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Heartfailure

11

DEFINITIONHEARTFAILUREAclinicalsyndromeinwhichanabnormalityofcardiacstructureorfunctionisresponsiblefortheinabilityofthehearttoejectorfillwithbloodataratecommensuratewiththerequirementsofthemetabolizingtissues.Heartfailureresultsinaconstellationofclinicalmanifestations,includingcirculatorycongestion,dyspnea,fatigue,andweakness.2 DEFINITIONHEARTFAILURE2FORMSOFHEARTFAILURESystolicvsdiastolicheartfailureLow-outputvshigh-outputheartfailureAcutevschronicheartfailureRight-sidedvsleft-sidedheartfailure3FORMSOFHEARTFAILURESystolicUNDERLYINGCAUSES

IschemicheartdiseaseCardiomyopathiesCongenital,valvularandhypertensiveheartdisease(potentialtreatable)4UNDERLYINGCAUSESIschemicheaPRECIPITATINGFACTORS

InfectionArrhythmiasPhysical,dietary,fluid,environmental,andemotionalexcessesMyocardialinfarctionPulmonaryembolismAnemiaThyrotoxicosisandpregnancyAggravationofhypertensionRheumatic,viral,andotherformsofmyocarditisInfectiveendocarditis5PRECIPITATINGFACTORSInfectioPATHOGENESISChronichemodynamicoverload→eccentricventricularhypertrophyChronicpressureoverload→concentricventricularhypertrophyVentr.hypertrophy→ventr.DilatationRemodelingofventricle→HFActivationofendogenousneurohormonalsystemandcytokines6PATHOGENESISChronichemodynami

“7“7

CLINICALMANIFESTATIONOFHF

Primary

SymptomsDyspneaOrthopneaParoxysmal(nocturnal)dyspneaAcutepumnonaryedema8CLINICALMANIFESTATIONOFHFCLINICALMANIFESTATIONOFHFOthersymptomsFatigueandweaknessAbdominalsymptomsCerebralsymptoms9CLINICALMANIFESTATIONOFHFOtPHYSICALFINDINGSOFHFGeneralfindings↓Pulsepressure（severeHF)↓SBPwithcool,diaphoreticextremities,andCheyne-StokesrespirationCyanosis,sinustachycardia10PHYSICALFINDINGSOFHFGeneralPHYSICALFINDINGSOFHFCardiovascularfindingsS3and

S4CardiomegalyMurmursPulsusalternansDistentionofjv.(↑systemicv.p)11PHYSICALFINDINGSOFHFCardioPHYSICALFINDINGSOFHFPulmonaryralesCardiacedemaSymmetricanddependentinthelegsMostprominetineveningHydrothoraxandascitesCongestivehepatomegaly.12PHYSICALFINDINGSOFHFPulmonaLABORATORYEXAMINATIONN-terminal-pro-BNPandBNPTwo-dimensioanlechocardiographywithDopplerflowstudiesChestroentgenogramECG13LABORATORYEXAMINATIONN-terminEchocardiogram

2DechowithDoplertechniqueforsystolicanddiastolicfunctionofLVLVDdandLVDs（DdandDs）LVEF14Echocardiogram2DechowithDoDIAGNOSISOFHFCombinationoftheclinicalmanifestationofHF,togetherwiththefindingscharacteristicofoneoftheunderlyingformsofheartdisease.15DIAGNOSISOFHFCombinationofDIFF.DIAGNOSISOFHFPulmonarydiseasePulmonaryembolismAnkleedemaEnlargementoftheliverandascites16DIFF.DIAGNOSISOFHFPulmonarTREATMENTOFHFCorrectionoftheunderlyingcauseRemovaloftheprecipitatingcausePreventionofdeteriorationofcardiacfunctionControlofthecongestiveHFstate17TREATMENTOFHFCorrectionoft

GENERALMEASURES

TreatingcoronaryriskfactorsModeratedietaryNarestrictionDailymeasurementofweightPreventrespiratoryinfectionAviodingexcessivealcohol,temperatureextremes,andtiringtripsGENERALMEASURESTreatingcoTREATMENTOFHFControlofexcessivefluidDietDiureticsThiazidediureticsMetolazoneFrusemideBumetanidetorsemidePotassium-sparingdiuretics19TREATMENTOFHFControlofexceTREATMENTOFHFBlockadeofrenin-angiotensin-aldosteroneandadrenergicsystemACEinhibitorsAngiotensinreceptorblockersBeta-adrenoceptorblockersAldosteroneantagonist20TREATMENTOFHFBlockadeofrenTREATMENTOFHFEnhancementofmyocardialcontractilityDigitalisSympathomimeticaminesPhosphodiesteraseinhibitors21TREATMENTOFHFEnhancementofTREATMENTOFHFVasodilatorsNitratesNitroglycerineIsosorbidedinitrateMononitratesNitroprussidenesiritide22TREATMENTOFHFVasodilators22TREATMENTOFHFVentricularresynchronizationManagementofarrhythmiaAnticoagulantsRefractoryheartHFAssistedcirculation/cardiactransplant.23TREATMENTOFHFVentricularresSTAGEAAthighriskforHFbutwithoutstructuralheartdiseaseorsymptomsofHF.TreathypertensionEncouragesmokingcessationTreatlipiddisordersEncourageregularexerciseDiscouragealcoholintake,illicitdruguseControlmetabolicsyndromeACEIorARBinappropriatepatientsforvasculardiseaseordiabetes24STAGEAAthighriskforHFbutSTAGEBStructuralheartdiseasebutwithoutsignsorsymptomsofHFAllmeasuresunderStageAACEIorARBinappropriatepatientsBeta-blockersinappropriatepatients25STAGEBStructuralheartdiseasSTAGECStructuralheartdiseasewithpriororcurrentsymptomsofHF.AllmeasuresunderStagesAandBDietarysaltrestrictionDRUGSFORROUTINEUSEDiureticsforfluidretentionACEIBeta-blockersDRUGSINSELECTEDPATIENTSAldosteroneantagonistARBsDigitalisHydralazine/nitratesDEVICESINSELECTEDPATIENTSBiventricularpacingImplantabledefibrillators26STAGEC26STAGEDRefractoryHFrequiringspecializedinterventions.AppropriatemeasuresunderStagesA,B,CDecisionre:appropriatelevelofcareOPTIONSCompassionateend–of-lifecare/hospiceExtraordinarymeasureshearttransplantchronicinotropespermanentmechanicalsupportexperimentalsurgeryordrugs27STAGEDRefractoryHFreq

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