英文班内科学心力衰竭.pptx

英文班内科学心英文班内科学心力衰竭力衰竭英文班内科学心力衰竭第1页Heart failure(HF)Conception:heart failure is a final common pathway for many cardiac disorders of diverse etiology and pathogenic mechanisms.It is a clinical syndrome,manifested as a result of the inability of the heart to match its output to the metabolic needs of the body even though the filling pressure of the heart is adequate.英文班内科学心力衰竭第2页Categories of HF1.left,rightandwhole2.acuteandchronic3.systolicanddiastolic英文班内科学心力衰竭第3页stage of HFA.Pre-heartfailureB.Pre-clincalheartfailureC.ClinicalheartfailureD.Refractoryend-stageheartfailure英文班内科学心力衰竭第4页New York Heart Association Functional ClassificationClass No limitation of physical activity No sympotoms with ordinary exertion Class Slight limitation of physical activity Ordinary activity causes symptomsClassMarked limitation of physical activityLess than ordinary activity causes symptomsLess than ordinary activity causes symptoms Asymptomatic at restClassInability to carry out any physical activity withoutdiscomfortSympotoms at rest英文班内科学心力衰竭第5页Stage and Class of HF心衰分期是心衰分期是NYHANYHA分级补充，但不能分级补充，但不能替换替换 NYHANYHA分级分级NYHANYHA分级分级 在详细病人在详细病人可上下变动可上下变动 (对治疗反应和对治疗反应和/或疾病进程不一样或疾病进程不一样)分期分期 随心脏重构加重随心脏重构加重只能进展只能进展 英文班内科学心力衰竭第6页6-minwalkdistance milddegree：450mmoderatedegree：150-450mseveredegree：150mEvaluationofchronicHFcardiacfunction 英文班内科学心力衰竭第7页Fundamental causes1.primarymyocardialdisease2.increasedburdenstotheheart英文班内科学心力衰竭第8页Fundamental causes1.primarydecreasedmyocardialcontractilityA.coronaryheartdiseaseB.myocarditis,cardiomyopathyC.myocardialmetabolicdisorder英文班内科学心力衰竭第9页Fundamental causes2.increasedburdenstotheheartincreasedafterload(pressureload):A.hypertensionB.aorticstenosisC.pulmonarystenosisD.pulmonaryhypertension英文班内科学心力衰竭第10页Fundamental causes 2.increasedburdenstotheheartincreasedpreload(volumeload):A.mitralincompetenceB.aorticincompetenceC.tricuspidincompetenceD.atrialseptaldefect(ASD)E.ventricularseptaldefect(VSD)F.patentductusarteriosus(PDA)G.hyperthyroidismH.anemia 英文班内科学心力衰竭第11页英文班内科学心力衰竭第12页Precipitating causesA.infection,especiallyrespiratoryinfectionB.arrhythmias,AFC.physicaloremotionalexcessese.g.pregnancyanddeliveryD.rapidintravenousinfusion,excessivesalttakingE.malpraticeF.primarydiseasedeteriorationoranewdiseasehappens英文班内科学心力衰竭第13页Pathogenesis and pathophysiology1.Compensateheartfailure2.Ventricularremodeling3.Aboutdiastolicinsufficiency4.Humoralfactorschange英文班内科学心力衰竭第14页1.Compensate heart failurelFrank-Starlingprinciplelneurohumoralactivationlmyocardialhypertrophy英文班内科学心力衰竭第15页1.Compensate heart failurecardiacdilatation,bywayoftheFrank-Starlingprinciple,contractileforceincreases.英文班内科学心力衰竭第16页1正常静息正常静息2正常活动正常活动3心衰活动心衰活动3心衰静息心衰静息心肌收缩性心肌收缩性BADC左室舒张末容量左室舒张末容量图图321正正常常和和心心力力衰衰竭竭时时对对机机体体活活动动时时代代偿偿情情况况最最 大大 活活动动活动活动静息静息左室作功左室作功呼呼 吸吸 困困难难肺水肿肺水肿E4静息静息致死性心肌受损致死性心肌受损英文班内科学心力衰竭第17页1.Compensate heart failureneurohumoralactivationa.Increaseinsympatheticnervousactivityb.RAASactivated(renninangiotensionaldosteronesystem)英文班内科学心力衰竭第18页心力衰竭心力衰竭神经体液代偿和失代偿神经体液代偿和失代偿交感神经激活交感神经激活水、钠潴留水、钠潴留水肿水肿 肺瘀血肺瘀血血流动力学异常血流动力学异常血管收缩血管收缩心肌耗氧量增加心肌耗氧量增加心肌氧供给降低心肌氧供给降低心肌细胞功效心肌细胞功效障碍和坏死障碍和坏死心肌重塑心肌重塑功效恶化功效恶化疾病进展疾病进展血管担心素血管担心素儿茶酚胺儿茶酚胺毒性作用毒性作用心肌细胞凋亡心肌细胞凋亡肾素肾素-血管担心素系统激活血管担心素系统激活代偿代偿失代偿失代偿心衰症状心衰症状体征加重体征加重治疗目标治疗目标增强心肌收缩增强心肌收缩英文班内科学心力衰竭第19页心肌细胞死亡心肌细胞死亡心力衰竭心力衰竭心肌细胞死亡心肌细胞死亡+心肌能量消耗心肌能量消耗后负荷后负荷血管收缩血管收缩心排血量心排血量神经体液兴奋神经体液兴奋RASSASInSP3循环循环心肌能量消耗心肌能量消耗胞浆胞浆Ca2+cAMPInSP3心脏心脏心肌松弛性心肌松弛性变力效应变力效应+心律失常心律失常猝死猝死图图322肾素肾素血管担心素和交感血管担心素和交感肾肾上腺素能系统激活时对心脏代偿功效影响上腺素能系统激活时对心脏代偿功效影响2.RAASinHeartFailure英文班内科学心力衰竭第20页2.RAASinHeartFailure英文班内科学心力衰竭第21页1.Compensate heart failure myocardial hypertrophy MyocardialcellhypertrophysystolepowerNotincreasednumberMyocardialfibreincreasednumberenergyMyocardialcompliance(顺应性）英文班内科学心力衰竭第22页2.Ventricular remodeling英文班内科学心力衰竭第23页2.Ventricular remodelingheart failure is the result of ventricular remodeling.ReducethemyocardialcellsdecreaseofthesystolicfunctionIncreasedmyocardialfibrosis decreaseoftheVentricularcomplianceHeart cavity expansionmyocardial hypertrophyextracellular matrixcollagen fibersMyocardial cells英文班内科学心力衰竭第24页3.about diastolic insufficiency Characteristic:inthesecases,fillingoftheleftorrightventricleisabnormal.Mechanism:lmyocardialrelaxationisimpaired.lMyocardialcompliancedecreasing.outcome:diastolicpressures-venousereturn-fluidretention,dyspnea,intolerance英文班内科学心力衰竭第25页4.some cytofactors take part in heart failure ANP(atrialnatriureticpeptide)BNP(brainnatriureticpeptide)AVP(argininevassopressin)Endothelin(NE,angiotensin)Urine volumeperipheral vascularsympathetic nervousRAASVentricular remodeling 英文班内科学心力衰竭第26页 Ventricular remodelingneurohumoral activationheart failure英文班内科学心力衰竭第27页Chronic heart failure,CHF英文班内科学心力衰竭第28页Clinical manifestations1.Left heart failurepulmonarycongestionlesscardiacoutput2.Right heart failuresystemicvenouscongestion3.Whole heart failure英文班内科学心力衰竭第29页1.Left heart failure 1)dyspnea1.exertional dyspnea2.paroxysmal nocturnal dyspnea3.orthopnea,4.acute pulmonary edema 英文班内科学心力衰竭第30页1.Left heart failure2)cough,hemoptysis,spit pink sputum 3)fatigue,dizziness,palpitation.4)oliguria,renal dysfunction英文班内科学心力衰竭第31页signsign 1)pulmonary basal rales bilaterally or right-side2)enlarged left heart pulsus alternans,protodiastolic gallop P2 increasedPulmonaryedema英文班内科学心力衰竭第32页 2.Right heart failuresymptomuabdominaldiscomfortuanorexia(厌食)unausea,vomituexertionaldyspnea英文班内科学心力衰竭第33页 2.Right heart failuresignuliver enlargeduascitesudistention of jugular veinsuhepatojugular reflux(+)uperipheral edema,most mark in dependent partsucyanosisuprotodiastolic gallop,u functional murmurs of tricuspid and pulmonary valve英文班内科学心力衰竭第34页3.Whole heart failureLHFRHF英文班内科学心力衰竭第35页laboratory examinationBNP and NT-proBNP英文班内科学心力衰竭第36页阳性阳性阴性阴性NT-proBNP NT-proBNP 临床应用流程图临床应用流程图辅助诊疗心衰辅助诊疗心衰辅助判断进展期心衰患者预后辅助判断进展期心衰患者预后英文班内科学心力衰竭第37页laboratory examinationCnTIbloodroutineexaminationroutineurineexaminationbiochemicalexaminationFT3,FT4,TSH英文班内科学心力衰竭第38页ECG(electrocardiogram)lischemialOMIlconductionblocklarrhysmia英文班内科学心力衰竭第39页X-rayPulmonarycongestionPleuraleffusionKerlryBRightpulmonaryarterybroadeningPulmonaryhilarbutterflyshape英文班内科学心力衰竭第40页 EchocardiogramlLVEF50%lE/A1.2lLVEDV/LVESVLVEDV/LVESVlLVEDD/LVESDLVEDD/LVESDlventricularwallmotionCardiac magnetic resonance,CMR99MTC-MIBI SPECT(radionuclide)Coronary angiography英文班内科学心力衰竭第41页CardiacCatheterizationSwan-GanzPCWP12mmHgCI2.5L/（min.m2）英文班内科学心力衰竭第42页CardiopulmonaryExerciseTesting(CPET)lChronicstableHFlMeasurementofrateofoxygenuptake(VO2),rateofCO2production(VCO2),duringmaximal“symptom-limited”exercise英文班内科学心力衰竭第43页英文班内科学心力衰竭第44页Diagnosis and differential diagnosis1.Diagnosis:medical history+symptoms+signs+examExam:(1)ECG:rarely normal in systolic HF.(2)x-ray:to detect cardiomegaly and pulmonary congestion.(3)Echocardiogram:It is critical importance.to determine the underlying causes of HF to assess the severity of ventricular dysfunction a.function of contraction:LVEF50%b.function of relaxation:E/A1.2 英文班内科学心力衰竭第45页2.Differential diagnosis:cardiacasthmaBronchialasthmaHistoryHeartdiseaseallergichistoryageolderyoungtimenightspringHFsignyesnoLungsignpulmonarybasalrales typicalwheezingx-rayPulmonarycongestionLVlargeemphysemaalleviatesymptomsofdyspneaDiureticsdigitalisisosorbidedinitrateaftercoughoutsputumantispasmodic英文班内科学心力衰竭第46页2.Differential diagnosis:Pericardial effusion,Constrictive pericarditis:distention of jugular veins,hepatojugular reflux(+)liver enlarged,ascitesperipheral edema,most mark in dependent parts medical history signs of heart and perivascular echocardiogram,CMR the most sensitive specific noninvasive method英文班内科学心力衰竭第47页2.Differential diagnosis:Hepatocirrhosis with ascites and edema of lower extremity distention of jugular veins(-)hepatojugular reflux(-)英文班内科学心力衰竭第48页Treatment of chronic heart failurePrinciple:A.alleviatesymptoms,improvelifequality.B.treatmentforprimarydiseaseandprecipitatingcausesC.AntagonismofneurohumoralactivationD.inhibitionofprogressiveventricularremodelingE.reducemortalityandextendlife.英文班内科学心力衰竭第49页Treatment of chronic heart failurelGenerallPharmacologic treatmentlNon-medicine treatment英文班内科学心力衰竭第50页General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation英文班内科学心力衰竭第51页General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation1.LifestylemanagementuEducationuRegulateweightuDietarymanagement:salttake2.Restandaction3.Treatmentforprimarydiseaseandprecipitating 英文班内科学心力衰竭第52页General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation1.Rest2.Dietarymanagement:salttake3.Diuretics furosemidedihydrochlorothiazide(potassium-losing)antistone(potassium-sparing)英文班内科学心力衰竭第53页The main point of diuretics applicationl对于有症状心衰，当液体负荷过重已表现为肺淤血或外周水肿时，利尿剂是基本治疗。应用利尿剂可快速改进呼吸困难并增加运动耐量（I类提议，证据级别A）l尚无大型随机对照试验评定这类药品对症状和生存影响。l如能耐受，利尿剂一直应与ACEI和-受体阻滞剂一起使用。（I类提议，证据级别C）。英文班内科学心力衰竭第54页 襻利尿剂应作为首选。噻嗪类仅适适用于轻度液体潴留、伴高血压和肾功效正常心衰患者(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),逐步加量。一旦病情控制即以最小有效量长久维持。每日体重改变是最可靠检测利尿剂效果和调整利尿剂剂量指标。长久服用利尿剂应严密观察不良反应出现如电解质紊乱、症状性低血压，以及肾功效不全，尤其在服用剂量大和联适用药时（类，B级）。The main point of diuretics application英文班内科学心力衰竭第55页General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation1.Rest2.Dietarymanagement:salttake3.Diuretics4.Vasodilator sodium nitroprusside(SNP)nitroglecerinregitine(酚妥拉明酚妥拉明)英文班内科学心力衰竭第56页The main point of Vasodilator applicationl直接血管扩张剂对于CHF治疗无特殊作用。（类类，A级）l血管扩张剂可用于不能耐受ACEI或ARBs患者；伴有心绞痛或高血压可考虑应用（类，B级）l禁忌证：血容量不足，低血压、肾功效衰竭 心脏流出道或瓣膜狭窄患者英文班内科学心力衰竭第57页General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation1.Digitalis （1）effection:Positiveinotropic：inhibitNa+-K+-ATPenzymeintrocellularNa+、K+Na+-Ca2+exchangeintrocellularCa2+myocardialsystolepowerintrocellularK+，digitalispoisoning英文班内科学心力衰竭第58页General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation1.Digitalis （1）effection:Positiveinotropic：Electrophysiological Inhibitcondutionsystem,espiciallyatriventricularjunction.Improvetheautorhythmictyofatrium,junctionregionandventricle.英文班内科学心力衰竭第59页General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation1.Digitalis （1）effection:Positiveinotropic：ElectrophysiologicalParasympatheticstimulatinganti-sympatheticnerveexciting 英文班内科学心力衰竭第60页General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation1.Digitalis （1）effection:Positiveinotropic：ElectrophysiologicalParasympatheticstimulatingRoleintherenaltubulecellsreducingsodiumreabsorptioninhibitthesecretionofrenin 英文班内科学心力衰竭第61页General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation1.Digitalis （2）applicationindication:chroniccongestiveheartfailurecomplicatedbyatrailflutterandfibrillationandarapidventricularrate英文班内科学心力衰竭第62页General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation1.Digitalis （2）applicationcontraindication:WPWwithAFdegreeAVB,degreeAVBsicksinussyndrome(SSS)Hypertrophiccardiomyopathy(HOCM)severemitralstenosis(SMS)acutemyocardiacinfarction(first24h英文班内科学心力衰竭第63页General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation1.Digitalis (3)digitalispoisoningfactors：K+,O2,RFClincalexpression:gastricbowelreaction;arrhythmia;neurologicalandvisualchangeDiagnosis：2.0ng/ml英文班内科学心力衰竭第64页ArrhythmiaofdigitalispoisoninglVentricularPrematurebeatlNonparoxysmalatrioventricularjunctionaltachycardialAtrialPrematurebeatlAtrialfibrillatonlAtrioventricularblocklST-TchangelikefishhookCharacteristicfeature英文班内科学心力衰竭第65页General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation1.Digitalis Treatmentofdigitalispoisoningdrugwithdrawaltachycadia:supplyK+,Lidocainivbradicadia：atropiniv,notsuitableforpacemakernotsuitableforisoprenalinedisablecardioerter英文班内科学心力衰竭第66页General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation 1、Digitalis2 2、-excitant-excitantDopamine：NEprecursor2g/kg.minDopamine-R(+)expandrenalartery2-5g/kg.min12-R(+)myocardialcontractility,Vasodilate5-10g/kg.min-R(+)BP,HRDobutamine：Dopaminederivatives2g/kg.min10g/kg.minVasodilate,HR-smalleffects英文班内科学心力衰竭第67页General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation 1、Digitalis2、-excitant3、Phosphodiesteraseinhibitors1、effect:restrainactivityofphosphodiesterase，thedegradationofcAMP(-)cAMPCa2+channelactivationCa2+-inflowmyocardialcontractility英文班内科学心力衰竭第68页General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation 1、Digitalis2、-excitant3、Phosphodiesteraseinhibitors1、effect:2、indications：refractoryheartfailureend-stageheartfailurebeforehearttransplantation英文班内科学心力衰竭第69页General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation 1、Digitalis2、-excitant3、Phosphodiesteraseinhibitors1、effect:2、indications：3、drugs：氨力农(Amrinone)VD5-10g/kg.min米力农(Milrinone)VD0.5g/kg.min英文班内科学心力衰竭第70页General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation 1、Digitalis2、-excitant3、Phosphodiesteraseinhibitors1、effect:2、indications：3、drugs：4、defect：side-effect;mortality英文班内科学心力衰竭第71页AII AII 产生是经过各种通道产生是经过各种通道 血管担心素原血管担心素原肾素肾素血管担心素血管担心素 I(1-10)I(1-10)Ang IIAng II（1-81-8）ACEACEAT1AT1AT2AT2血管收缩血管收缩 增殖增殖醛固酮增加醛固酮增加血管扩张血管扩张 抗增殖抗增殖Ang1-7Ang1-7受体激活受体激活血管扩张血管扩张 抗增殖抗增殖ARB英文班内科学心力衰竭第72页General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation 1、RAASinhibitor1.AngiotensinConvertingEnzymeInhibitors(ACEI)vdilatebloodvesselsvinhibitRAS,sympatheticsystemvreversetheventricularremodelingvimprovearterystiffnessandsensitivityvImproveendothelialfunctionAT,Inhibitthedegradationofbradykinin英文班内科学心力衰竭第73页General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation 1、RAASinhibitor1.AngiotensinConvertingEnzymeInhibitors(ACEI)Clinicalstatusvsymptoms,exercisetolerancevmortalityvdelaytheprogressofheartfailurevreducinghospitalizationratesvpreventHFaftermyocardialinfarction英文班内科学心力衰竭第74页General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation 1、RAASinhibitor1.AngiotensinConvertingEnzymeInhibitors(ACEI)Captopril6.2525mg23/dEnalapril10mg2/dCilazapril2.5mg/dBenazepril2.510mg/dPerindopril24mg/dFosinopril510mg/dRamipril2.5mg/d英文班内科学心力衰竭第75页General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation 1、RAASinhibitor1.AngiotensinConvertingEnzymeInhibitors(ACEI)applicationmethodsustartingwithsmalldosesuiftolerated,graduallyincreasethedoseumonitoringofrenalfunctionandionsrenalfunctionchange,highpotassium,drycough,angioedema英文班内科学心力衰竭第76页General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation 1、RAASinhibitor1.AngiotensinConvertingEnzymeInhibitors(ACEI)Contraindication:anuricrenalfailurepregnancyandbrestfeedingwomanallergeRelativeContraindication:renalarterystenosisbilaterallyCr225mol/lk+5.5mmol/lhypotension英文班内科学心力衰竭第77页General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation 1、RAASinhibitor1.AngiotensinConvertingEnzymeInhibitors(ACEI)2.An