英文班內科學心力衰竭

HeartFailure(HF)

2020/12/181Heartfailure(HF)

Conception:heartfailureisafinalcommonpathwayformanycardiacdisordersofdiverseetiologyandpathogenicmechanisms.Itisaclinicalsyndrome,manifestedasaresultoftheinabilityofthehearttomatchitsoutputtothemetabolicneedsofthebodyeventhoughthefillingpressureoftheheartisadequate.2020/12/182CategoriesofHF1.left,rightandwhole2.acuteandchronic3.systolicanddiastolic2020/12/183stageofHFPre-heartfailurePre-clincalheartfailureClinicalheartfailureRefractoryend-stageheartfailure2020/12/184NewYorkHeartAssociationFunctionalClassificationClassⅠNolimitationofphysicalactivityNosympotomswithordinaryexertionClassⅡSlightlimitationofphysicalactivity

Ordinaryactivitycausessymptoms

ClassⅢ

Markedlimitationofphysicalactivity

Lessthanordinaryactivitycausessymptoms

Asymptomaticatrest

ClassⅣ

Inabilitytocarryoutanyphysicalactivitywithout

discomfort

Sympotomsatrest2020/12/185StageandClassofHF心衰分期是NYHA分級的補充，但不能替代

NYHA分級NYHA分級–

在具體病人可上下變動

(對治療的反應和/或疾病進程不同)分期–

隨心臟重構加重只能進展

2020/12/1866-minwalkdistance

milddegree：＞450mmoderatedegree：150-450mseveredegree：＜150mEvaluationofchronicHFcardiacfunction

2020/12/187Fundamentalcausesprimarymyocardialdiseaseincreasedburdenstotheheart2020/12/188Fundamentalcauses1.primarydecreasedmyocardialcontractility

coronaryheartdiseasemyocarditis,cardiomyopathymyocardialmetabolicdisorder2020/12/189Fundamentalcauses2.increasedburdenstotheheart①increasedafterload(pressureload):hypertensionaorticstenosispulmonarystenosispulmonaryhypertension2020/12/1810Fundamentalcauses

2.increasedburdenstotheheart②increasedpreload(volumeload):mitralincompetenceaorticincompetencetricuspidincompetenceatrialseptaldefect(ASD)ventricularseptaldefect(VSD)patentductusarteriosus(PDA)hyperthyroidismanemia

2020/12/18112020/12/1812Precipitatingcausesinfection,especiallyrespiratoryinfectionarrhythmias,AFphysicaloremotionalexcessese.g.pregnancyanddeliveryrapidintravenousinfusion,excessivesalttakingmalpraticeprimarydiseasedeteriorationoranewdiseasehappens2020/12/1813Pathogenesisandpathophysiology1.Compensateheartfailure2.Ventricularremodeling3.Aboutdiastolicinsufficiency4.Humoralfactorschange2020/12/18141.CompensateheartfailureFrank-Starlingprincipleneurohumoralactivationmyocardialhypertrophy2020/12/18151.Compensateheartfailure①cardiacdilatation,bywayoftheFrank-Starlingprinciple,contractileforceincreases.2020/12/18161正常靜息2正?；顒?’心衰活動3心衰靜息心肌收縮性BADC左室舒張末容量圖3–2–1正常和心力衰竭時對機體活動時的代償情況最大活動活動靜息左室作功呼吸困難肺水腫E4靜息致死性心肌受損2020/12/18171.Compensateheartfailure②neurohumoralactivationa.Increaseinsympatheticnervousactivityb.RAASactivated(renninangiotensionaldosteronesystem)2020/12/1818心力衰竭——神經(jīng)體液的代償和失代償交感神經(jīng)激活水、鈉潴留水腫肺瘀血血流動力學異常血管收縮心肌耗氧量增加心肌氧供應降低心肌細胞功能障礙和壞死心肌重塑功能惡化疾病進展血管緊張素Ⅱ兒茶酚胺毒性作用心肌細胞凋亡腎素-血管緊張素系統(tǒng)激活代償失代償心衰癥狀體征加重治療目標增強心肌收縮2020/12/1819心肌細胞死亡心力衰竭心肌細胞死亡++↑心肌能量消耗↑后負荷血管收縮↓心排血量神經(jīng)體液興奮RASSASInSP3循環(huán)↑心肌能量消耗↑胞漿Ca2+cAMPInSP3

心臟↓心肌松弛性↑變力效應+－—心律失常猝死圖3–2–2腎素—血管緊張素和交感—腎上腺素能系統(tǒng)激活時對心臟代償功能的影響2.RAASinHeartFailure2020/12/18202.RAASinHeartFailure2020/12/18211.Compensateheartfailure③myocardialhypertrophy

MyocardialcellhypertrophysystolepowerNotincreasednumberMyocardialfibreincreasednumberenergyMyocardialcompliance(順應性）2020/12/18222.Ventricularremodeling

2020/12/18232.Ventricularremodeling

heartfailureistheresultofventricularremodeling.Reducethemyocardialcellsdecrease

of

the

systolic

functionIncreasedmyocardialfibrosis

decrease

of

theVentricularcomplianceHeartcavityexpansionmyocardialhypertrophyextracellularmatrixcollagenfibersMyocardialcells

Compensatedstage

Decompensatedstage2020/12/18243.aboutdiastolicinsufficiency①Characteristic:inthesecases,fillingoftheleftorrightventricleisabnormal.②Mechanism:myocardialrelaxationisimpaired.Myocardialcompliancedecreasing.

③outcome:diastolicpressures↑----venousereturn↓---fluidretention,dyspnea,intolerance2020/12/18254.somecytofactorstakepartinheartfailure

ANP(atrialnatriureticpeptide)BNP(brainnatriureticpeptide)AVP(argininevassopressin)Endothelin(NE,angiotensin)UrinevolumeperipheralvascularsympatheticnervousRAASVentricularremodeling2020/12/1826

Ventricularremodelingneurohumoralactivationheartfailure2020/12/1827Chronicheartfailure,CHF2020/12/1828Clinicalmanifestations1.Leftheartfailurepulmonarycongestionlesscardiacoutput2.Rightheartfailuresystemicvenouscongestion3.Wholeheartfailure2020/12/18291.Leftheartfailure

1)dyspnea1.exertionaldyspnea2.paroxysmalnocturnaldyspnea3.orthopnea,4.acutepulmonaryedema2020/12/18301.Leftheartfailure

2)cough,hemoptysis,spitpinksputum3)fatigue,dizziness,palpitation.4)oliguria,renaldysfunction

2020/12/1831sign

1)pulmonarybasalralesbilaterallyorright-side2)enlargedleftheartpulsusalternans,protodiastolicgallopP2increasedPulmonaryedema2020/12/1832

2.Rightheartfailuresymptomabdominaldiscomfortanorexia(厭食)nausea,vomitexertionaldyspnea2020/12/1833

2.Rightheartfailuresignliverenlargedascitesdistentionofjugularveinshepatojugularreflux(+)peripheraledema,mostmarkindependentpartscyanosisprotodiastolicgallop,functionalmurmursoftricuspidandpulmonaryvalve2020/12/18343.WholeheartfailureLHF＋RHF2020/12/1835laboratoryexamination

BNPandNT-proBNP心室擴張心衰張力增大BNP釋放2020/12/1836呼吸困難,虛弱,

運動受限等癥狀(NT-proBNP)

慢性心衰

轉至心臟?？评^續(xù)下一步診斷陽性陰性NT-proBNP臨床應用流程圖輔助診斷心衰輔助判斷進展期心衰患者預后2020/12/1837laboratoryexamination

CnTIbloodroutineexaminationroutineurineexaminationbiochemicalexaminationFT3,FT4,TSH2020/12/1838ECG(electrocardiogram)ischemiaOMIconductionblockarrhysmia2020/12/1839X-rayPulmonarycongestionPleuraleffusionKerlryBRightpulmonaryarterybroadeningPulmonaryhilarbutterflyshape2020/12/1840EchocardiogramLVEF＞50%E/A＞1.2LVEDV/LVESVLVEDD/LVESDventricularwallmotionCardiacmagneticresonance,CMR99MTC-MIBISPECT(radionuclide)Coronaryangiography2020/12/1841CardiacCatheterizationSwan-GanzPCWP＜12mmHgCI＞2.5L/（min.m2）2020/12/1842CardiopulmonaryExerciseTesting(CPET)ChronicstableHFMeasurementofrateofoxygenuptake(VO2),rateofCO2production(VCO2),duringmaximal“symptom-limited”exercise2020/12/18432020/12/1844DiagnosisanddifferentialdiagnosisDiagnosis:medicalhistory+symptoms+signs+examExam:ECG:rarelynormalinsystolicHF.x-ray:todetectcardiomegalyandpulmonarycongestion.(3)Echocardiogram:Itiscriticalimportance.①todeterminetheunderlyingcausesofHF②toassesstheseverityofventriculardysfunctiona.functionofcontraction:LVEF>50%b.functionofrelaxation:E/A≥1.2

2020/12/18452.Differentialdiagnosis:cardiacasthmaBronchialasthmaHistoryHeartdiseaseallergichistoryageolderyoungtimenightspringHFsignyesnoLungsignpulmonarybasalralestypicalwheezingx-rayPulmonarycongestionLVlargeemphysemaalleviatesymptomsofdyspneaDiureticsdigitalisisosorbidedinitrateaftercoughoutsputumantispasmodic2020/12/18462.Differentialdiagnosis:②Pericardialeffusion,Constrictivepericarditis:distentionofjugularveins,hepatojugularreflux(+)liverenlarged,ascitesperipheraledema,mostmarkindependentparts

medicalhistorysignsofheartandperivascularechocardiogram,CMR…themostsensitive…specificnoninvasivemethod2020/12/18472.Differentialdiagnosis:③Hepatocirrhosiswithascitesandedemaoflowerextremitydistentionofjugularveins(-)hepatojugularreflux(-)2020/12/1848Treatmentofchronicheartfailure

Principle:alleviatesymptoms,improvelifequality.treatmentforprimarydiseaseandprecipitatingcausesAntagonismofneurohumoralactivationinhibitionofprogressiveventricularremodelingreducemortalityandextendlife.2020/12/1849TreatmentofchronicheartfailureGeneralPharmacologictreatmentNon-medicinetreatment2020/12/1850GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation2020/12/1851GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation1.LifestylemanagementEducationRegulateweightDietarymanagement:salttake2.Restandaction3.Treatmentforprimarydiseaseandprecipitating

2020/12/1852GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation1.Rest2.Dietarymanagement:salttake3.Diuretics

furosemidedihydrochlorothiazide(potassium-losing)antistone(potassium-sparing)2020/12/1853Themainpointofdiureticsapplication對于有癥狀的心衰，當液體負荷過重已表現(xiàn)為肺淤血或外周水腫時，利尿劑是基本的治療。應用利尿劑可迅速改善呼吸困難并增加運動耐量（I類建議，證據(jù)級別A）尚無大型隨機對照試驗評估這類藥物對癥狀和生存的影響。如能耐受，利尿劑始終應與ACEI和β-受體阻滯劑一起使用。（I類建議，證據(jù)級別C）。2020/12/1854

襻利尿劑應作為首選。噻嗪類僅適用于輕度液體潴留、伴高血壓和腎功能正常的心衰患者(I類，B級)。利尿劑通常從小劑量開始(氫氯噻嗪25mg/d，呋塞米20mg/d，托塞米10mg/d),逐漸加量。一旦病情控制即以最小有效量長期維持。每日體重變化是最可靠檢測利尿劑效果和調整利尿劑劑量的指標。長期服用利尿劑應嚴密觀察不良反應的出現(xiàn)如電解質紊亂、癥狀性低血壓，以及腎功能不全，特別在服用劑量大和聯(lián)合用藥時（Ⅰ類，B級）。Themainpointofdiureticsapplication2020/12/1855GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation1.Rest2.Dietarymanagement:salttake3.Diuretics4.Vasodilator

sodiumnitroprusside(SNP)nitroglecerinregitine(酚妥拉明))2020/12/1856ThemainpointofVasodilatorapplication直接血管擴張劑對于CHF的治療無特殊作用。（Ⅲ類，A級）血管擴張劑可用于不能耐受ACEI或ARBs的患者；伴有心絞痛或高血壓可考慮應用（Ⅰ類，B級）禁忌證：血容量不足，低血壓、腎功能衰竭

心臟流出道或瓣膜狹窄患者2020/12/1857GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation1.Digitalis

（1）effection:Positiveinotropic：

inhibitNa+-K+-ATPenzyme

introcellularNa+、K+Na+-Ca2+exchange

introcellularCa2+myocardialsystolepower

introcellularK+，digitalispoisoning2020/12/1858GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation1.Digitalis

（1）effection:Positiveinotropic：Electrophysiological

Inhibitcondutionsystem,espiciallyatriventricularjunction.

Improvetheautorhythmictyofatrium,junctionregionandventricle.2020/12/1859GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation1.Digitalis

（1）effection:Positiveinotropic：ElectrophysiologicalParasympatheticstimulatinganti-sympatheticnerveexciting

2020/12/1860GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation1.Digitalis

（1）effection:Positiveinotropic：ElectrophysiologicalParasympatheticstimulatingRoleintherenaltubulecellsreducingsodiumreabsorptioninhibitthesecretionofrenin

2020/12/1861GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation1.Digitalis

（2）application

indication:chroniccongestiveheartfailurecomplicatedbyatrailflutterandfibrillationandarapidventricularrate2020/12/1862GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation1.Digitalis

（2）application

contraindication:WPWwithAFⅡdegreeAVB,ⅢdegreeAVBsicksinussyndrome(SSS)Hypertrophiccardiomyopathy(HOCM)severemitralstenosis(SMS)acutemyocardiacinfarction(first24h2020/12/1863GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation1.Digitalis

(3)digitalispoisoningfactors：K+,O2,RFClincalexpression:gastricbowelreaction;arrhythmia;neurologicalandvisualchangeDiagnosis：>2.0ng/ml2020/12/1864ArrhythmiaofdigitalispoisoningVentricularPrematurebeatNonparoxysmalatrioventricularjunctionaltachycardiaAtrialPrematurebeatAtrialfibrillatonAtrioventricularblockST-TchangelikefishhookCharacteristicfeature2020/12/1865GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation1.Digitalis

Treatmentofdigitalispoisoningdrugwithdrawaltachycadia:supplyK+

,Lidocainivbradicadia：atropiniv,notsuitableforpacemakernotsuitableforisoprenalinedisablecardioerter2020/12/1866GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、Digitalis2、β-excitantDopamine：NEprecursor2g/kg.min

Dopamine-R(+)

expandrenalartery2-5g/kg.min

β1

β2-R(+)myocardialcontractility,Vasodilate5-10g/kg.min

α-R(+)BP,HRDobutamine：Dopaminederivatives

2g/kg.min

10g/kg.min

Vasodilate,HR--smalleffects2020/12/1867GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、Digitalis2、β-excitant3、Phosphodiesteraseinhibitors

1、effect:restrainactivityofphosphodiesterase，thedegradationofcAMP(-)cAMPCa2+

channelactivationCa2+

-inflowmyocardialcontractility2020/12/1868GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、Digitalis2、β-excitant3、Phosphodiesteraseinhibitors

1、effect:2、indications：refractoryheartfailureend-stageheartfailurebeforehearttransplantation2020/12/1869GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、Digitalis2、β-excitant3、Phosphodiesteraseinhibitors

1、effect:2、indications：3、drugs：氨力農(nóng)(Amrinone)VD5-10g/kg.min

米力農(nóng)(Milrinone)VD0.5g/kg.min2020/12/1870GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、Digitalis2、β-excitant3、Phosphodiesteraseinhibitors

1、effect:2、indications：3、drugs：4、defect：

side-effect;mortality2020/12/1871

AII產(chǎn)生是通過多種通道血管緊張素原腎素血管緊張素I(1-10)

AngII（1-8）ACEAT1AT2血管收縮增殖醛固酮增加血管擴張抗增殖Ang1-7Ang1-7受體激活血管擴張抗增殖ARB2020/12/1872GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、RAASinhibitorAngiotensinConvertingEnzymeInhibitors(ACEI)

dilatebloodvessels

inhibitRAS,sympatheticsystemreversetheventricularremodeling

improvearterystiffnessandsensitivity

ImproveendothelialfunctionATⅡ↓,Inhibitthedegradationofbradykinin2020/12/1873GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、RAASinhibitorAngiotensinConvertingEnzymeInhibitors(ACEI)

Clinicalstatus

symptoms↓,exercisetolerance↑

mortality↓

delaytheprogressofheartfailurereducinghospitalizationrates

preventHFaftermyocardialinfarction

2020/12/1874GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、RAASinhibitorAngiotensinConvertingEnzymeInhibitors(ACEI)

Captopril6.25～25mg2～3/dEnalapril10mg2/dCilazapril2.5mg/dBenazepril2.5～10mg/dPerindopril2～4mg/dFosinopril5～10mg/dRamipril2.5mg/d2020/12/1875GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、RAASinhibitorAngiotensinConvertingEnzymeInhibitors(ACEI)

applicationmethodsstartingwithsmalldosesiftolerated,graduallyincreasethedosemonitoringofrenalfunctionandions

renalfunctionchange,highpotassium,drycough,angioedema

2020/12/1876GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、RAASinhibitorAngiotensinConvertingEnzymeInhibitors(ACEI)

Contraindication:

①anuricrenalfailure

②pregnancyandbrestfeedingwoman

③allergeRelativeContraindication:①renalarterystenosisbilaterally②Cr>225μmol/l③k+>5.5mmol/l④hypotension2020/12/1877GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、RAASinhibitorAngiotensinConvertingEnzymeInhibitors(ACEI)AngiotensinIIreceptorantagonist(ARB)ATⅡ-AT1receptor↓InhibitRASNoaffectingthedegradationofbradykinin2020/12/1878GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、RAASinhibitorAngiotensinConvertingEnzymeInhibitors(ACEI)AngiotensinIIreceptorantagonist(ARB)applicationmethods

lessdrycoughandangioedemawhenHF,firstchoseACEIwhenHF,shouldnotbecombinedapplicationofACEIandARB

Losartan50mg/d;valsartan80mg/d2020/12/1879GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、RAASinhibitorAngiotensinConvertingEnzymeInhibitors(ACEI)AngiotensinIIreceptorantagonist(ARB)Aldosterone

antagonists

spironolactone(SPI)potassium-sparingdiureticreversetheventricularremodeling

improveprognosis2020/12/1880GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

1、RAASinhibitorAngiotensinConvertingEnzymeInhibitors(ACEI)AngiotensinIIreceptorantagonist(ARB)Aldosterone

antagonists

renininhibitorACEI/ARB

increasing

plasma

renin

activityrenin

inhibitior

has

the

effect

of

cardiorenal

protectionnotACEI/ARBreplacementtherapy2020/12/1881GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

RAASinhibitor

-blockersympatheticactivation↑b1receptorsb2receptorsa1receptorsmetoprololbisoprolol↓arrythmiadilatebloodvessels;↓themyocardialO2Cardiactoxicity

carvedilol2020/12/1882GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

RAASinhibitor

-blockerInhibitionofsympatheticactivation

improveprognosis1-blockermetoprolol,bisoprolol

12α-blokercarvedilolapplicationmethodsstartingwithsmalldosesiftolerated,graduallyincreasethedosemonitoringofBp,HR,ECG2020/12/1883GeneraltreatmentdecreasedburdensincreasedsystolepowerAnti-neurohumoralactivation

RAASinhibitor

-blockerContraindication:

bronchospasm

severebradycardia

≥Ⅱ。atrioventricularblock

severeperipheralvasculardisease

acuteheartfailure

2020/12/1884TreatmentofchronicheartfailureTherecentadvancesaboutthetreatmentofHF

MicturitionrestrainthesympatheticnervoussystemdilatebloodvesselsrhBNPlevosimendanIncreasetheCa2+sensitivity→myocardialcontractilityMediateATP-K+channel→dilatebloodvesselsivabradineInhibiteSANIfcurrenttolvaptanCombineV2receptor→H2O2reabsoption↓2020/12/1885TreatmentofchronicheartfailureNon-medicinetreatment2020/12/1886CardiacResynchronizationTherapy(CRT)2020/12/1887LeftVentricularAssistDevice（LAVD）TransitedtreatmentforhearttransplantationAdjuvanttherapyforacuteHF2020/12/1888TreatmentofchronicheartfailureNon-medicinetreatmenthearttransplantationcellreplacementtherapy--SCT(stemcelltransplantation)2020/12/1889

Acuteheartfailure,AHF2020/12/1890CategoriesofAHF1.Acuteleftheartfailure2.Acuterightheartfailure3.non-cardiacacuteheartfailure2020/12/1891CategoriesofAHFAcuteleftheartfailuredecrease