cardiovascular-symptoms心血管症状课件

CommonsymptomsoftheCardiovascularSystemDr.hechao

ThecardiologydepartmentoffirstclinicmedicalcollegeInterestingfacts...TheheartdoesnotrestformorethanafractionofasecondatatimeDuringalifetimeitcontractsmorethan4billiontimesCoronaryarteriessupplymorethan10millionlitersofbloodtothemyocardiuminalifetimeInterestingfacts….Cardiacoutput(heartrateXstrokevolume)canvaryunderphysiologicconditionsfrom3to30liters/minuteRemember:Normalcardiacoutputforadultsis5-6liters/minuteCardiacindexcorrectsforbodysize(Cardiacoutputdividedbybodysurfacearea)CommonDiseasesoftheHeartCoronaryarterydiseaseHypertensionRheumaticheartdiseaseBacterialendocarditisCongenitalheartdiseaseOTHERVERYCOMMONDISEASESOFTHEHEARTCONGESTIVEHEARTFAILURECARDIOMYOPATHYARRHYTHMIASCommonSymptomschestpainPalpitationoedemaDyspneaSyncope

ChestPainChestPainCardiovasculardiseaseisthe1stcauseofdeathintheUnitedStates5.4%ofallvisitstotheEDareforchestpain2.5%ofpatientswithanacutemyocardialinfarction(AMI)aresenthome20%ofallEDmalpracticeclaimsareformisdiagnosedchestpaincomplaints.BedifficulttodiagnoseChestPainWhythediseasesofdifferentorgansystemspresentwithsimilarsymptoms?VisceralpainSomaticpain9VisceralPainSensorynervesfrominternalorgansenterthespinalcordatmultiplelevelsandthusthepainisdifficulttodescribeandlocalizeAchingPressureHeavinessSomaticPainSensorynervesfromthesestructuresenterthespinalcordatspecificlevelsandthepainiseasilydescribedandlocalizedSharp,stabbingPatientswillpointtoanareaofwelllocalizedpainBone,skin,muscle,parietalpleuraCausesofchestpainCardiovascularA.C.S.(AcuteCoronarysyndrome)PericarditisAorticdissectionAorticstenosisPulmonaryPulmonaryembolismPleurisyPneumothoraxPneumoniaPediatricsKawasakidiseaseHypertrophiccardiomyopathyCongenitalheartdisease

GastrointestinalEsophagealrefluxEsophagealspasmEsophagealrupturePepticulcerdiseaseGallbladderdiseasePancreatitisChestWallPainHerpesZosterCostochondritisCervicalradiculopathyRibfractureAnxietyEvaluationofChestPainGOALEarlydetectionandsafemanagementoflife-threateningdiseasesCompletehistoryisveryimportantTimelyandappropriatetestingDonotfocusonabenigndiseaseandmissalife-threateningillness14EvaluationofchestpainMaintainahighindexofsuspicionforlife-threateningillnessRapidtriageIsthepatientatriskforseriousillness?AbnormalvitalssignsPatientlookssick,diaphoretic,shortofbreath,alteredlevelofconsciousness.RiskfactorsorhistoryofcardiovasculardiseaseCardiacmonitor,IV,oxygenEKGwithin10minutesofpatientarrivalHistoryCompletehistorymostimportantFocusonthecharacteristicsofthepain,associatedsymptoms,riskfactors,andhistoryofcardiovasculardiseasePainscale1-101-nopain10-worstpossiblepainHistoryDurationofthepainPainlastingsecondsprobablynotcardiacConstantpainforlongerthan8-12hourswithnegativeworkupprobablynotcardiacIntensityofpainImmediateonsetofseverepainAorticdissectionPainreachesmaximumintensitygraduallyACS(AcuteCoronarysyndrome)HistoryQualityofthepainBurningpainGastrointestinalTearingpainAorticdissectionSharp,stabbingpainUsuallynotischemicUpto20%ofpatientswithAMIdescribepainassharpBeworsewithbreathingorcoughingPleuriticpain-Lung,musculoskeletal,pericardialPleuriticchestpainisdescribedinupto6%ofMIpatients.HistoryQualityofthepainLocalizedpainreproducedbymovementorpalpationoftheaffectedareaChestwallpainVisceralpainradiatestothejaw,arms,andneckACSShortnessofbreathNausea&VomitingDiaphoresisfatiguepalpitationsRiskfactorsAge>40MalePost-menopausalfemaleHypertensionHyperlipidemiaCigarettesmokingDiabetesFamilyhistoryObesityDrugabuseCocaineTheabsenceofriskfactorsdoesnotruleoutcardiacdisease`20AcuteCoronarySyndrome

(ACS)UnstableAnginaNewonsetofsymptomsSymptomsthatoccuratrestAchangeinthepatient’susualpatternofanginaNoSTelevation,noelevationofcardiacenzymesEKGwillbenormalabout50%ofpatientsEvidenceofischemia-STdepressionorT-waveinversionACSAcuteMyocardialInfarctionSTEMISTelevationof>1mminatleast2contiguousleadsElevatedcardiacenzymesNon-STEMISTdepressionandTwaveinversionNewleftbundlebranchblockorQwavesElevationofcardiacenzymesSTEMI-STelevationMINon-STEMIAnginalEquivalents

AtypicalChestPainUpto33%ofACSwillnothavechestpainDyspneawithexertionoratrestShoulder,arm,orjawpainonlyNauseaLightheaded,dizzy,orsyncopeGeneralizedweaknessDiaphoresisAcutechangeinmentalstatusPalpitationsEKGThebesttesttorapidlydiagnoseanacuteMIObtainwithin10minutesofpatient’sarrivalUpto50%ofinitialEKGSwillbenormalorhavenon-diagnosticchangesSerialEKGSBiomarkersTroponinTandIPreferredmarkerProteinlocatedincardiacmusclePoorsensitivityfirst6hoursafteronsetofsymptomsRepeatin8-12hoursafteronsetofsymptomsCanbeelevatedwithPulmonaryembolismAorticdissectionRenalfailureSepsisCardiactraumaorsurgeryCHF(Chronicheartfailure)BiomarkersCPKLocatedincardiacandskeletalmuscleCPK/MBisthecardiacisoenzymePoorsensitivityfirst6hoursafteronsetofsymptomsRepeattestingin8-12hoursUsefulindetectingreinfarctionMyoglobinFoundinskeletalandcardiacmuscleGoodsensitivityearlyafteronsetofsymptoms butpoorspecificityBiomarkersTest/PeriodOnsetPeak

DurationCPK/MB3-12hours

18-24hours36-48hoursTroponin3-12hours

18-24hoursUpto10daysMyoglobin1-4hours6-7hours

24hoursNote:Repeatin8-12hoursPulmonaryEmbolismMajorityforminthedeepveinsofthepelvisandlowerextremitiesSizeoftheclotwilldeterminesignsandsymptomsLargeclotscancausesyncope,abnormalvitals,suddendeathPulmonaryEmbolismRiskfactorsPreviousDVT(DeepVeinThrombosis)orPEPregnancyCancerRecentsurgeryProlongedbedrestAge>50SmokingOralcontraceptivesObesityInheritedblooddisordersPulmonaryEmbolismSignsandsymptomsDyspneaPleuriticchestpainTachycardiaCoughHemoptysisFeverrarely>39℃SyncopeEvidenceofDVTintheextremitiesPulmonaryEmbolismEKGSinustachycardiaNon-specificSTandTwavechangesRightheartstrainpatternRBBB(Rightbundlebranchblock)Chestx-rayUsuallynormalornon-specificchangesArterialbloodgas(ABG)NotusefulinthediagnosisofaPECanhaveanormalPO2andA-agradientwithPEPulmonaryEmbolismD-DimerFibrindegradationproductTestsensitivity95%,specificitylow50%WhatcanelevatetheD-DimerPregnancyCancerTraumaRecentsurgeryDisseminatedintravascularcoagulation(DIC)

PulmonaryEmbolismHighriskpatientsDonotobtainaD-DimerimmediatelytogoothertestingCTScanV/QScanPulmonaryangiogramPericarditisInflammationofthecardiacpericardiumPainisduetoirritationoftheparietalpleuraSharppleuriticsubsternalpainRadiatestotheback,neck,orshoulderWorsewithcough,inspiration,supineImproveswithleaningforwardPericardialfrictionrub,tachycardia,dyspneaEKGDiffuseSTelevationTroponiniselevatedinupto22%PericarditisEKGSpontaneousPneumothoraxSuddenruptureofalungblebTallthinmalesage20-40UnderlyinglungdiseaseSmokersSuddenonsetofsharppain,worsewithinspiration,andSOB(shortnessofbreath)PhysicalexamDecreasedbreathsoundsontheaffectedsideTensionpneumothorax-ImmediatelifethreatDecreasedvenousreturntotheheartSevererespiratorydistress,tachycardia,hypotensionPneumothoraxTensionPneumothoraxAorticDissectionStartsasatearintheintimaoftheaortathatspreadsthroughthemedialwallunderelevatedsystolicaorticpressureMortalityuntreated28%in24hours50%in48hours70%inoneweekRiskfactorsHypertensionPregnancyLupus,syphilis,endocarditisMarfan’sdiseaseAorticDissectionHistorySuddenonsetofsharp,tearing,maximalpainPainradiatestotheneckorbackAorticDissectionPhysicalexamMajoritywillbehypertensiveDifferenceinbloodpressurebetweenarmsMurmurofaorticregurgitationNeurologicdeficitsChestpainwithneurologicdeficit,THINKDISSECTIONEKG-usefultoruleinoroutMIChestX-rayWidenedmediastinumRuleoutotheretiologiesGastrointestinalEtiologyinupto40%ofchestpaincomplaintsDifficulttodiscernfromACSPaindescribedasburning,pressure,ordullAcidRefluxSubsternal,epigastricburningpainPainworsewithalcohol,caffeine,certainfoodsWorsesupineandinthemorningRelievedwithantacidsGastrointestinalEsophagealspasmOftenassociatedwithrefluxdiseaseDull,pressure,substernalpainlastingforhoursCanberelievedwithNitroglycerinNTG(nitroglycerin)relaxessmoothmusclesPainreliefwithNTGNOTdiagnosticofACSPepticulcerdiseasePancreatitisandgallbladderdiseaseIncludelipaseandliverfunctiontestsinyourworkupBoerhaave’sSyndromeForcefulvomitingafterexcessiveeatinganddrinkingcausesesophagealrupture.MediastinalcontaminationofstomachcontentsSuddenonsetofseverepainradiatingtothebackMortalityis10-50%anddirectlyrelatedtothedelayinmakingthediagnosisandinitiatingtreatmentChestWallPainThecauseinupto30%ofEDvisitsWelllocalized,sharp,positionalpainReproduciblebypalpatingaspecificareaofthechestwallCostochondritisPainandtendernessatthecostochondralorcostosternaljointsTreatmentsRestHeatNSAID(non-steroidalanti-inflammatorydrug)MentalIllnessThecauseinupto10%ofEDvisitsPatientsarewithvaguesymptomsandhistoryHyperventilationcancausenon-specificST-TwavechangesAdiagnosisofexclusionChestPainCervicaldiscdiseaseNerverootcompressioncauseschestpainHerpesZosterSharpburningpainbeforetherashPainandherpeticrashinadermatomedistributionHerpesZosterPALPITATIONSDefinitionUncomfortableawarenessofheartbeatorundueawarenessofheartaction.Definedasthumping,poundingorflutteringsensationinthechest.IntermittentorSustainedRegularorIrregularEtiologyandPathogenesisPalpitationisduetoAlterationinheartrateSinustachycardia&BradycardiaAlterationinheartrhythmAtrialfibrillationAugmentationofmyocardialcontractionAnxietystates&DrugsFEATURESUGGESTSHEARTMISSESANDTHUMPSECTOPICBEATSWORSEATRESTECTOPICBEATSVERYFASTREGULARSVT(supraventriculartachycardia)/VT(ventriculartachycardia)SUDDENONSETSVT/VTOFFSET

WITH

VAGALMANOEUVRESSVTFASTANDIRREGULARAF(atrialfibrillation)andATRIALFLUTTERwithvaryingblockFORCEFULANDREGULAR–NOTFASTAWARENESSOFSINUSRHYTHM(ANXIETY)SEVEREDIZZINESSORSYNCOPEVTorBRADYARRHYTHMIASPRE-EXISTINGHEARTFAILUREVTCausesofPalpitationsCARDIAC43%PSYCHIATRIC31%MISCELLANEOUS10%UNKNOWN16%CardiovascularCausesArrhythmiasPrematureatrialandventricularcontractionsSupraventricularandventriculararrhythmiasWPW(Wolff-Parkinson-White)syndromeAtrialfibrillationAtrialflutterwithvaryingblockBrady-arrhythmias:completeheartblockSick-sinussyndromeCardiovascularCausesNon-arrhythmiccardiaccausesMitralvalveprolapse(withorwithoutassociatedarrhythmias)AorticinsufficiencyAtrialmyxomaPulmonaryembolismCongenitalheartdiseasesSystemichypertensionPericarditisPacemakerinducedtachycardiaPsychiatricCausesIncludePanicattacksAnxietystatesSomatizationPsychiatricCausesFeatureAlongerdurationofsensation>15minMultiplicityofsymptomsCardiacevaluationstillmaybenecessaryinpatientswithsuspectedpanicdisorder.ArrhythmiccausesmustberuledoutbeforethediagnosisofanxietyorpanicdisorderMiscellaneousCausesHyperkineticcirculatorystates:AnaemiaFeverThyrotoxicosisHypoglycemiaPhaeochromocytomaMiscellaneousCausesDrugs:AminophyllineAtropineThyroxineTricyclicantidepressantsVasodilatorsDigitalisMiscellaneousCausesOthers:CaffeineCocaineAmphetaminesTobaccoEthanolOthersSpontaneousskeletalmusclecontractionsofthechestwallSystemicmastocytosisPhysiologicalcausesExertionExcitementPregnancyNeurocirculatoryastheniaVaso-vagalattackAPPROACHTOTHEPATIENTWITHPALPITATIONS“Principalgoalinassessingpatientswithpalpitationsistodetermineifthesymptomiscausedbyalifethreateningarrhythmia〞HOWTOEVALUATEPALPITATIONSTEP1Ispalpitationcontinuousorintermittent?IntermittentP.arecommonlycausedbyprematureatrialorventricularcontractionsVentricularend-diastolicdimensionPost-extrasystolicpotentiationHOWTOEVALUATEPALPITATIONSTEP2Isheartbeatregularorirregular?Regular,sustainedpalpitationsSVT(supraventriculartachycardia)and/orVT

(ventriculartachycardia)Irregular,sustainedpalpitationsAtrialfibrillationHOWTOEVALUATEPALPITATIONSTEP3:Whatistheheartrate?STEP4:Doespalpitationsoccurindiscreteattacks?Isonsetabrupt?Whatcanterminateattacks?VentriculararrhythmiasareonsetsuddenlyHoldingbreathorvagalmanoeuvresdecreasepalpitationsinSVTSTEP5Arethereanyassociatedsymptoms?Chestpain:ArrhythmogenicMI(myocardialinfarction)Dyspnea:HeartfailureduetoarrhythmiasSyncope:Lowcardiacoutputduringarrhythmias,hypoglycemia,phaeochromocytomaSweating:Anxiety,hypoglycemiaDiarrhoea:ThyrotoxicosisHOWTOEVALUATEPALPITATIONSTEP6:Arethereanyprecipitatingfactors?ExerciseStressAlcoholintakeDrugsSTEP7:Isthereahistoryofstructuralheartdisease?CoronaryheartdiseasesValvularheartdiseasesHOWTOEVALUATEPALPITATIONPhysicalexaminationVitalsignsJugularvenouspressureandpulseAuscultationofthechestandprecordiumExaminationECGRestingECGExerciseECG24-hourECG

ExaminationOthersHolterLooprecordings(externalorimplantable)Mobilecardiacoutpatienttelemetry.EventrecorderExaminationHoltermonitorImplantablelooprecordersManagementinaNutshellRe-assuranceLifestylemodificationCorrectionofco-morbiddiseasesAnxiolyticsandBeta-blockersAnti-arrhythmicdrugs/electricalconversionRecurrentlife-threateningventriculararrhythmiasarecurrentlybeingtreatedwithImplantableCardioverter-defibrillatordevicesoedemaDefinitionTheexcessiveaccumulationofintestitialfluidApathologicprocesscausedbydiseasesNotaccompaniedwithcellularedemaClassificationAccordingtotherangethatedemafluidspreadsto:GeneralizededemaLocalizededemaAccordingtothecauseofedema:RenaledemaHepaticedemaCardiacedemaMalnutritionaledemalymphedemaClassificationGeneralizededema:PuffinessofthefaceIndentationoftheskin“pittingedema〞Ascites&HydrothoraxLocalizededemeEdemaPittingedemaAscitesEtiologyandpathogenesis

ImbalanceoffluidexchangebetweenplasmaandinterstitialcompartmentImbalanceoffluidexchangebetweenextra-andintra-bodyImbalanceoffluidexchangebetweenplasmaandinterstitialcompartmentCapillariesFigure7-7TotalPressureDifferencesInsideandOutsideCapillary↑↑permeability↓obstruction1.Increasedcapillarybloodpressure

Causes:ElevatedplasmavolumeIncreasedvenouspressureGeneralvenouspressure,i.e.congestiveheartfailureLocalvenouspressure,i.e.venousthrombosisArteriolardilationi.e.acuteimflammation↑Capillarybloodpressure↑Forcedrivingfluidintointerstitium↑FormationofinterstitialfluidEdemaWhengreaterthanlymphaticcompensatoryreturn2.DecreasedplasmacolloidosmoticpressureCauses:PlasmaalbumincontentdecreaseDecreaseofproteinproductioni.e.hepaticcirrhosis,malnutritionExcessivelossofproteini.e.nephrosisElevatedcatabolismofproteini.e.chronicdebilitatingdiseases,suchasmalignanttumor↓Plasmacolloidosmoticpressure↓Forcedrawingwaterbackintocapillaryfrominterstitium↑FormationofinterstitialfluidEdemaWhengreaterthanlymphaticcompensatoryreturn3.ObstructionoflymphticCauses:BlockagebycancerBlockagebyinfection,especiallywithfilarial4.Increasedcapillarypermeability↑Capillarypermeability↑Filtrationofmoreproteinfromcapillarytointerstitium↑formationofinterstitialfluidEdemaWhengreaterthanlymphaticcompensatoryreturn↓PlasmacolloidosmoticpressureCauses:InflammationInfectionBurnAllergicresponseTraumaAnoxiaAcidosisImbalanceoffluidexchangebetweenextra-andintra-body

------RenalretentionofsodiumandwaterInnormalcondition,99-99.5%oftotalvolumeofsodiumandwaterfiltratedviaglomeruliarereabsorbedbytubules.60-70%offiltratesareactivelyreabsorbedbyproximalconvolutedtubule.Thereabsorptionsofsodiumandwateratdistaltubuleandcollectionductareregulatedbyhormone.Glomerular(filtration)andtubular(reabsorption)balance(G-Tbalance)RetentionofsodiumandwaterGFR(glomerularfiltrationrate)decreases,whiletubularreabsorptiondoesnotdecreaseaccordingly;Tubularreabsorptionincreases,whileGRFdoesnotincreased.↓GFR↑Reabsorptionofproximaltubule↑ReabsorptionofdistaltubuleandcollectiontubuleG-TimbalanceFactorsdeterminingtheGFR:

FiltrationareaandmembranepermeabilityFiltrationpressureEffectivecirculatingbloodvolumeorrenalbloodvolume1.Decreasedglomerularfiltrationrate(GFR)1.↓GFRCausesExtensiveglomerulardamageAcuteorchronicglomerulonephritisDecreaseofeffectivecirculatingbloodvolumeCongestiveheartfailure,nephroticsyndrome↓RenalbloodvolumeRenin-angiotensinsystemSympathetic-adrenalmedullarysystem↓GFR

-IncreasedreabsorptioninproximaltubuleIncreasedfiltrationfraction(FF)2.glomerularfiltrationrate(GFR)renalplasmaflow(RPF)=FFGFR:amountofplasmafilteredatglomerulusintoBowman’scapsuleFFisthefractionofrenalplasmaflowthatisfilteredattheglomerulusInnormalcondition:FF:20%TheproteinconcentrationintheplasmaenteringtheperitubularcapillariesincreasesTheperitubularcapillaryoncoticpressureincreasesEnhancingfluidreabsorptionfromtherenalinterstitialspacetothecapillaryDecreasesrenalinterstitialpressurefavoringreabsorptionacrossthetubularepitheliumandminimizingbackfluxfromtherenalinterstitialspacetothetubulelumen.↑ReabsorptioninproximaltubuleIncreasedFFIncreasedFFmakeelevatedreabsorptionofproximaltubuleCausesofFFincreasingCongestiveheartfailureNephroticsyndromeDecreasedeffectivecirculatorybloodvolumeSympathetic-adrenalmedullarysystemexcitingEfferentarterioleconstrictsstrongerthanafferentone↑EfferentarterioleresistanceGFRisincreasedrelativetorenalplasmaflow↑FFQuestionWhydoescongestiveheartfailurecauseedema?↑Generalvenouspressure↓PlasmacolloidosmoticpressurbecauseofdilutionofbloodDysfunctionoflymphaticreturnbecauseofincreasedvenouspressure↓GFR↑FF↑ADHand↑ADSDifferentialdiagnosisHeartfailureRenaldiseasesCirrhosisNutritionaloriginIdiopathicOthersDifferentialdiagnosis

HeartFailureOccursatlowerpartofthebody(lowerextremities)SymmetriclocationThepresenceofheartdiseasesCardiacenlargementGalloprhythmDyspneaBasilarralesVenousdistentionHepatomegalyDifferentialdiagnosis

RenaldiseasesHypoalbuminemia&RetentionofsodiumandwaterAssociated:HematuriaProteinuriaHypertentionImpairedrenalfunctionaltestCharacteristicofedemaPuffinessofthefaceDifferentialdiagnosis

Cardiac/Renaldisease

RenalCardiacLocationonsetfromtheface,onsetfromthelowerperiobitalareaspartofthebodyProgressionprogressquicklyprogressslowlyIdentitysoftandmobilerelativelysolid,lessmobileOthersignsproteinuriasignsofheartfailure:hypertensioncardiacenlargementimpairedrenalvenousdistentionfunctionaltesthepatomegaly

Differentialdiagnosis

Liverdiseases(cirrhosis)ClinicalevidenceofhepaticdiseaseJaundiceSpiderangiomasAscitesAscitesrefractorytothetreatmentcirrhosisDifferentialdiagnosis

IdiopathicedemaExclusiveinwomenPeriodicepisodesAccompaniedbyabdominaldistentionDifferentialdiagnosis

OtherCausesofEdemaHypothyroidismPregnancyEstrogensAngioneuroticApproachtothepatient

GeneralizedLocalizedorHeart

Liver

Kidney

Venousobstruction

Lymphaticobstruction

DyspneaHowtodescribethesesensationsCannotgetenoughairAirdoesnotgoallthewaydownSmotheringfeelinginthechestTightnessinthechestFatigueinthechestDefinitionDilatationofnares(鼻翼扇动),cyanosis(紫绀),useofaccessorymusclesofrespirationAbnormalitiesofrespiratoryrate,depthorrhythmEtiologyRespiratorydiseaseCardicdiseaseToxicNero-PsychogenicHaematologicaldiseaseIncreaseofabdominalpressure(massiveascites(腹水),pregnancy(怀孕)etc)NormalpersonmayexperiencethephysiologicdyspneaduringheavyexerciseEnvironmentshortofoxygenRespiratorydyspneaRespiratorydyspneaiscausedbyabnormalventilationandgasexchange.Reductioninventilatorycapacity,hypercapnia(二氧化碳潴留)andhypoxemia(低氧血症)resultingfromrespiratorydisease.Threeclinicaltypes:inspiratorydyspnea,expiratorydyspnea,mixeddyspnea.InspiratorydyspneaClinicalcharacteristics:visibleindrawingoverthesternalnotch,thesupraclavicularspaces,theintercostalspacesandtheepigastriumintheinspiration(三凹症).Accompaniedbyacoarse,lowpitchedinspiratorywheezinganddrycough.Stenosisandobstructionoflarynx,trachea,andbronchiExpiratorydyspneaClinicalcharacteristics:expirationisprolongedandlabouredwithwheezing.Cause:thedecreaseoflungelasticityandspasmnarrowingofthebronchiolesandsmallerbronchi.Familiardiseases:emphysema(肺气肿),bronchialasthma(支气管哮喘)andchronicasthmaticbronchitis(喘慢支).MixeddyspneaClinicalcharacteristics:breathingisdifficultduringbothinspirationandexpiration.Respiratoryfrequencyincreaseandrespirationsuperficial.Cause:decreaseofventilatorsandgasexchangecapacityFamiliardiseases:severepneumonia(肺炎),pulmonaryfibrosis(肺纤维化),massiveatelectasis(大片肺不张)etcCardiacdyspneaCardiacdyspneaisusuallyattributabletopulmonaryvascularcongestionresultingfromtheleftand/orrightheartfailure.Dyspneaistheprimarysymptomofleftheartfailure.LeftheartfailureBasaldiseases:CoronaryheartdiseaseHypertensiveheartdiseaseRheumaticheartdiseaseCongenitalheartdiseaseLeftheartfailureMechanism:LungcongestiondecreasegasdispersionAlveoliarestiffandmoreworkisneededtoovercomeelasticrecoilThehighalveolarpressurestimulatestretchreceptorHighpulmonarycirculationpressurestimulaterespiratorynervecenterLeftheartfailureClinicalrepresentation:Exhausteddyspnea(劳力性呼吸困难)Orthopnea(端坐呼吸)Paroxysmalnocturnaldyspnea(夜间阵发性呼吸困难)ExhausteddyspneaDifficultyinbreathingwhenthepatientisinactivityrelivedwhenherelax.Doingexerciseimpelmorebloodintopulmonarycirculation.Moreoxygenisneededforbodydemand,especiallytheheart.FunctionalclassificationClassⅠ–nolimitation:OrdinaryphysicalactivitydoesClassⅡ–slightlimitationofphysicalactivityClassⅢ–MarkedlimitationofphysicalactivityClassⅣ–inabilitytocarryoranyphysicalactivitywithoutdiscomfortOrthopneaDifficultyinbreathinginthesupinepositionrelivedbysittingupReducethedegreeofpulmonarycongestionbypoolingbloodinthelowerextremitiesImprovethediaphragmaticmovementIncreasevitalcapacityParoxysmalnocturnaldyspnea

Thepatientawakesshortofbreathatnight,butoftenobtainreliefbysittingupforaperiodoftime.Physicalexamination:moistralesatthebothlungbases,tachycardia,wheezingandbronchospasm(cardiacasthma心源性哮喘).ParoxysmalnocturnaldyspneaReason:Supinepostureforsleepimpelmorebloodintopulmonarycirculation,anddecreasevitalcapacity.Vagusexcitementcausecoronaryarteryconstrictionandbronchiolesspasm.RightheartfailureBasaldiseases:Acutecorpulmonale(肺心病)whichcausedbypulmonaryembolism(肺栓塞)Chroniccorpulmonalewhichcausedbychronicobstructivepulmonarydisease(慢阻肺)RightheartfailureMechanism:Thepressureofrightatriaandsuperiorvenacavaisthenaturalstimulusofrespiratorycenter.Hypoxemiaandtheaccumulationoftheacidmetabolitesstimulaterespiratorycenter.Therestrictionoftherespiratorymovementcausedbyenlargementofliver,ascitesandpleuraleffusion.BiventricularfailureLeftheartfailureplusrightheartfailuremaycauseseveredyspnea?ToxicdyspneaInthemetabolicacidosis(uremia尿毒症anddiabeticacidosis糖尿病性酸中毒),theacidmetabolitesstimulatetherespiratorycenter,causingdeepandregularrespiration(Kussmanul)withsnoring.ToxicdyspneaTheoverdoseofmorphineandpentobarbitalcandepressrespiratorycentercausingslowrespirationorCheyne-Stokessrespiration.Neuro-PsychogenicdyspneaTherespiratorycenterlosesthebloodsupplyoriscompressedwhilepatientsufferingfromcerebrovasculardisease.Therespirationbecomesdeep,slowandirregular.Nero-PsychogenicdyspneaPatientsufferfromhysteriawillbeseenrepetitivedeep,signingrespirationwithnumbnessofextremitiesorlips,cheiropedalspasm.HaematologicldyspneaThedecreaseofoxygen-carryingcapacityandoxygencontentdevelopabnormalrespirationandincreaseheartrate,suchassevereanemia,carbonmonoxide.Hypotensioncanstimulaterespirationwhenpatientsufferfromshock.AccompanyingsymptomsParoxysmaldyspneawithwheezing,Itispresentinbronchialasthmaandcardiacasthma.Paroxysmalseveredyspneaisoftenseeninacutelarynxedema(急性喉水肿),spontaneouspneumothorax(自发性气胸),massivepulmonaryembolism.AccompanyingsymptomsDyspneawithchestpain.Itisfrequentlyobservedinlobarpneumonia(大叶性肺炎),pulmonaryinfarction(肺堵塞),spontaneouspneumothorax,acuteexudativepleurisy(急性渗出性胸膜炎),acutemyocardialinfarction(急性心肌梗死),and