprecipitatingcausesAntagonismofneurohumoralactivationinhibitionofprogressiveventricularremodelingreducemortalityandextendlife.第49页TreatmentofchronicheartfailureGeneralPharmacologictreatmentNon-medicinetreatment第50页GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation第51页GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation1.LifestylemanagementEducationRegulateweightDietarymanagement:salttake2.Restandaction3.Treatmentforprimarydiseaseandprecipitating

第52页GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation1.Rest2.Dietarymanagement:salttake3.Diuretics

furosemidedihydrochlorothiazide(potassium-losing)antistone(potassium-sparing)第53页Themainpointofdiureticsapplication对于有症状旳心衰，当液体负荷过重已体现为肺淤血或外周水肿时，利尿剂是基本旳治疗。应用利尿剂可迅速改善呼吸困难并增长运动耐量（I类建议，证据级别A）尚无大型随机对照实验评估此类药物对症状和生存旳影响。如能耐受，利尿剂始终应与ACEI和β-受体阻滞剂一起使用。（I类建议，证据级别C）。第54页

襻利尿剂应作为首选。噻嗪类仅合用于轻度液体潴留、伴高血压和肾功能正常旳心衰患者(I类，B级)。利尿剂一般从小剂量开始(氢氯噻嗪25mg/d，呋塞米20mg/d，托塞米10mg/d),逐渐加量。一旦病情控制即以最小有效量长期维持。每日体重变化是最可靠检测利尿剂效果和调节利尿剂剂量旳指标。长期服用利尿剂应严密观测不良反映旳浮现如电解质紊乱、症状性低血压，以及肾功能不全，特别在服用剂量大和联合用药时（Ⅰ类，B级）。Themainpointofdiureticsapplication第55页GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation1.Rest2.Dietarymanagement:salttake3.Diuretics4.

Vasodilator

sodiumnitroprusside(SNP)nitroglecerinregitine(酚妥拉明))第56页ThemainpointofVasodilatorapplication直接血管扩张剂对于CHF旳治疗无特殊作用。（Ⅲ类，A级）血管扩张剂可用于不能耐受ACEI或ARBs旳患者；伴有心绞痛或高血压可考虑应用（Ⅰ类，B级）禁忌证：血容量局限性，低血压、肾功能衰竭

心脏流出道或瓣膜狭窄患者第57页GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation1.Digitalis

（1）effection:Positiveinotropic：

inhibitNa+-K+-ATPenzyme

introcellularNa+、K+Na+-Ca2+exchange

introcellularCa2+myocardialsystolepower

introcellularK+，digitalispoisoning第58页GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation1.Digitalis

（1）effection:Positiveinotropic：Electrophysiological

Inhibitcondutionsystem,espiciallyatriventricularjunction.

Improvetheautorhythmictyofatrium,junctionregionandventricle.第59页GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation1.Digitalis

（1）effection:Positiveinotropic：ElectrophysiologicalParasympatheticstimulatinganti-sympatheticnerveexciting

第60页GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation1.Digitalis

（1）effection:Positiveinotropic：ElectrophysiologicalParasympatheticstimulatingRoleintherenaltubulecellsreducingsodiumreabsorptioninhibitthesecretionofrenin

第61页GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation1.Digitalis

（2）application

indication:chroniccongestiveheartfailurecomplicatedbyatrailflutterandfibrillationandarapidventricularrate第62页GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation1.Digitalis

（2）application

contraindication:WPWwithAFⅡdegreeAVB,ⅢdegreeAVBsicksinussyndrome(SSS)Hypertrophiccardiomyopathy(HOCM)severemitralstenosis(SMS)acutemyocardiacinfarction(first24h第63页GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation1.Digitalis

(3)digitalispoisoningfactors：K+,O2,RFClincalexpression:gastricbowelreaction;arrhythmia;neurologicalandvisualchangeDiagnosis：>2.0ng/ml第64页ArrhythmiaofdigitalispoisoningVentricularPrematurebeatNonparoxysmalatrioventricularjunctionaltachycardiaAtrialPrematurebeatAtrialfibrillatonAtrioventricularblockST-TchangelikefishhookCharacteristicfeature第65页GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation1.Digitalis

Treatmentofdigitalispoisoningdrugwithdrawaltachycadia:supplyK+

,Lidocainivbradicadia：atropiniv,notsuitableforpacemakernotsuitableforisoprenalinedisablecardioerter第66页GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、Digitalis2、β-excitantDopamine：NEprecursor2g/kg.min

Dopamine

-R(+)

expandrenalartery2-5g/kg.min

β1

β2-R(+)myocardialcontractility,Vasodilate5-10g/kg.min

α-R(+)BP,HRDobutamine：Dopaminederivatives

2g/kg.min

10g/kg.min

Vasodilate,HR--smalleffects第67页GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、Digitalis2、β-excitant3、Phosphodiesteraseinhibitors

1、effect:restrainactivityofphosphodiesterase

，thedegradationofcAMP(-)

cAMPCa2+

channelactivationCa2+

-inflowmyocardialcontractility

第68页GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、Digitalis2、β-excitant3、Phosphodiesteraseinhibitors

1、effect:2、indications

：refractoryheartfailureend-stageheartfailure

beforehearttransplantation

第69页GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、Digitalis2、β-excitant3、Phosphodiesteraseinhibitors

1、effect:2、indications

：3、drugs：氨力农(Amrinone)VD5-10g/kg.min

米力农(Milrinone)VD0.5g/kg.min第70页GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、Digitalis2、β-excitant3、Phosphodiesteraseinhibitors

1、effect:2、indications

：3、drugs：4、defect

：

side-effect;mortality

第71页

AII产生是通过多种通道血管紧张素原肾素血管紧张素I(1-10)

AngII（1-8）ACEAT1AT2血管收缩增殖醛固酮增长血管扩张抗增殖Ang1-7Ang1-7受体激活血管扩张抗增殖ARB第72页GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、RAASinhibitorAngiotensinConvertingEnzymeInhibitors(ACEI)

dilatebloodvessels

inhibitRAS,sympathetic

systemreversetheventricularremodeling

improvearterystiffnessandsensitivity

Improveendothelialfunction

ATⅡ↓,Inhibitthedegradationof

bradykinin第73页GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、RAASinhibitorAngiotensinConvertingEnzymeInhibitors(ACEI)

Clinicalstatus

symptoms↓,exercisetolerance

↑

mortality↓

delaytheprogressofheartfailure

reducinghospitalizationrates

preventHFaftermyocardialinfarction

第74页GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、RAASinhibitorAngiotensinConvertingEnzymeInhibitors(ACEI)

Captopril6.25～25mg2～3/dEnalapril10mg2/dCilazapril2.5mg/dBenazepril2.5～10mg/dPerindopril2～4mg/dFosinopril5～10mg/dRamipril2.5mg/d第75页GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、RAASinhibitorAngiotensinConvertingEnzymeInhibitors(ACEI)

applicationmethods

startingwithsmalldosesiftolerated,gradually

increasethedosemonitoringofrenalfunctionandions

renalfunctionchange,highpotassium,drycough,angioedema

第76页GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、RAASinhibitorAngiotensinConvertingEnzymeInhibitors(ACEI)

Contraindication:

①anuricrenalfailure

②pregnancyandbrestfeedingwoman

③allergeRelativeContraindication:①renalarterystenosisbilaterally②Cr>225µmol/l③k+>5.5mmol/l④hypotension第77页GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、RAASinhibitorAngiotensinConvertingEnzymeInhibitors(ACEI)AngiotensinIIreceptorantagonist(ARB)ATⅡ-AT1receptor↓InhibitRASNoaffectingthedegradationof

bradykinin第78页GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、RAASinhibitorAngiotensinConvertingEnzymeInhibitors(ACEI)AngiotensinIIreceptorantagonist(ARB)applicationmethods

lessdrycoughandangioedema

whenHF,firstchoseACEIwhenHF,shouldnotbecombinedapplication

of

ACEIandARB

Losartan50mg/d;valsartan80mg/d第79页GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、RAASinhibitorAngiotensinConvertingEnzymeInhibitors(ACEI)AngiotensinIIreceptorantagonist(ARB)Aldosterone

antagonists

spironolactone(SPI)potassium-sparingdiureticreversetheventricularremodeling

improveprognosis第80页GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、RAASinhibitorAngiotensinConvertingEnzymeInhibitors(ACEI)AngiotensinIIreceptorantagonist(ARB)Aldosterone

antagonists

renininhibitorACEI/ARB

increasing

plasma

renin

activityrenin

inhibitior

has

the

effect

of

cardiorenal

protectionnotACEI/ARBreplacementtherapy第81页GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

RAASinhibitor

-blockersympatheticactivation↑b1receptorsb2receptorsa1receptorsmetoprololbisoprolol↓arrythmiadilatebloodvessels;↓themyocardialO2Cardiactoxicity

carvedilol第82页GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

RAASinhibitor

-blockerInhibitionofsympatheticactivation

improveprognosis1-

blockermetoprolol,bisoprolol

12α-

blokercarvedilolapplicationmethods

startingwithsmalldosesiftolerated,gradually

increasethedosemonitoringofBp,HR,ECG第83页GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

RAASinhibitor

-blocker

Contraindication:

bronchospasm

severebradycardia

≥Ⅱ。atrioventricularblock

severeperipheralvasculardisease

acuteheartfailure

第84页TreatmentofchronicheartfailureTherecentadvancesaboutthetreatmentofHF

MicturitionrestrainthesympatheticnervoussystemdilatebloodvesselsrhBNPlevosimendanIncreasetheCa2+sensitivity→myocardialcontractilityMediateATP-K+channel→dilatebloodvesselsivabradineInhibiteSANIfcurrenttolvaptanCombineV2receptor→H2O2reabsoption↓第85页TreatmentofchronicheartfailureNon-medicinetreatment第86页CardiacResynchronizationTherapy(CRT)第87页LeftVentricularAssistDevice（LAVD）TransitedtreatmentforhearttransplantationAdjuvanttherapyforacuteHF第88页TreatmentofchronicheartfailureNon-medicinetreatmenthearttransplantationcellreplacementtherapy--SCT(stemcelltransplantation)第89页

Acuteheartfailure,AHF第90页CategoriesofAHF1.Acuteleftheartfailure2.Acuterightheartfailure3.non-cardiacacuteheartfailure第91页CategoriesofAHFAcuteleftheartfailuredecreasedmyocar