HF心衰英文课件.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,HF心衰英文课件,Heart failure(HF),Meaning of HF,1.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.,中国心力衰竭流行病学,推算我国目前成年人中约,400,万心衰患者,随着年龄增加，心力衰竭患病率显著上升,城市农村，北方南方，,与我国冠心病和高血压的地区分布一致,冠心病和高血压是心力衰竭的主要病因,1.中华心血管病杂志 2007;35(12):1076-95.2.顾东风等.中华心血管病杂志 2003;31(1):3-6,.,心力衰竭预后,过去,40,年，心衰导致的死亡增加,6,倍（,AHA 2005,）,2007,年中国心衰诊疗指南指出，有临床症状的患者,5,年生存率与恶性肿瘤相仿,25%,新发心力衰竭患者在,1,年内死亡,(ESC 1999,）,心力衰竭反复入院治疗很常见，超过,50%,患者半年内即再入院治疗,(,Krumholz,et al.1997,Vinson et al.1990,Burns et al.1997),狄兰.托马斯,蒋介石,伊丽莎白.泰勒,聂荣臻,叶利钦,詹姆斯.门罗,詹姆斯.布朗,”Two new epidemics of cardiovascular,disease are emerging:heart failure and,atrial fibrillation.”,Eugene Braunwald,NEJMNow 1997,心力衰竭心脏疾病的最后战场,E Braunwald ACC 2003,2.HF=systolic HF and/or diastolic HF,3.HF and cardiac dysfunction,(1)cardiac dysfunction=systolic dysfunction or diastolic dysfunction via instrumental examination without signs,(2)HF=cardiac dysfunction+signs,The Donkey Analogy,Ventricular dysfunction limits a patients ability to perform the routine activities of daily living,Lets compare our heart to this donkey,and our body to the wagon,that this donkey has to,pullevery day.,Fundamental causes,1.primary decreased myocardial,contractility such as,coronar heart disease,(hungry),myocarditis,cardiomyopathy.,(injury),治疗,Fundamental causes,2.increased burdens to the heart,increased afterload(pressure load):hypertension,aortic stenosis,pulmonary stenosis,pulmonary hypertension.,Fundamental causes,increased preload(volume load):,mitral incompetence,aortic incompetence,tricuspid incompetence,atrial septal defect(ASD),ventricular septal defect(VSD),(PDA),hyperthyroidism,anemia,心脏功能的生理基础,心排血量,心肌收缩力,前负荷,（舒张期容量）,后负荷,（射血阻抗）,心率,房室收缩协调性,心脏机械结构完整性,原发性心肌损害：缺血性心肌损害,心肌炎或心肌病,心肌代谢障碍（糖尿病性心肌病等）,高血压、瓣膜狭窄（半月瓣）,心脏瓣膜关闭不全、血液返流,左、右心分流或动静脉分流,全身血容量增加，如贫血、甲亢,心力衰竭的基本病因,Precipitating causes,1.infection,especially respiratory infection,2.arrhythmias,3.physical or emotional excesses e.g.pregnancy and delivery,4.rapid intravenous infusion,excessive salt taking,5.electrolyte imbalance,6.primary disease deterioration or a new disease happens,Pathogenesis and pathophysiology,1.Compensate heart failure,2.some cytofactors take part in heart failure,3.about diastolic insufficiency,4.ventricular remodeling,1.Compensate heart failure,cardiac dilatation,by way of the Frank-Starling principle,contractile force increases.,cardiac hypertrophy,neurohumoral activation,a.Increase in sympathetic nervous activity,b.RAAS activated(rennin angiotension aldosterone system),N Engl J Med 2003;348:2007-18,收缩性 vs 舒张性,急性心梗后的心室重建,开始心梗,心梗持续,（几小时至几天）,全面重建,（几天至几月）,在舒张性和收缩性心力衰竭中的心室重建,正常的心脏,心脏肥厚,（舒张性心衰）,心脏扩大,（收缩性心衰）,高血压和心梗后的心室重构,浓度水平,血浆,去甲肾上腺素,(pg/mL),NL,HF,血浆,肾素激活,(ng/mL/h),15,12,9,6,3,0,NL,HF,精氨酸,血管加压素,(pg/mL),12,6,4,2,0,NL,HF,心房钠尿肽,(pg/mL),300,250,200,150,100,50,0,NL,HF,内皮素,-1,(pg/mL),8,6,4,2,0,NL,HF,600,500,400,300,200,100,0,Adapted from Cohn JN.Cardiology.1997;88:26,.,neurohumoral activation,累计死亡率(%),月,NE 900pg/ml,100,80,60,40,20,0,0,12,24,36,48,60,总 体,P50%,b.function of relaxation:E/A1.2,Diagnosis and differential,diagnosis,2.Differential diagnosis,:,Bronchial asthma:,young,allergichistory,typical wheezing(哮鸣音),alleviate symptoms of dyspnea after cough out sputum,Diagnosis and differential,diagnosis,Pericardial effusion,Constrictive pericarditis:,medical history,signs of heart and perivascular,echocardiogram the most sensitive and specific noninvasive method,Diagnosis and differential diagnosis,Hepatocirrhosis with ascites and edema of lower extremity,distention of jugular veins,hepatojugular reflux(+).,Treatment of chronic heart failure,Principle:,alleviate symptoms,improve life quality.,inhibition of progressive ventricular remodeling.,reduce mortality and extend life.,Treatment of chronic heart failure,treatment of the underlying causes and precipitating causes,2.rest and restriction of salt take(1.5-2.5g/d),3.pharmacologic treatment,Non-pharmacological management,A strong relationship between healthcare professionals and patients as well as sufficient social support from an active social network has been shown to improve adherence to treatment.It is recommended that family members be invited to participate in education programmes and decisions regarding treatment and care,Sabate E.Adherence to Long-term Therapies.Evidence for Action.Geneva:WHO;2003.,People involved in care,The Players,调整生活方式,1,限钠：,轻度,心衰患者,23g/d,，,中到重度,心衰患者,2 g/d,。,2限水：低钠血症，血钠130mg/L，液体摄入量,2L/d,。,3营养和饮食：,低脂,饮食，,戒烟,，肥胖患者应,减轻体重,；心脏恶液质者，给予,营养支持,，如血清白蛋白。,4,休息,和适度,运动,心理和精神治疗,压抑、焦虑和孤独,在心衰恶化中发挥重要作用主要的死亡预后因素；,情感,干预；,心理,疏导；,酌情应用,抗抑郁药物,。,Pharmacological therapy,Moity:rPrbidognosis:,Reduce mortality,Improve quality of life,Prevention:,Reduce hospitalization,Treatment of chronic heart failure,1)Diuretics:,furosemide,dihydrochlorothiazide(potassium-losing),antistone(potassium-sparing),Diuretics,Diuretics are recommended in patients with HF and clinical signs or symptoms of congestion.,Class of recommendation I,level of evidence B,利尿剂临床应用,起始和维持：,小剂量开始,，如呋噻米每日,20mg,，氢氯噻嗪每日,25mg,逐渐增量,直至尿量增加，体重每日减轻,0.5-1.0Kg,。,一旦病情控制,(,如肺部罗音消失，水肿消退，体重稳定,),，以,最小有效剂量长期维持,。,维持期间，据液体潴留情况,随时调整,剂量。,利尿剂抵抗,心衰进展和恶化时常需,加大,利尿剂,剂量,，最终,再大剂量,亦,无反应,时，即出现利尿剂抵抗。,解决方案：,静脉应用,利尿剂如呋噻米持续静脉滴注(1040mg/h)；,2种或2种以上利尿剂,联合使用,；,应用增加肾血流的药物,，如短期应用小剂量的多巴胺150250g/min。,Treatment of chronic heart failure,2)Angiotensin Converting Enzyme Inhibitors(ACEI),-improve prognosis,long-term use of ACEI has significant effects,such as captopril,benazepril,ACE inhibitors,Unless contraindicated or not tolerated,an ACEI should be used in all patients with symptomatic HF and a LVEF 40%.,Treatment with an ACEI improves ventricular function and patient well-being,reduces hospital admission for worsening HF,and increases survival.,In hospitalized patientstreatment with an ACEI should be initiated before discharge.,Class of recommendation I,level of evidence A,CONSENSUS(1987)and SOLVD-Treatment(1991),血管紧张素转换酶抑制剂(ACEI),降低,心衰患者,死亡率,，是治疗心衰的,首选药物,。,越严重,的心衰患者,受益越大,。,显著降低死亡率、因心衰住院和再梗死率。,ACEI应用方法,采用,目标剂量,或患者,能耐受的最大剂量,。,极小剂量开始,，每隔周剂量加倍，最大耐受量可长期维持。,监测血压、血钾和肾功能,。如果肌酐增高,225 mol/l,k+5.5mmol/l,hypotension,ACEI不良反应,低血压。,肾功能恶化。,高血钾。,咳嗽：干咳。,血管性水肿。,Treatment of chronic heart failure,3)the agent of improving myocardial contractility,digitalis:Digoxin(0.125mg qd po),Cedilanid(0.2-0.4mg st iv),indication:,chronic congestive heart failure complicated by atrail flutter and fibrillation and a rapid ventricular rate,地高辛应用要点,适用于,已应用ACEI/ARB、受体阻滞剂和利尿剂,治疗,而,仍持续有症状的心衰,患者。,适用于,伴快速心室率的房颤,患者。,NYHA级,患者和,疾病早期,不主张应用。,维持量疗法,，0.25mg/d。,70岁以上，肾功能减退,者宜用,0.125mg每日或隔日一次,。,地高辛,血清浓度与疗效无关,，不需用于监测剂量。,地高辛不良反应,主要见于大剂量时，包括：,心律失常,。,胃肠道症状,。,神经精神症状,。,常出现于血清地高辛药物浓度2.0ng/ml时，也可见于地高辛水平较低时。Treatment of chronic heart failure,contraindication:,1)WPW with AF,2)degree AVB,degree AVB,3)sick sinus syndrome(SSS),4)hypertrophic obstructive cardiomyopathy(HOCM),5)severe mitral stenosis(SMS),6)acute myocardiac infarction(first 24 h)(AMI),adrenegic receptors activators a.Dopamine:2-5g/kg,min myocardial contractility vascular dilatation HR-,Phosphodiesterase inhibitors,a.Amrinone,b.Milrinone,4)Beta blocker:,-improve prognosis,metaprolol carvedilol,受体阻滞剂应用要点,无限期终身使用受体阻滞剂,（禁忌证或不能耐受除外）：慢性收缩性心衰，NYHA、级病情稳定患者，以及阶段B、无症状性心衰或NYHA级的患者(LVEF40%)。,严密监护下应用,：NYHA 级心衰患者。,在,ACEI,和,利尿剂基础上加用,受体阻滞剂。,最适剂量下使用,。受体阻滞剂应用要点,清晨静息心率,不宜低于55次/分,。,需监测,低血压、液体潴留和心衰恶化、心动过缓、房室阻滞及无力等不良反应。,从,极小剂量开始,，每24周剂量加倍。,症状改善常在治疗23个月后才出现，即使症状不改善，亦能防止疾病的进展；不良反应一般不妨碍长期用药。,受体阻滞剂禁忌证,1)支气管痉挛性疾病、心动过缓(心率60次/分)、度及以上房室阻滞(除非已安装起搏器)。,2)心衰患者伴液体潴留，利尿后再开始应用。,5)Aldosterone-receptors inhibitors,-improve prognosis,antistone,Treatment of chronic heart failure,chronic heart failure-choice of pharmacologic therapy(systolic dysfunction),NYHA ACEI Diuretic Digitalis Vasodilator Beta blocker,+After AMI,+/-+,+,+,心力衰竭的药物治疗,改善血流动力学 纠正神经内分泌异常,强心药,利尿剂,扩血管药,转换酶抑制剂,受体阻滞剂,醛固酮抑制剂,心力衰竭治疗药物,延长寿命 中性（改善症状）缩短寿命,转换酶抑制剂,受体阻滞剂,醛固酮抑制剂,洋地黄,肾上腺素能受体兴奋剂,磷酸二酯酶抑制剂,利尿剂,Acute cardiac insufficiency,Underlying and precipitating causes,1.tight mitral stenosis,especially in presence of rapid heart rate,2.extensive AMI,3.hypertension,4.tachyarrhythmia and severe bradyarrhythmia,5.rapid intravenous infusion,Clinical manifestation,1.extreme degree of,breathlessness,and,anxiety,with sensation of,suffocation,sitting up gasping for breath,pale,and,cyanotic,restless,and,sweating,coughing and wheezing,producing copious,frothy sputum(white or pink in color),2.,rales,extending from base upward to fill the whole chest.,BP,at first may be elevated,in severe attacks BP drops and shock supervenes.,S1,HR,P2,protodiastolic gallop.,Treatment,1.put in sitting position,2.inhalation of high concentration O2,3.Marphine 5-10 mg iv or ih,4.furosemide 20-40 mg iv,5.vasodilators:sodium nitroprusside(SNP),nitroglecerin,regitine(酚妥拉明),6.digitalis:cedilanid 0.4-0.8mg in 5%GS 20ml st iv in 20 min.,7.aminophyllin:0.125-0.25 in 5%GS 20ml st iv in 10 min.,THE END,