心衰問答專業(yè)知識宣貫

Question1

Tenyearsurvivalaftertheonsetofheartfailure:80-90%60-79%40-59%20-39%Under20%第1頁PrognosisinHeartFailure

Menover45yearsofAgeSurviving(%)YearsfromDiagnosis第2頁PrognosisinHeartFailure

Womenover45yearsofAgeSurviving(%)YearsfromDiagnosis第3頁Question2

Potentialunderlyingcausesofheartfailureinclude:CoronaryarterydiseaseHemochromatosisMitralregurgitationVentricularseptaldefectalloftheabove第4頁HeartFailure

TheFinalCommonPathwayischemicdiseasevalvulardiseasecardiomyopathypericardialdiseasehypertensioncongenital

HeartFailure第5頁Question3

Thepathophysiologyofheartfailurecanbestbedescribedas:afailureofprotectivemechanismsactivationofharmfulpathwaysintroductionofpathogenicinfluencesinappropriateactivationofnormalmechanismsalloftheabove第6頁PhysiologicResponsetoHeartFailureLVDysfunction

Renal-AdrenalCarotidandLABaroreceptors

Renin-AngiotensinAldosteroneSympatheticOutputSodiumandfluidretentiontachycardiavasoconstriction第7頁Question4

PhysiologiceffectsofAngiotensinIIinclude:vasoconstrictionactivationofthirstsodiumretentionaldosteronereleasealloftheabove第8頁Renin-AngiotensinSystemReninAngiotensinIAngiotensinII

decreasedrenalperfusion

decreasedNadeliverysympatheticactivityAVPReleasevasoconstrictionaldosteroneIncreasedthirstNEreleasesodiumretentiondecreasedGFR第9頁Question5

Thefollowingisafeatureoftheheartfailurestate:reducedcirculatingcatecholaminesincreasedleftventricularenddiastolicpressurereducedplasmavolumeincreasedrenalsodiumexcretionreducedpulmonarycapillarywedgepressure第10頁CompensatoryMechanismsinHeartFailureincreasedpreloadincreasedsympathetictoneincreasedcirculatingcatecholaminesincreasedRenin-angiotensin-aldosteroneincreasedvasopressinincreasedatrialnatriureticfactor第11頁Question6

Patientswithearlyheartfailuretypicallypresentwith:NosymptomsDyspneaonexertiononlyDyspneawithminimalactivityDyspneaatrestAcuterespiratorydistress第12頁HeartFailure

ClinicalManifestations

Symptomsdyspneafatigueexertionallimitationweightgainpoorappetitecough

Signstachycardia,tachypneaedemajugularvenousdistensionpulmonaryralespleuraleffusionhepato/splenomegalyascitescardiomegalyS3gallop第13頁Dyspnea

ClinicalPresentationsexertionalshortnessofbreathcoughorthopneaparoxyxmalnocturnaldyspneasevererespiratorydistressrespiratoryfailure第14頁NYHAFunctionalClassificationClassI:

patientswithcardiacdiseasebutno limitationofphysicalactivityClassII: ordinaryactivitycausesfatigue, palpitations,dyspneaoranginalpainClassIII:

lessthanordinaryactivitycauses fatigue,palpitations,dyspneaoranginaClassIV:symptomsevenatrest第15頁Question7

Edemainheartfailuretakesthefollowingform:PeripheraledemaSacraledemaAbdominaldistentionanasarcaAnyoftheabove第16頁Edema

ClinicalPresentationswhere-peripheral,sacral,generalizedobjectiveweightgainbloatingabdominaldistension第17頁Question8

Signsofrightheartfailureincludeallthefollowingexcept:PeripheraledemaPulmonaryralesElevatedjugularveinshepatomegalyPleuraleffusions第18頁LeftvsRightHeartFailureLeftHeartFailurepulmonarycongestionRightHeartFailureperipheraledemasacraledemaelevatedJVPasciteshepatomegalysplenomegalypleuraleffusion第19頁Question9

Adiagnosisofheartfailureisbestextablishedonthebasisofthefollowing:Dyspneaatrest,increasedheartsizeonchestXrayandelevatedjugularveinsDyspneawithstairclimbing,increasedheartsizeonchestXrayandheartrateof105Restdyspnea,interstitialedemaonchestXray,andelevatedjugularveinsOrthopnea,flowredistributiononchestXRay,andcracklesinlungbasesPND,bilateralpleuraleffusionsandcracklesinlungbases第20頁CriteriaforDiagnosisofCHFHISTORY

Pointsrestdyspnea 4orthopnea 4PND 3dyspneawalkingonlevel 2dyspneaonclimbing 1CHESTX-Rayalveolarpulmonaryedema 4interstitialpulmedema 3bilateralpleuraleffusion 3CTratio>0.50 3flowredistribution 2PHYSICAL

PointsHR91-110 1HR>110 2JVP>6cm 2JVP>6cm&hepatom 3lungcracklesinbase 1lungcracklesabovebase 2wheezing 3S3 38-12points-definiteCHF5-7points-possibleCHF<5points-unlikelyCHF第21頁Question10

Allthefollowingmedicationscanprecipitateheartfailureinsusceptiblepatientexcept:metoprololspironolactoneprocainamidediltiazemrosiglitazone第22頁PrecipitatingCausesofHeartFailure1.ischemia2.changeindiet,drugsorboth3.increasedemotionalorphysicalstress4.cardiacarrhythmias(eg.atrialfib)5.infection6.concurrentillness7.uncontrolledhypertension8.Newhighoutputstate(anemia,thyroid)9.pulmonaryembolism10.Mechanicaldisruption(suddenMR,VSD,AR)第23頁Question11

Thefollowinginvestigationsshouldalwaysbecarriedoutinpatientpresentingwithheartfailureexcept:RenalfunctiontestsAventilation-perfusionscanBloodcountsElectrocardiogramEchocardiogram第24頁InvestigationsforHeartFailure

EKGevidenceofischemia,infarction,LVH,RVHrhythmanalysisChestX-RaycardiacsizeevidenceofpulmonaryvascularityBloodworkCBC,renalfunction,electrolytesAssessmentofLVFunction第25頁Question12

PatientA.B.presentswithclearsignsofleftheartfailureandrespondsquicklytostandardtherapy.Follow-upassessmentrevealsnormalLVsystolicfunction.Themostlikelyunderlyingcauseofthispatient’sheartfailureis:DiastolicdysfunctionMitralvalvedisruptionPulmonaryembolismDilatedcardiomyopathyIschemicheartdisease第26頁HeartFailurewithNormalLVsystolicfunctionbetweensymptomaticepisodesischemiasuddenincreaseinmyocardialdemandsdiastolicLVdysfunction第27頁Question13

Thefollowingmechanismscontributetomyocardialdysfunctioninheartfailurepatients:IncreasedcirculatingepinephrineIncreasedcirculatingnorepinephrineIncreasedaldosteroneproductionIncreasedangiotensinproductionalloftheabove第28頁RationaleforTreatmentofHeartFailureLVdysfunctionsympatheticactivation

Renin-angiotensin

Adrenalstimulation

epinephrinenorepinephrineangiotensinIaldosteroneangiotensinII第29頁Question14

Allofthefollowinghavebeenshowntoimproveprognosisinpatientswithheartfailureexcept:digoxincarvedilolenalaprilmetoprololramipril第30頁MedicalManagementofHeartFailureDrugsthatimprovesymptomsfurosemidethiazidediureticsspironolactonedigoxinACEInhibitorsbetablockersaldosteroneantagonistsDrugsthatimproveprognosisACEinhibitorsbetablockersspironolactone*第31頁RationaleforTreatmentofHeartFailureLVdysfunctionsympatheticactivation

Renin-angiotensin

Adrenalstimulation

epinephrinenorepinephrineangiotensinIaldosteroneangiotensinIIBABsACEIsARBsspironolactone第32頁BetaBlockerTrialsMortalityperyear第33頁EnalaprilvsPlaceboinSymptomaticCHF

CONSENSUSProbabilityofDeathMonths第34頁Question15

Thefollowingarealladverseeffectsofbetablockersexcept:bronchospasmbradycardiahypotensiondepressionanxiety第35頁BetaBlockers

AdverseEffectsexcessivefatiguebradycardia,heartblockhypotensionreactiveairwaysmooddisturbances,depressionintermittentclaudicationimpotence

第36頁BetaBlockersinHeartFailure

PracticalTipsstartwithlowdoses(3.125-6.25mgcarvedilolbidor6.25-12.5mgmetoprololbid)increasedoseslowlyatintervalsof2weeksormoreavoidinpatientswithbronchospasmoradvancedheartblockwithoutpacemakerimprovementsymptomaticallyandobjectivelymaybeslowavoidabruptwithdrawl

第37頁Question16

ThefollowingarealladverseeffectsofACEInhibitorsexcept:Renaldysfunctionbradycardiahypotensioncoughhyperkalemia第38頁ACEInhibitors

AdverseEffectshypotensionrenaldysfunctionhyperkalemiacoughskinrashtastedisturbanceangioneuroticedema

第39頁Question17

Currentevidencesupportsthefollowingapproachwithrespecttodigoxin:ShouldbeusedinallpatientswithLVdysfunctionShouldbeusedchronicallyinpatientswithcontrolledheartfailuretoimprovesymptomstatusShouldbeusedchronicallyinpatientswithcontrolledheartfailuretoimproveprognosisShouldbeusedacutelyinpatientswithnewonsetheartfailureDigoxinhasnoroleinheartfailurepatients第40頁DigitalisandotherInotropicDrugs

RecommendationstoimprovesymptomsandreducehospitalizationsinpatientsinsinusrhythmwhoremainsymptomaticonACEIspatientsinatrialfibrillationandLVfailureparenteraluseofdopaminergicagentsorphosphodiesteraseinhibitorsnotrecommendedroutinely,butmaybeusedinselectpatientswithintractableheartfailure第41頁Question18

CurrentevidencesupportsthefollowingapproachwithrespecttoAngiotensinreceptorantagonists:ShouldbeusedinallpatientswithLVdysfunctionShouldbeusedchronicallyinpatientswithcontrolledheartfailuretoimprovesymptomstatusShouldbeusedchronicallyinpatientswithcontrolledheartfailuretoimproveprognosisShouldbeusedinpatientsunabletotolerateACEInhibitorsHavenoroleinheartfailurepatients第42頁AngiotensinReceptorBlockers

IndicationsmaybeconsideredforpatientsunabletotolerateACEIs第43頁AngiotensinReceptorBlockers

AdverseEffectshypotensionrenaldysfunctionhyperkalemia

第44頁Question19

CurrentevidencesupportsthefollowingapproachwithrespecttoAldosteroneantagonists:ShouldbeusedinallpatientswithLVdysfunctionShouldbeusedchronicallyinpatientswithcontrolledheartfailuretoimprovesymptomstatusShouldbeusedchronicallyinpatientswithcontrolledheartfailuretoimproveprognosisShouldbeusedinpatientswithsevereheartfailuretoimprovesymptomsShouldbeusedinpatientswithsevereheartfailuretoimprovesymptomsandprognosis第45頁AldosteroneAntagonistsinHeartFailure

EvidenceRALEStrial1663patientswithclassIII-IVheartfailurealreadyonACEIrandomizedtospironolactone(25mgod)vsplaceboafter2years,30%reductioninmortalityintreatmentgroup第46頁AldosteroneAntagonistsinHeartFailure

IndicationsPatientswithseveresymptomaticheartfailurewhoarealreadyonstandardmedications第47頁Question20

Currentevidencesupportsthefollowingapproachwithrespecttodiuretics:ShouldbeusedinallpatientswithLVdysfunctionShouldbeusedonlyinpatientswithactiveheartfailureShouldbeusedallpatientswhohavehadsymptomaticheartfailuretopreventrecurrencesShouldbeusedinallpatientswithsevereLVdysfunctionHavenoroleinheartfailurepatients第48頁DiureticsinHeartFailureveryusefulformanagementofacutecongestivestateproducerapidsymptomreliefhavenoprognosticadvantageinstablepatients第49頁DiureticsinHeartFailure

AgentsUsedfurosemidehydrochlorthiazidemetolazone第50頁Question21

Thefollowingarealladverseeffectsoffurosemideexcept:renaldysfunctionskinrashhypotensionhyponatremiahyperkalemia第51頁DiureticsinHeartFailure

AdverseEffectselectrolytedisturbances(K,Na)hypotensionrenaldysfunctionrashototoxicity(ethacrynicacid,furosemide)第52頁Question22

Thefollowingarealloptionstoconsiderinpatientswithhighlysymptomaticandrefractoryheartfailureexcept:revascularizationresynchronizationtherapycardiactransplantationplasmapheresisdialysis第53頁Patientswith:hypertensionCADDMriskforCMPPatientswith:priorMILVsystolicdysfunctionasymptomaticvalvediseasePatientswith:knownstructuralheartdiseaseSOBfatigue

exercisetolerancePatientswith:markedsymptomsdespitefulltherapyTherapytreatRFsencourageexercisediscouragealcoholTherapyallforStageAACEIsBABsTherapyallforStagesAandBdirueticsdigoxindietaryrestrictionsTherapyallforABCassistdevicestransplantationStructuralheartdiseaseSymptomsofHeartFailureRefractorySymptomsSTAGEASTAGEBSTAGECSTAGEDAtrisk第54頁Question23

Thefollowingallsupportthediagnosisofacutepericarditisexcept:typicalchestdiscomfortSTelevationonEKGhistoryofaprecedingviralillnessS4galloppericardialfrictionrub第55頁AcutePericarditis

DiagnosticCriteriachestpainpericardialfrictionrubEKGchanges第56頁Question24

TheearliestEKGchangesseeninacutepericarditis:STsegmentdepressionSTsegmentelevationhyperacuteTwavesTwavedepressionPRdepression第57頁EKGinAcutePericarditis1.

DiffuseSTsegmentelevation

(exceptaVRandV1)+PRsegmentdepression2.STnormalizes,Twavesflatten3.TwavesinvertwhereSTswereelevated4.Returntonormalpattern第58頁Question25

Pericardialtamponadeshouldbesuspectedinthefollowingsituations:enlargedheartshadowonchestXrayunexplainedhypotensionunexplainedseveredyspneaexaggeratedinspiratorydeclineinBPalloftheabove第59頁PericardialTamponade

PhysicalExaminationFindingshypotensiontachycardiatachypneadistantheartsoundselevatedJVPpulsusparadoxus第60頁Question26

Causesofpericardialeffusio