英文班内科学心力衰竭

HeartFailure(HF)

2020/12/181Heartfailure(HF)

Conception:heartfailureisafinalcommonpathwayformanycardiacdisordersofdiverseetiologyandpathogenicmechanisms.Itisaclinicalsyndrome,manifestedasaresultoftheinabilityofthehearttomatchitsoutputtothemetabolicneedsofthebodyeventhoughthefillingpressureoftheheartisadequate.2020/12/182CategoriesofHF1.left,rightandwhole2.acuteandchronic3.systolicanddiastolic2020/12/183stageofHFPre-heartfailurePre-clincalheartfailureClinicalheartfailureRefractoryend-stageheartfailure2020/12/184NewYorkHeartAssociationFunctionalClassificationClassⅠNolimitationofphysicalactivityNosympotomswithordinaryexertionClassⅡSlightlimitationofphysicalactivity

Ordinaryactivitycausessymptoms

ClassⅢ

Markedlimitationofphysicalactivity

Lessthanordinaryactivitycausessymptoms

Asymptomaticatrest

ClassⅣ

Inabilitytocarryoutanyphysicalactivitywithout

discomfort

Sympotomsatrest2020/12/185StageandClassofHF心衰分期是NYHA分级的补充，但不能替代

NYHA分级NYHA分级–

在具体病人可上下变动

(对治疗的反应和/或疾病进程不同)分期–

随心脏重构加重只能进展

2020/12/1866-minwalkdistance

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

2020/12/187Fundamentalcausesprimarymyocardialdiseaseincreasedburdenstotheheart2020/12/188Fundamentalcauses1.primarydecreasedmyocardialcontractility

coronaryheartdiseasemyocarditis,cardiomyopathymyocardialmetabolicdisorder2020/12/189Fundamentalcauses2.increasedburdenstotheheart①increasedafterload(pressureload):hypertensionaorticstenosispulmonarystenosispulmonaryhypertension2020/12/1810Fundamentalcauses

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

2020/12/18112020/12/1812Precipitatingcausesinfection,especiallyrespiratoryinfectionarrhythmias,AFphysicaloremotionalexcessese.g.pregnancyanddeliveryrapidintravenousinfusion,excessivesalttakingmalpraticeprimarydiseasedeteriorationoranewdiseasehappens2020/12/1813Pathogenesisandpathophysiology1.Compensateheartfailure2.Ventricularremodeling3.Aboutdiastolicinsufficiency4.Humoralfactorschange2020/12/18141.CompensateheartfailureFrank-Starlingprincipleneurohumoralactivationmyocardialhypertrophy2020/12/18151.Compensateheartfailure①cardiacdilatation,bywayoftheFrank-Starlingprinciple,contractileforceincreases.2020/12/18161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的代偿情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2020/12/18171.Compensateheartfailure②neurohumoralactivationa.Increaseinsympatheticnervousactivityb.RAASactivated(renninangiotensionaldosteronesystem)2020/12/1818心力衰竭——神经体液的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加心肌氧供应降低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标增强心肌收缩2020/12/1819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的影响2.RAASinHeartFailure2020/12/18202.RAASinHeartFailure2020/12/18211.Compensateheartfailure③myocardialhypertrophy

MyocardialcellhypertrophysystolepowerNotincreasednumberMyocardialfibreincreasednumberenergyMyocardialcompliance(顺应性）2020/12/18222.Ventricularremodeling

2020/12/18232.Ventricularremodeling

heartfailureistheresultofventricularremodeling.Reducethemyocardialcellsdecrease

of

the

systolic

functionIncreasedmyocardialfibrosis

decrease

of

theVentricularcomplianceHeartcavityexpansionmyocardialhypertrophyextracellularmatrixcollagenfibersMyocardialcells

Compensatedstage

Decompensatedstage2020/12/18243.aboutdiastolicinsufficiency①Characteristic:inthesecases,fillingoftheleftorrightventricleisabnormal.②Mechanism:myocardialrelaxationisimpaired.Myocardialcompliancedecreasing.

③outcome:diastolicpressures↑----venousereturn↓---fluidretention,dyspnea,intolerance2020/12/18254.somecytofactorstakepartinheartfailure

ANP(atrialnatriureticpeptide)BNP(brainnatriureticpeptide)AVP(argininevassopressin)Endothelin(NE,angiotensin)UrinevolumeperipheralvascularsympatheticnervousRAASVentricularremodeling2020/12/1826

Ventricularremodelingneurohumoralactivationheartfailure2020/12/1827Chronicheartfailure,CHF2020/12/1828Clinicalmanifestations1.Leftheartfailurepulmonarycongestionlesscardiacoutput2.Rightheartfailuresystemicvenouscongestion3.Wholeheartfailure2020/12/18291.Leftheartfailure

1)dyspnea1.exertionaldyspnea2.paroxysmalnocturnaldyspnea3.orthopnea,4.acutepulmonaryedema2020/12/18301.Leftheartfailure

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

2020/12/1831sign

1)pulmonarybasalralesbilaterallyorright-side2)enlargedleftheartpulsusalternans,protodiastolicgallopP2increasedPulmonaryedema2020/12/1832

2.Rightheartfailuresymptomabdominaldiscomfortanorexia(厌食)nausea,vomitexertionaldyspnea2020/12/1833

2.Rightheartfailuresignliverenlargedascitesdistentionofjugularveinshepatojugularreflux(+)peripheraledema,mostmarkindependentpartscyanosisprotodiastolicgallop,functionalmurmursoftricuspidandpulmonaryvalve2020/12/18343.WholeheartfailureLHF＋RHF2020/12/1835laboratoryexamination

BNPandNT-proBNP心室扩张心衰张力增大BNP释放2020/12/1836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2020/12/1837laboratoryexamination

CnTIbloodroutineexaminationroutineurineexaminationbiochemicalexaminationFT3,FT4,TSH2020/12/1838ECG(electrocardiogram)ischemiaOMIconductionblockarrhysmia2020/12/1839X-rayPulmonarycongestionPleuraleffusionKerlryBRightpulmonaryarterybroadeningPulmonaryhilarbutterflyshape2020/12/1840EchocardiogramLVEF＞50%E/A＞1.2LVEDV/LVESVLVEDD/LVESDventricularwallmotionCardiacmagneticresonance,CMR99MTC-MIBISPECT(radionuclide)Coronaryangiography2020/12/1841CardiacCatheterizationSwan-GanzPCWP＜12mmHgCI＞2.5L/（min.m2）2020/12/1842CardiopulmonaryExerciseTesting(CPET)ChronicstableHFMeasurementofrateofoxygenuptake(VO2),rateofCO2production(VCO2),duringmaximal“symptom-limited”exercise2020/12/18432020/12/1844DiagnosisanddifferentialdiagnosisDiagnosis:medicalhistory+symptoms+signs+examExam:ECG:rarelynormalinsystolicHF.x-ray:todetectcardiomegalyandpulmonarycongestion.(3)Echocardiogram:Itiscriticalimportance.①todeterminetheunderlyingcausesofHF②toassesstheseverityofventriculardysfunctiona.functionofcontraction:LVEF>50%b.functionofrelaxation:E/A≥1.2

2020/12/18452.Differentialdiagnosis:cardiacasthmaBronchialasthmaHistoryHeartdiseaseallergichistoryageolderyoungtimenightspringHFsignyesnoLungsignpulmonarybasalralestypicalwheezingx-rayPulmonarycongestionLVlargeemphysemaalleviatesymptomsofdyspneaDiureticsdigitalisisosorbidedinitrateaftercoughoutsputumantispasmodic2020/12/18462.Differentialdiagnosis:②Pericardialeffusion,Constrictivepericarditis:distentionofjugularveins,hepatojugularreflux(+)liverenlarged,ascitesperipheraledema,mostmarkindependentparts

medicalhistorysignsofheartandperivascularechocardiogram,CMR…themostsensitive…specificnoninvasivemethod2020/12/18472.Differentialdiagnosis:③Hepatocirrhosiswithascitesandedemaoflowerextremitydistentionofjugularveins(-)hepatojugularreflux(-)2020/12/1848Treatmentofchronicheartfailure

Principle:alleviatesymptoms,improvelifequality.treatmentforprimarydiseaseandprecipitatingcausesAntagonismofneurohumoralactivationinhibitionofprogressiveventricularremodelingreducemortalityandextendlife.2020/12/1849TreatmentofchronicheartfailureGeneralPharmacologictreatmentNon-medicinetreatment2020/12/1850GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation2020/12/1851GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation1.LifestylemanagementEducationRegulateweightDietarymanagement:salttake2.Restandaction3.Treatmentforprimarydiseaseandprecipitating

2020/12/1852GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation1.Rest2.Dietarymanagement:salttake3.Diuretics

furosemidedihydrochlorothiazide(potassium-losing)antistone(potassium-sparing)2020/12/1853Themainpointofdiureticsapplication对于有症状的心衰，当液体负荷过重已表现为肺淤血或外周水肿时，利尿剂是基本的治疗。应用利尿剂可迅速改善呼吸困难并增加运动耐量（I类建议，证据级别A）尚无大型随机对照试验评估这类药物对症状和生存的影响。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）。2020/12/1854

襻利尿剂应作为首选。噻嗪类仅适用于轻度液体潴留、伴高血压和肾功能正常的心衰患者(I类，B级)。利尿剂通常从小剂量开始(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整利尿剂剂量的指标。长期服用利尿剂应严密观察不良反应的出现如电解质紊乱、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）。Themainpointofdiureticsapplication2020/12/1855GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation1.Rest2.Dietarymanagement:salttake3.Diuretics4.Vasodilator

sodiumnitroprusside(SNP)nitroglecerinregitine(酚妥拉明))2020/12/1856ThemainpointofVasodilatorapplication直接血管扩张剂对于CHF的治疗无特殊作用。（Ⅲ类，A级）血管扩张剂可用于不能耐受ACEI或ARBs的患者；伴有心绞痛或高血压可考虑应用（Ⅰ类，B级）禁忌证：血容量不足，低血压、肾功能衰竭

心脏流出道或瓣膜狭窄患者2020/12/1857GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation1.Digitalis

（1）effection:Positiveinotropic：

inhibitNa+-K+-ATPenzyme

introcellularNa+、K+Na+-Ca2+exchange

introcellularCa2+myocardialsystolepower

introcellularK+，digitalispoisoning2020/12/1858GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation1.Digitalis

（1）effection:Positiveinotropic：Electrophysiological

Inhibitcondutionsystem,espiciallyatriventricularjunction.

Improvetheautorhythmictyofatrium,junctionregionandventricle.2020/12/1859GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation1.Digitalis

（1）effection:Positiveinotropic：ElectrophysiologicalParasympatheticstimulatinganti-sympatheticnerveexciting

2020/12/1860GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation1.Digitalis

（1）effection:Positiveinotropic：ElectrophysiologicalParasympatheticstimulatingRoleintherenaltubulecellsreducingsodiumreabsorptioninhibitthesecretionofrenin

2020/12/1861GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation1.Digitalis

（2）application

indication:chroniccongestiveheartfailurecomplicatedbyatrailflutterandfibrillationandarapidventricularrate2020/12/1862GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation1.Digitalis

（2）application

contraindication:WPWwithAFⅡdegreeAVB,ⅢdegreeAVBsicksinussyndrome(SSS)Hypertrophiccardiomyopathy(HOCM)severemitralstenosis(SMS)acutemyocardiacinfarction(first24h2020/12/1863GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation1.Digitalis

(3)digitalispoisoningfactors：K+,O2,RFClincalexpression:gastricbowelreaction;arrhythmia;neurologicalandvisualchangeDiagnosis：>2.0ng/ml2020/12/1864ArrhythmiaofdigitalispoisoningVentricularPrematurebeatNonparoxysmalatrioventricularjunctionaltachycardiaAtrialPrematurebeatAtrialfibrillatonAtrioventricularblockST-TchangelikefishhookCharacteristicfeature2020/12/1865GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation1.Digitalis

Treatmentofdigitalispoisoningdrugwithdrawaltachycadia:supplyK+

,Lidocainivbradicadia：atropiniv,notsuitableforpacemakernotsuitableforisoprenalinedisablecardioerter2020/12/1866GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-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--smalleffects2020/12/1867GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、Digitalis2、β-excitant3、Phosphodiesteraseinhibitors

1、effect:restrainactivityofphosphodiesterase，thedegradationofcAMP(-)cAMPCa2+

channelactivationCa2+

-inflowmyocardialcontractility2020/12/1868GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、Digitalis2、β-excitant3、Phosphodiesteraseinhibitors

1、effect:2、indications：refractoryheartfailureend-stageheartfailurebeforehearttransplantation2020/12/1869GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-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.min2020/12/1870GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、Digitalis2、β-excitant3、Phosphodiesteraseinhibitors

1、effect:2、indications：3、drugs：4、defect：

side-effect;mortality2020/12/1871

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加血管扩张抗增殖Ang1-7Ang1-7受体激活血管扩张抗增殖ARB2020/12/1872GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、RAASinhibitorAngiotensinConvertingEnzymeInhibitors(ACEI)

dilatebloodvessels

inhibitRAS,sympatheticsystemreversetheventricularremodeling

improvearterystiffnessandsensitivity

ImproveendothelialfunctionATⅡ↓,Inhibitthedegradationofbradykinin2020/12/1873GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、RAASinhibitorAngiotensinConvertingEnzymeInhibitors(ACEI)

Clinicalstatus

symptoms↓,exercisetolerance↑

mortality↓

delaytheprogressofheartfailurereducinghospitalizationrates

preventHFaftermyocardialinfarction

2020/12/1874GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、RAASinhibitorAngiotensinConvertingEnzymeInhibitors(ACEI)

Captopril6.25～25mg2～3/dEnalapril10mg2/dCilazapril2.5mg/dBenazepril2.5～10mg/dPerindopril2～4mg/dFosinopril5～10mg/dRamipril2.5mg/d2020/12/1875GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、RAASinhibitorAngiotensinConvertingEnzymeInhibitors(ACEI)

applicationmethodsstartingwithsmalldosesiftolerated,graduallyincreasethedosemonitoringofrenalfunctionandions

renalfunctionchange,highpotassium,drycough,angioedema

2020/12/1876GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、RAASinhibitorAngiotensinConvertingEnzymeInhibitors(ACEI)

Contraindication:

①anuricrenalfailure

②pregnancyandbrestfeedingwoman

③allergeRelativeContraindication:①renalarterystenosisbilaterally②Cr>225µmol/l③k+>5.5mmol/l④hypotension2020/12/1877GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、RAASinhibitorAngiotensinConvertingEnzymeInhibitors(ACEI)AngiotensinIIreceptorantagonist(ARB)ATⅡ-AT1receptor↓InhibitRASNoaffectingthedegradationofbradykinin2020/12/1878GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、RAASinhibitorAngiotensinConvertingEnzymeInhibitors(ACEI)AngiotensinIIreceptorantagonist(ARB)applicationmethods

lessdrycoughandangioedemawhenHF,firstchoseACEIwhenHF,shouldnotbecombinedapplicationofACEIandARB

Losartan50mg/d;valsartan80mg/d2020/12/1879GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、RAASinhibitorAngiotensinConvertingEnzymeInhibitors(ACEI)AngiotensinIIreceptorantagonist(ARB)Aldosterone

antagonists

spironolactone(SPI)potassium-sparingdiureticreversetheventricularremodeling

improveprognosis2020/12/1880GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、RAASinhibitorAngiotensinConvertingEnzymeInhibitors(ACEI)AngiotensinIIreceptorantagonist(ARB)Aldosterone

antagonists

renininhibitorACEI/ARB

increasing

plasma

renin

activityrenin

inhibitior

has

the

effect

of

cardiorenal

protectionnotACEI/ARBreplacementtherapy2020/12/1881GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

RAASinhibitor

-blockersympatheticactivation↑b1receptorsb2receptorsa1receptorsmetoprololbisoprolol↓arrythmiadilatebloodvessels;↓themyocardialO2Cardiactoxicity

carvedilol2020/12/1882GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

RAASinhibitor

-blockerInhibitionofsympatheticactivation

improveprognosis1-blockermetoprolol,bisoprolol

12α-blokercarvedilolapplicationmethodsstartingwithsmalldosesiftolerated,graduallyincreasethedosemonitoringofBp,HR,ECG2020/12/1883GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

RAASinhibitor

-blockerContraindication:

bronchospasm

severebradycardia

≥Ⅱ。atrioventricularblock

severeperipheralvasculardisease

acuteheartfailure

2020/12/1884TreatmentofchronicheartfailureTherecentadvancesaboutthetreatmentofHF

MicturitionrestrainthesympatheticnervoussystemdilatebloodvesselsrhBNPlevosimendanIncreasetheCa2+sensitivity→myocardialcontractilityMediateATP-K+channel→dilatebloodvesselsivabradineInhibiteSANIfcurrenttolvaptanCombineV2receptor→H2O2reabsoption↓2020/12/1885TreatmentofchronicheartfailureNon-medicinetreatment2020/12/1886CardiacResynchronizationTherapy(CRT)2020/12/1887LeftVentricularAssistDevice（LAVD）TransitedtreatmentforhearttransplantationAdjuvanttherapyforacuteHF2020/12/1888TreatmentofchronicheartfailureNon-medicinetreatmenthearttransplantationcellreplacementtherapy--SCT(stemcelltransplantation)2020/12/1889

Acuteheartfailure,AHF2020/12/1890CategoriesofAHF1.Acuteleftheartfailure2.Acuterightheartfailure3.non-cardiacacuteheartfailure2020/12/1891CategoriesofAHFAcuteleftheartfailuredecrease