福建醫(yī)科大學(xué)附屬第一醫(yī)院晉學(xué)慶課件

1、福建醫(yī)科大學(xué)附屬第一醫(yī)院福建醫(yī)科大學(xué)附屬第一醫(yī)院晉學(xué)慶晉學(xué)慶重癥心衰治療指南與臨床實(shí)踐指南與臨床實(shí)踐的關(guān)系evidence-based medicineproblem-based medicine心臟重癥特點(diǎn) 1.心衰 合并多器官功能衰竭，心、肺、腎 2.心衰 心臟受損嚴(yán)重為突出表現(xiàn)，大面積心梗， 心臟手術(shù)，重癥心肌炎 3.心衰 特殊原因，少見，特別是一些新的藥品， 器械your heart is an amazing powerhouse that pumps your heart is an amazing powerhouse that pumps and circulates 5 or

2、 6 gallons of blood each and circulates 5 or 6 gallons of blood each minute through your entire body.minute through your entire body.understanding how the heart worksunderstanding how the heart worksto understand heart disease, you must first know how the heart works. the heart is like any other mus

3、cle, requiring blood to supply oxygen and nutrients for it to function. it beats about 100,000 times a day, pumping blood through your circulatory system. the cycle of pumping blood throughout your body carries fresh oxygen to your lungs and nutrients to your bodys tissues. blood also takes waste, s

4、uch as carbon dioxide, away from your tissues,. without this process, we could not live.heart disease: the number-one killerheart disease: the number-one killerheart disease affects about 14 million men and women in the united states, and it has a high mortality rateone of the most devastating conse

5、quences of heart one of the most devastating consequences of heart disease can be sudden cardiac arrest.disease can be sudden cardiac arrest.blockage of the coronary arteries by plaque may blockage of the coronary arteries by plaque may cause a heart attack (myocardial infarction) or a cause a heart

6、 attack (myocardial infarction) or a fatal rhythm disturbance (sudden cardiac arrest).fatal rhythm disturbance (sudden cardiac arrest).sudden cardiac death - a fatal consequence of heart diseasesudden cardiac death - a fatal consequence of heart diseaseeveryones experience with heart disease is diff

7、erent. some people experience shortness of breath or chest pain and make it to the hospital in time to be treated. others are not as lucky. for some people, sudden cardiac arrest can be the first symptom they experience, and it is often deadly unless treated immediately.besides chest pain (angina) a

8、nd shortness of breath, some other besides chest pain (angina) and shortness of breath, some other common symptoms of heart disease include jaw pain, back pain, and common symptoms of heart disease include jaw pain, back pain, and heart palpitations.heart palpitations.what are common symptoms of hea

9、rt disease?what are common symptoms of heart disease?symptoms of heart disease usually occur during exercise or activity. thats because the heart experiences increased demand for nutrients and oxygen that cannot be met because the coronary arteries are blocked. other symptoms of heart disease includ

10、echest pain (angina),shortness of breath,jaw pain, andback pain, especially on the left side.doctors use a variety of tests to detect heart doctors use a variety of tests to detect heart disease. one common test is the electrocardiogram disease. one common test is the electrocardiogram (ecg or ekg).

11、(ecg or ekg).what is an electrocardiogram (ekg)?what is an electrocardiogram (ekg)? a healthy heart works as an electrical pump and needs a strong blood supply to conduct electricity. people with heart disease, however, have a weak blood supply, so their hearts conduct electricity poorly. an electro

12、cardiogram (ekg) is a noninvasive test that measures the electrical activity of the heart. an ekg takes approximately five minutes and is painless. many other heart conditions can be diagnosed with an ekg, for exampleabnormal heart rhythms,evidence of prior heart attack,evidence of an evolving heart

13、 attack,unstable angina,congenital heart abnormalities,evidence of abnormal blood electrolytes, andevidence of inflammation of the heart (myocarditis, pericarditis).sometimes, if an electrocardiogram comes back sometimes, if an electrocardiogram comes back normal, doctors will use stress tests to de

14、tect normal, doctors will use stress tests to detect heart disease.heart disease.another test option is another test option is echocardiography,echocardiography, which which uses sound waves to generate images of the heart.uses sound waves to generate images of the heart.computerized tomography (ct)

15、 scans are used to computerized tomography (ct) scans are used to show that heart disease is not present and that show that heart disease is not present and that the coronary arteries are normal.the coronary arteries are normal.coronary angiography coronary angiography via cardiac catheterization vi

16、a cardiac catheterization is considered the gold standard of heart is considered the gold standard of heart disease tests.disease tests.heart disease treatment is different for everyone.heart disease treatment is different for everyone.for some patients with heart disease, medications for some patie

17、nts with heart disease, medications may be necessary.may be necessary.when medications arent enough, sometimes when medications arent enough, sometimes invasive procedures are used to help treat heart invasive procedures are used to help treat heart disease.disease.heart disease is a highly preventa

18、ble and heart disease is a highly preventable and reversible disease. a healthy diet is a major reversible disease. a healthy diet is a major factor in controlling heart disease.factor in controlling heart disease.other lifestyle changes that can be made to help other lifestyle changes that can be m

19、ade to help prevent heart disease include drinking alcohol in prevent heart disease include drinking alcohol in moderation and quitting smoking.moderation and quitting smoking.exercise, controlling high blood pressure and diabetes, and exercise, controlling high blood pressure and diabetes, and taki

20、ng daily aspirin are more ways to reduce your chances taking daily aspirin are more ways to reduce your chances of developing heart disease.of developing heart disease. 心臟重癥病房的治療手段進(jìn)展心臟重癥病房的治療手段進(jìn)展3.1 呼吸機(jī)輔助通氣3.2 腎臟替代治療3.3 主動(dòng)脈內(nèi)球囊反搏術(shù)(iabp)和左心輔助裝置(lvad)3.4 ecmo（體外膜肺氧合）在國(guó)外，特別是歐美發(fā)達(dá)國(guó)家，心臟重癥醫(yī)學(xué)的誕生起源于心肺復(fù)蘇術(shù)的開始，要

21、早于真正的綜合性icu的建立。從1962年開始，melter he和day分別創(chuàng)立冠心病監(jiān)護(hù)病房，從此心臟重癥醫(yī)學(xué)在世界發(fā)達(dá)國(guó)家特別是歐美地區(qū)迅速發(fā)展，以ccu或cicu為代表的心臟重癥監(jiān)護(hù)病房已經(jīng)成為心臟醫(yī)療中心中不可缺少的組成部分，代表了一家中心的心臟醫(yī)療水平，救治水平和管理水平，更與醫(yī)療單位或中心的現(xiàn)代化水平掛鉤定義 心力衰竭是由于任何心臟結(jié)構(gòu)或功能異常導(dǎo)致心室充盈或射血功能受損的一組臨床綜合征，其主要臨床表現(xiàn)為呼吸困難和乏力（活動(dòng)耐量受限），以及液體潴留（肺淤血和外周水腫）。心衰為各種心臟疾病的眼中和終末階段，發(fā)病率高，是當(dāng)今最重要的心血管病之一。心衰發(fā)展分為4個(gè)階段根據(jù)心衰發(fā)生發(fā)展的

22、過程，從心衰的危險(xiǎn)因素進(jìn)展成結(jié)構(gòu)性心臟病，出現(xiàn)心衰癥狀，直至難治性終末期心衰,可分成4個(gè)階段。前心衰(a)前臨床心衰(b)臨床心衰(c)難治性終末期心衰(d)這4個(gè)階段不同于紐約心臟協(xié)會(huì)(nyha)的心功能分級(jí)。心衰階段的劃分正是體現(xiàn)了重在預(yù)防的概念，其中預(yù)防患者從階段a進(jìn)展至階段b，即防止發(fā)生結(jié)構(gòu)性心臟病，以及預(yù)防從階段b進(jìn)展至階段c,以至于進(jìn)展到d階段。依據(jù)左室射血分?jǐn)?shù)(lvef),心衰可分為 lvef降低的心衰(heart failure reduced left ventricular ejection fraction, hf-ref) lvef保留的心衰(heart failure

23、 with preserved left ventricular ejection fraction, hf-pef).lvef是心衰患者分類的重要指標(biāo)，也與預(yù)后及治療反應(yīng)相關(guān)。lvef保留或正常的情況下收縮功能仍可能是異常的。case 1女性，83歲反復(fù)活動(dòng)后氣喘5年，加重1月5年來(lái)反復(fù)活動(dòng)后氣喘，發(fā)作時(shí)端坐呼吸，咳白色泡沫樣痰，夜間陣發(fā)性加劇，經(jīng)治療后好轉(zhuǎn)。近1月來(lái)癥狀加劇，不能平臥，雙下肢浮腫。既往有高血壓病，糖尿病病史20多年。入院肺部ct掃描入院診斷， 心功能衰竭，心功能iv 級(jí)。 肺部感染 冠狀動(dòng)脈粥樣硬化性心臟病，急性冠脈 綜合癥 高血壓病 糖尿病入院后治療方案抗感染糾正心衰（強(qiáng)

24、心、利尿、擴(kuò)血管）治療后癥狀改善，但反復(fù)發(fā)作左室內(nèi)徑在正常上限，室壁未見增厚，心腔形態(tài)失常、心尖部圓鈍，前壁、室間隔中段以下及整個(gè)心尖部運(yùn)動(dòng)減弱或無(wú)運(yùn)動(dòng)，余室壁運(yùn)動(dòng)未見明顯異常，整體收縮不協(xié)調(diào)；二維法lvef30。 右心大小正常，室壁運(yùn)動(dòng)未見明顯異常 估計(jì)肺動(dòng)脈收縮壓至少57-62mmhg；討論病人下一步治療方案病人冠心病，引起心衰，繼發(fā)肺部感染，明確。但病人83歲，年齡大，不能平臥，是否因該pci。pci的風(fēng)險(xiǎn)：病人不能耐受手術(shù)，手術(shù)風(fēng)險(xiǎn)大。 some of the risk factors for heart disease some of the risk factors for hea

25、rt disease include smoking, high blood pressure, high include smoking, high blood pressure, high cholesterol, diabetes, and cholesterol, diabetes, and obesityobesitywhat are the risk factors for heart disease?what are the risk factors for heart disease?some of the common risk factors for heart disea

26、se includesmoking,high blood pressure (hypertension),high cholesterol,diabetes,family history of heart disease,peripheral artery disease, andobesity.additional heart disease risk factors include additional heart disease risk factors include lack of exercise, an unhealthy diet, stress, and lack of ex

27、ercise, an unhealthy diet, stress, and a type a personalitya type a personalitywhat are lifestyle risk factors for heart disease?what are lifestyle risk factors for heart disease?lifestyle risk factors that contribute to heart disease includelack of exercise,high-fat diet,emotional stress, andhaving

28、 a type a personality (aggressive, impatient, competitive).case2男性，30歲胸悶，氣喘，浮腫1月，加劇1周既往無(wú)高血壓病，糖尿病病史個(gè)人史：煙，20-40支/天 x 10年， 酒，白酒6-7兩/次x4-5次/周x5-6年每天3-4餐職業(yè)：刑警大隊(duì)隊(duì)長(zhǎng)。體格檢查bp 192/116 mmhghr 106 bpmibm 40.1 （height 170cm， wt 116kg）急性痛苦病容，端坐呼吸，雙肺滿布濕性羅音，哮鳴音。下肢可凹水腫。echocardiogramcomputed tomography of chestelectr

29、iocardiogram入院診斷1. 擴(kuò)張型心肌病 (原發(fā)性、酒精性、缺血性、心律失常，肥胖型）？ 心律失常 快速性心房撲動(dòng) 肺部感染 胸腔積液，心包積液左心室內(nèi)占位性病變（血栓、粘液瘤）2.肥胖3.高血壓病。治療策略1.保守藥物治療 降壓，利尿，抗菌素，低分子肝素鈣，呼吸機(jī)，倍他樂克，23.75mg qd2.介入，冠脈造影3. 心臟移植左心室附壁血栓左心室附壁血栓左室附壁血栓的形成多是繼發(fā)于急性心梗之后，是急性心梗的常見并發(fā)癥之一。附壁血栓形成后反過來(lái)引起急性心梗的可能很小，主要是可能會(huì)出現(xiàn)血栓的脫落，從而出現(xiàn)體循環(huán)動(dòng)脈栓塞的可能性加大，最常見的栓塞部位就是腦。所以目前的主要矛盾并不是并發(fā)心

30、梗的風(fēng)險(xiǎn)，而是并發(fā)腦栓塞的風(fēng)險(xiǎn)較大.討論病人通過正規(guī)的心衰藥物治療，以及抗菌素，低分子肝素鈣的治療，病人癥狀改善不明顯，bp130-140/90-100mmhgweight 108kg.房撲射頻消融術(shù)？控制體重措施 每日三餐，2兩/餐兩個(gè)月體重116 82kg。病人呼吸困難癥狀明顯改善，ucg提示ef從18%增加到30%左心室血栓消失。下肢水腫消失。心電圖仍然房撲。病人出院，門診隨訪。靜息心肌灌注顯像：左室心腔明顯擴(kuò)大，后壁心肌血流灌注輕度減低。隨訪6個(gè)月后病人一般情況穩(wěn)定，無(wú)心悸胸悶，氣喘等癥狀，已經(jīng)開始正常工作。思考病人的主要病因是肥胖，因此控制體重是主要的，開始階段對(duì)體重控制沒有重視，病

31、人癥狀控制不好，癥狀反復(fù)，從控制體重開始，病情逐步好轉(zhuǎn)并趨于穩(wěn)定。在之后的隨訪過程中，繼續(xù)控制體重，心臟結(jié)構(gòu)與功能明顯好轉(zhuǎn)。房撲轉(zhuǎn)為竇律。說明，對(duì)于肥胖型心肌病的治療，預(yù)后要比原發(fā)性擴(kuò)張型心肌病要好。should we target obesity in advanced heart failure?should we target obesity in advanced heart failure? obesity is a risk factor for the development of heart failure (hf), but has been associated with i