舒張性心力衰竭的超聲心動(dòng)圖評(píng)價(jià)及其診治現(xiàn)狀課件

1、舒張性心力衰竭的超聲心動(dòng)圖評(píng)價(jià)及其診治現(xiàn)狀衛(wèi)生部北京醫(yī)院心內(nèi)科 汪芳Mortality in DHF Owan TE et al. N Engl J Med. 2006; 355: 251-259; Bhatia RS et al. N Engl J Med. 2006; 355: 260-269. 1 year mortality293222.225.5舒張性心力衰竭（diastolic heart failure, DHF）有充血性心力衰竭典型的表現(xiàn)（肺循環(huán)和體循環(huán)淤血） 非心臟瓣膜病 靜息時(shí)伴異常的舒張性功能不全 收縮功能正?；騼H有輕微減低診 斷 要 點(diǎn)DHF的主要病因和誘發(fā)因素 老年人

2、，女性 心房顫動(dòng) 高血壓伴左心室肥厚 肺部感染 糖尿病 腎功能不全 冠心病心肌缺血 貧血 肥胖 限制性和浸潤(rùn)性心肌病參數(shù)SHFDHF病史冠心病高血壓糖尿病瓣膜性心臟病陣發(fā)性呼吸困難+ + + + + + + + + + + + + + + +體格檢查心界擴(kuò)大心音低鈍S3 奔馬律S4 奔馬律高血壓瓣膜返流啰音水腫頸靜脈充盈+ + + + + + + + + + + + + + + + + + + + + +胸部X線(X-ray)心臟擴(kuò)大肺淤血+ + + + + + + + + + + + + + +收縮性HF(SHF)與DHF: 癥狀與體征Givertz MM et al. In: Braunw

3、ald E, Zipes DP, Libby P, eds. Heart Disease, 7th edition. Philadelphia, Pa: WB Saunders. 2001;534-561.中國(guó)舒張性心力衰竭診斷標(biāo)準(zhǔn) （2007指南）有典型心衰的癥狀和體征；LVEF正常（45%），左心腔大小正常；UCG有左室舒張功能異常的證據(jù)；UCG檢查無(wú)瓣膜病，心包疾病及肥厚或限制型心肌病。舒張性心力衰竭的診斷標(biāo)準(zhǔn) 主要標(biāo)準(zhǔn)1. 臨床 心衰證據(jù) 弗萊明翰標(biāo)準(zhǔn) (2個(gè)主要或1個(gè)主要2個(gè)次要標(biāo)準(zhǔn)) 波士頓標(biāo)準(zhǔn) (5-7分:可能HF; 8-12分: 確診HF) 血漿BNP升高 (400 pg/ml

4、3) 或胸部X-線示肺淤血 心肺運(yùn)動(dòng)試驗(yàn)示肺功能減弱2.LVEF及心腔大小正常3. 左心室舒張、充盈異常，舒張期僵硬明確證據(jù)1. 左心室肥厚或向心性重構(gòu)2. 左房擴(kuò)大(無(wú)房顫)3. 多普勒超聲心動(dòng)圖或?qū)Ч軝z查有舒張功能不全的證據(jù)Yturralde RF and Gaasch WH. Prog Cardiovasc Dis 2005;47:314-319. Korenstein D et al. BMC Emerg Med 2007;7:6超聲心動(dòng)圖診斷要點(diǎn)Mitral inflowPulm venous flowTDIColour M-mode flow propagation velocit

5、y LA size, LA volumeLV ejection fractionLV hypertrophy2DDoppler正常人 23 6 ml/m2 松弛異常 25 8 ml/m2 假性正常 31 8 ml/m2 （34ml/m2 ）限制性充盈 48 12 ml/m2 J Am Coll Cardiol, 2005; 45:87-92左心房容量指數(shù)（LA容量/體表面積）與舒張功能異常呈正比 NormalSystolicHeart FailureDiastolicHeart FailureAurigemma, Zile, GaaschCirculation 2005Phases of ca

6、rdiac cycleEEAAEAEAa reversalSDSDnormalabnormalMitral A durationPV a durationMitral inflowPV flowDOPPLER FLOW VELOCITY彩色多普勒M型（CMM）Normal VpSlow VpFlow propagation velocity of mitral inflow by colour M-modeNormalAbnormalrelaxationPseudo-normalizedEmAmSmAmSmEm彩色多普勒M型（CMM）normal diastolic diastolic sys

7、tolic dysfunction heart failure heart failuresmsmsmEmsmEmEmEmAmAmAmAmmmmmTDI of mitral annulus velocity, E / Em is also useful to detect impaired LV relaxation in patient with atrial fibrillationDae-Won Sohn, et al JASE 1999Estimation of LV filling pressure using E / Em SR Ommen, RA Nishimura et al

8、Circulation 2000 S.F Nagueh et alCirculation 1999Exception :in pts with constrictive pericarditis E / E is inversely proportional to PCWP Jong-Won Ha, Jae Oh et al Circulation 2001S. F NaguehCirculation 1999E / VpFor estimation of filling pressureGrade E/ADT S/D Pva A-a dur Vp Tau(ms) (cm/s) (ms) (c

9、m/s)Normal 1-2 150-200 1 35 45 NMild 200 1 35 20 45 Mild-mod 200 1 35 20 45Moderate 1-2 150-200 0.5- 35 20 2 150 35 20 45Indices of diastolic dysfunctionParameters to identify patients with elevated LV filling pressureEnlarged LADT 35 cm/sE / A 2E / Em 15E / Vp 2S fraction of PV flow 40% or S50% DMi

10、tral A duration PV a reversal durationEstimation of LV filling pressuredeceleration time (DT) 20 mmHgprovided that LVEF is abnormal eg. 15 indicates PCWP 20 mmHguseful even in AF, sinus tachycardiabut not accurate in constrictive pericarditisVentricular relaxationDiastolic suctionErectile coronary e

11、ffectViscoelastic forces of myocardiumPericardial restraintVentricular interactionAtrial contributionFactors influencing LV filling during diastoleLoad dependenceChamber complianceNon-uniformity of relaxationHeart rateloading conditionmitral regurgitationAginghypertrophic cardiomyopathy constrictive

12、 pericardiatistechnical limitations etcLimitations舒張性心力衰竭治療原則 建 議 分類(lèi) 證據(jù)級(jí)別* 醫(yī)師應(yīng)當(dāng)根據(jù)發(fā)表的指南控制收縮期和舒張期高血壓 I A* 醫(yī)師應(yīng)當(dāng)控制心房顫動(dòng)患者的心室率 I C* 醫(yī)師應(yīng)當(dāng)使用利尿劑控制肺充血和周?chē)运[ I C* 冠狀動(dòng)脈疾病患者有癥狀性或可證實(shí)的心肌缺血對(duì)心 臟舒張功能有不利影響時(shí)，最好行冠狀動(dòng)脈重建治療 IIa C* 心房顫動(dòng)患者恢復(fù)并維持竇性心律可能有助于改善癥狀 IIb C* 高血壓患者應(yīng)用受體阻滯劑、ACEI、ARB或 鈣拮抗劑，可能有助于最大程度緩解癥狀 IIb C* 應(yīng)用洋地黃來(lái)最大程度減輕

13、心力衰竭癥狀的價(jià)值尚不清楚 IIb C 06年AHA/ACC對(duì)舒張性心力衰竭患者的治療建議DHF治療推薦Heart Failure Society of America Practice Guideline (2006) 低鈉飲食 C 容量過(guò)度負(fù)荷患者使用噻嗪類(lèi)或襻利尿劑 C 使用ARBs或ACEIs ARBs :B, ACEI :C 合并冠心病或糖尿病患者使用ACEIs或ARBs C 使用阻滯劑 心肌梗死史 A 高血壓 B 需要控制心室率的心房顫動(dòng) B 使用CCB diltilzem或verapamil用于阻滯劑不能耐受的心房顫動(dòng) C 心絞痛癥狀 A 高血壓 CAdams KF, et al

14、. J Card Fail 2006;12:10-38總 結(jié)DHF診斷步驟(ESC共識(shí),2007) HF的癥狀或體征LVEF 50% 且 左心室舒張末期容積指數(shù)(LVED VI) 12 mmHg或左心室舒張末壓16 mmHg組織多普勒NT proBNP 220 pg/mlBNP 200 pg/mlE/E 1515 E/E 8超聲血流多普勒 :. E/A DT. 肺靜脈血流. 左房擴(kuò)大 . 左心室肥厚. 房顫NT proBNP 220 pg/mlor BNP 200 pg/mlDHF組織多普勒E / E 8 From Paulus. Eur Heart J. 2007Treatment of d

15、iastolic heart failureImprove acute symptom of pulmonary congestionTreat underlying / precipitating causediuretics, nitratesHypertensionIschemiaAtrial arrhythmia: diuretics, ACE I, ARB, b-blockers, Ca-blockers: b-blockers, nitrates, Ca-blockers, revascularization: rate control, rhythm control, warfarin謝謝！Invasive cardiac catherization , relaxation abnormality is assessed byintracardiac pressures negative peak dP/dt time constant of relaxatio