醫(yī)學(xué)精品課件：英文班內(nèi)科學(xué)心力衰竭2(PPT 128頁(yè))

1、Heart Failure (HF) 第1頁(yè)，共128頁(yè)。Heart failure (HF) 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

2、 the body even though the filling pressure of the heart is adequate.第2頁(yè)，共128頁(yè)。Categories of HF1. left, right and whole 2. acute and chronic3. systolic and diastolic 第3頁(yè)，共128頁(yè)。stage of HFPre-heart failurePre-clincal heart failureClinical heart failureRefractory end-stage heart failure第4頁(yè)，共128頁(yè)。New Yo

3、rk Heart Association Functional ClassificationClass No limitation of physical activity No sympotoms with ordinary exertion Class Slight limitation of physical activity Ordinary activity causes symptoms Class Marked limitation of physical activity Less than ordinary activity causes symptoms Asymptoma

4、tic at rest Class Inability to carry out any physical activity without discomfort Sympotoms at rest第5頁(yè)，共128頁(yè)。Stage and Class of HF心衰分期是NYHA分級(jí)的補(bǔ)充，但不能替代 NYHA分級(jí)NYHA分級(jí) 在具體病人可上下變動(dòng) (對(duì)治療的反應(yīng)和/或疾病進(jìn)程不同)分期 隨心臟重構(gòu)加重只能進(jìn)展 第6頁(yè)，共128頁(yè)。6-min walk distance mild degree： 450mmoderate degree： 150-450msevere degree： 150mEv

5、aluation of chronic HF cardiac function 第7頁(yè)，共128頁(yè)。Fundamental causesprimary myocardial diseaseincreased burdens to the heart第8頁(yè)，共128頁(yè)。Fundamental causes1. primary decreased myocardial contractility coronary heart disease myocarditis ,cardiomyopathymyocardial metabolic disorder 第9頁(yè)，共128頁(yè)。Fundamental

6、causes2. increased burdens to the heart increased afterload (pressure load): hypertension aortic stenosis pulmonary stenosis pulmonary hypertension第10頁(yè)，共128頁(yè)。Fundamental causes 2.increased burdens to the heart increased preload (volume load): mitral incompetence aortic incompetence tricuspid incompe

7、tence atrial septal defect (ASD) ventricular septal defect (VSD) patent ductus arteriosus(PDA) hyperthyroidism anemia 第11頁(yè)，共128頁(yè)。第12頁(yè)，共128頁(yè)。Precipitating causesinfection ,especially respiratory infectionarrhythmias,AFphysical or emotional excesses e.g. pregnancy and deliveryrapid intravenous infusio

8、n , excessive salt taking malpraticeprimary disease deterioration or a new disease happens第13頁(yè)，共128頁(yè)。Pathogenesis and pathophysiology1.Compensate heart failure 2. Ventricular remodeling 3.About diastolic insufficiency4. Humoral factors change第14頁(yè)，共128頁(yè)。1.Compensate heart failureFrank-Starling princi

9、pleneurohumoral activationmyocardial hypertrophy第15頁(yè)，共128頁(yè)。1.Compensate heart failurecardiac dilatation, by way of the Frank-Starling principle ,contractile force increases.第16頁(yè)，共128頁(yè)。1 正常靜息2 正?；顒?dòng)3 心衰活動(dòng)3 心衰靜息心肌收縮性BADC左室舒張末容量圖321 正常和心力衰竭時(shí)對(duì)機(jī)體活動(dòng)時(shí)的代償情況最大活動(dòng)活動(dòng)靜息左室作功呼吸困難肺水腫E4 靜息 致死性心肌受損第17頁(yè)，共128頁(yè)。1.Compens

10、ate heart failureneurohumoral activation a. Increase in sympathetic nervous activity b. RAAS activated (rennin angiotension aldosterone system)第18頁(yè)，共128頁(yè)。40年代心衰的概念 心衰 液體潴留向 動(dòng)脈泵血障礙 靜脈回流障礙 腎血流 靜脈壓 腎靜脈 腎微循環(huán) 回流障礙 障礙水鈉排泄障礙 水鈉排泄障礙 水腫 前向衰竭假說(shuō) 反向衰竭假說(shuō) 第19頁(yè)，共128頁(yè)。60年代心衰的概念 心衰 泵功能障礙 長(zhǎng)期靜脈和動(dòng)脈收縮 周圍至中央循環(huán) 心輸出量 前后負(fù)荷

11、重新分布 肺血管壓力 骨骼肌灌注 左室肥厚/擴(kuò)張 肺充血 運(yùn)動(dòng)能力第20頁(yè)，共128頁(yè)。近代心衰的概念 心衰 神經(jīng)激素異常 長(zhǎng)期神經(jīng)激素激活 細(xì)胞因子 水鈉潴留 冠脈及全身血管收縮 血管緊張素 過(guò)度氧化 和兒茶酚胺 心肌耗氧量 毒性作用 水腫 肺充血 心肌細(xì)胞功能障礙 及壞死血流動(dòng)力學(xué)異常 心臟重塑和功能 惡化進(jìn)展 細(xì)胞凋亡 疾病進(jìn)展 生存率降低第21頁(yè)，共128頁(yè)。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(dòng)力學(xué)異常血管收縮心肌耗氧量增加心肌氧供應(yīng)降低心肌細(xì)胞功能障礙和壞死心肌重塑功能惡化疾病進(jìn)展血管緊張素兒茶酚胺毒性作用心肌細(xì)胞凋亡腎素-血管緊張素系統(tǒng)激活代償失代

12、償心衰癥狀體征加重治療目標(biāo)增強(qiáng)心肌收縮第22頁(yè)，共128頁(yè)。心肌細(xì)胞死亡心力衰竭心肌細(xì)胞死亡+心肌能量消耗后負(fù)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+cAMP InSP3 心臟心肌松弛性變力效應(yīng)+心律失常猝死圖322 腎素血管緊張素和交感腎上腺素能系統(tǒng)激活時(shí)對(duì)心臟代償功能的影響 2. RAAS in Heart Failure第23頁(yè)，共128頁(yè)。心衰時(shí)的系統(tǒng) 血管緊張素原非腎素 緩激肽徑路 血管緊張素（激肽酶）血管緊張素失活片斷醛固酮受體 螺內(nèi)酯 Na+潴留 血管收縮 血管擴(kuò)張 心肌纖維化 血管肥大 生長(zhǎng)抑制 血管損傷 心肌肥大、纖維化 抗增生 血管功

13、能失調(diào) 血管保護(hù) 交感神經(jīng)激活 腎保護(hù)第24頁(yè)，共128頁(yè)。 2. RAAS in Heart Failure第25頁(yè)，共128頁(yè)。1.Compensate heart failure myocardial hypertrophy Myocardial cell hypertrophy systole power Not increased number Myocardial fibre increased number energy Myocardial compliance(順應(yīng)性）第26頁(yè)，共128頁(yè)。2.Ventricular remodeling 第27頁(yè)，共128頁(yè)。2.Ventr

14、icular remodeling heart failure is the result of ventricular remodeling.Reduce the myocardial cells decreaseofthesystolicfunction Increased myocardial fibrosis decreaseofthe Ventricular compliance Heart cavity expansionmyocardial hypertrophyextracellular matrixcollagen fibersMyocardial cells Compens

15、ated stage Decompensated stage第28頁(yè)，共128頁(yè)。3.about diastolic insufficiency Characteristic : in these cases ,filling of the left or right ventricle is abnormal. Mechanism:myocardial relaxation is impaired.Myocardial compliance decreasing. outcome :diastolic pressures -venouse return-fluid retention , d

16、yspnea , intolerance第29頁(yè)，共128頁(yè)。4.some cytofactors take part in heart failure ANP (atrial natriuretic peptide) BNP (brain natriuretic peptide) AVP (arginine vassopressin) Endothelin (NE, angiotensin)Urine volumeperipheral vascularsympathetic nervousRAASVentricular remodeling 第30頁(yè)，共128頁(yè)。 Ventricular r

17、emodelingneurohumoral activationheart failure第31頁(yè)，共128頁(yè)。Chronic heart failure,CHF第32頁(yè)，共128頁(yè)。Clinical manifestations1.Left heart failure pulmonary congestion less cardiac output 2.Right heart failure systemic venous congestion 3.Whole heart failure第33頁(yè)，共128頁(yè)。1.Left heart failure 1)dyspnea1.exertional

18、 dyspnea2.paroxysmal nocturnal dyspnea3.orthopnea,4.acute pulmonary edema 第34頁(yè)，共128頁(yè)。1.Left heart failure 2)cough, hemoptysis, spit pink sputum 3)fatigue,dizziness,palpitation. 4)oliguria,renal dysfunction 第35頁(yè)，共128頁(yè)。sign 1) pulmonary basal rales bilaterally or right-side2) enlarged left heart pulsu

19、s alternans, protodiastolic gallop P2 increasedPulmonary edema第36頁(yè)，共128頁(yè)。 2.Right heart failuresymptomabdominal discomfortanorexia(厭食)nausea,vomitexertional dyspnea第37頁(yè)，共128頁(yè)。 2.Right heart failuresignliver enlargedascitesdistention of jugular veinshepatojugular reflux(+)peripheral edema , most mark

20、 in dependent partscyanosisprotodiastolic gallop, functional murmurs of tricuspid and pulmonary valve第38頁(yè)，共128頁(yè)。3.Whole heart failureLHFRHF第39頁(yè)，共128頁(yè)。laboratory examination BNP and NT-proBNP心室擴(kuò)張心衰張力增大BNP釋放第40頁(yè)，共128頁(yè)。呼吸困難, 虛弱, 運(yùn)動(dòng)受限等癥狀(NT-proBNP) 慢性心衰 轉(zhuǎn)至心臟?？评^續(xù)下一步診斷陽(yáng)性陰性NT-proBNP 臨床應(yīng)用流程圖輔助診斷心衰輔助判斷進(jìn)展期心衰患

21、者預(yù)后第41頁(yè)，共128頁(yè)。laboratory examination CnTIblood routine examination routine urine examinationbiochemical examinationFT3,FT4,TSH第42頁(yè)，共128頁(yè)。ECG(electrocardiogram)ischemiaOMIconduction blockarrhysmia第43頁(yè)，共128頁(yè)。X-rayPulmonary congestion Pleural effusion Kerlry BRight pulmonary artery broadeningPulmonary

22、hilar butterfly shape第44頁(yè)，共128頁(yè)。 EchocardiogramLVEF 50%E/A 1.2LVEDV / LVESVLVEDD / LVESDventricular wall motionCardiac magnetic resonance,CMR99MTC-MIBI SPECT (radionuclide)Coronary angiography第45頁(yè)，共128頁(yè)。Cardiac CatheterizationSwan-Ganz PCWP12mmHg CI2.5L/（min.m2）第46頁(yè)，共128頁(yè)。Cardiopulmonary Exercise Te

23、sting (CPET)Chronic stable HFMeasurement of rate of oxygen uptake (VO2), rate of CO2 production (VCO2), during maximal “symptom-limited” exercise第47頁(yè)，共128頁(yè)。第48頁(yè)，共128頁(yè)。Diagnosis and differential diagnosisDiagnosis: medical history + symptoms + signs + examExam:ECG: rarely normal in systolic HF.x-ray:

24、 to detect cardiomegaly and pulmonary congestion.(3) Echocardiogram: It is critical importance . to determine the underlying causes of HF to assess the severity of ventricular dysfunction a. function of contraction: LVEF50% b. function of relaxation: E / A1.2 第49頁(yè)，共128頁(yè)。2. Differential diagnosis:car

25、diac asthma Bronchial asthma HistoryHeart diseaseallergichistoryageolderyoungtimenightspringHF signyesnoLung signpulmonary basal rales typical wheezing x-rayPulmonary congestion LV largeEmphysema(肺氣腫）alleviate symptoms of dyspnea Diuretics（利尿劑）Digitalis（洋地黃）isosorbide dinitrateafter cough out sputum

26、 Antispasmodic(解痙）第50頁(yè)，共128頁(yè)。2. Differential diagnosis: Pericardial effusion, Constrictive pericarditis: distention of jugular veins, hepatojugular reflux(+)liver enlarged, ascitesperipheral edema , most mark in dependent parts medical history signs of heart and perivascular echocardiogram, CMR the

27、most sensitive specific noninvasive method第51頁(yè)，共128頁(yè)。2. Differential diagnosis: Hepatocirrhosis with ascites and edema of lower extremity distention of jugular veins (-) hepatojugular reflux(-)第52頁(yè)，共128頁(yè)?；颊吣行?，23歲。半年前于“感冒”后出現(xiàn)逐漸加重的胸悶、心悸、氣急，近一月經(jīng) 常出現(xiàn)夜間陣發(fā)性呼吸困難，昨晚大便后 又出現(xiàn)呼吸困難并加重，不能平臥， 咳 嗽， 咳泡沫樣痰及粉 紅色血色痰而就診

28、入院。病例分析第53頁(yè)，共128頁(yè)。病例分析T37.50C、P130次/分、BP120/70mmHg，R30次/分, 明顯發(fā)紺，大汗，端坐呼吸。頸靜脈怒張，心界擴(kuò)大，第一心音減低和心動(dòng)過(guò)速；心尖區(qū)可聞及級(jí)收縮期雜音及舒張期奔馬律；雙肺布滿中小水泡音及哮鳴音；肝腫大、肝頸靜脈返流征陽(yáng)性；雙下肢輕度水腫。實(shí)驗(yàn)室檢查：血、尿、糞常規(guī)均正常； 肝、腎功能正常第54頁(yè)，共128頁(yè)。心電圖提示有竇性心動(dòng)過(guò)速伴不同程度的ST-T缺血性改變，同時(shí)伴有頻發(fā)室性早搏； X胸片呈普大型心臟，心胸比率0.66；心臟多普勒檢查示心腔均擴(kuò)大，其中左室擴(kuò)大最明顯，心臟搏動(dòng)明顯減弱；EF（心臟輸出量）在29%病例分析第55頁(yè)

29、，共128頁(yè)。病例分析診斷：擴(kuò)張型心肌病 全心衰竭 急性左心衰發(fā)作第56頁(yè)，共128頁(yè)。診 斷 依據(jù) 有擴(kuò)張性心臟病基礎(chǔ) 有全心衰竭表現(xiàn)有引起急性發(fā)作的誘因 有急性左心衰的臨床表現(xiàn)第57頁(yè)，共128頁(yè)。女性患者，36歲。病例主訴：因發(fā)熱、呼吸急促及心悸3周入院?，F(xiàn)病史：4年前病人開始于勞動(dòng)時(shí)自覺心慌氣短，近半年來(lái)癥狀加重，同時(shí)下肢出現(xiàn)浮腫。1個(gè)月前，經(jīng)常被迫采取端坐位并時(shí)常于晚間睡眠時(shí)驚醒，氣喘不止，經(jīng)急診搶救好轉(zhuǎn)。近三周來(lái)，出現(xiàn)惡寒發(fā)熱，咳嗽，痰中時(shí)有血絲，心悸氣短加重。第58頁(yè)，共128頁(yè)。既往史：患者于兒童時(shí)期曾因患咽喉腫痛而做扁桃體摘除術(shù)，以后時(shí)有膝關(guān)節(jié)腫痛史。病例第59頁(yè)，共128頁(yè)

30、。體檢：T39.6，P161次/分，R33次/分，BP 110/80mmHg。重癥病容，口唇發(fā)紫，半臥位，嗜睡；頸靜脈怒張，心界向兩側(cè)擴(kuò)大，心尖區(qū)可聽到明顯收縮期雜音，肺動(dòng)脈瓣第二音亢進(jìn)。兩肺可聞廣泛濕性羅音.腹膨隆，可聞移動(dòng)性濁音。肝于肋下6cm，壓痛；脾于肋下3 cm。指端呈杵狀，下肢明顯凹陷性水腫。 。病例第60頁(yè)，共128頁(yè)。實(shí)驗(yàn)室檢查：紅細(xì)胞3.01012/L白細(xì)胞18109/L中性粒細(xì)胞占90%尿量300-500ml/日 少量蛋白和紅細(xì)胞尿膽紅素（+）血漿總膽紅素31.6mol/L（正常17.1）直接膽紅素12.8mol/L (正常50%第64頁(yè)，共128頁(yè)。壓力指標(biāo)： LVEDP

31、 正常值 0.67 1.60Kpa （5 12mmHg） LAP 正常值 0.27 1.60Kpa （2 12mmHg） PAP 正常值 1.60 3.340.541.73KPa （12 25413mmHg） 平均壓 10.67 25.3KPa（8 19mmHg）PCWP 正常值 0.67 1.60KPa（5 12mmHg） 13 20mmHg（輕度增高） 2130mmHg（中度增高） 30mmHg（重度增高） 通常 PCWP18mmHg（2.4KPa）肺底出現(xiàn)濕羅音 PCWP25mmHg（3.3KPa）濕羅音12肺野 PCWP30mmHg（4KPa）肺水腫 若無(wú)二尖瓣狹窄時(shí)，PCWP=LAP

32、=LVEDP 第65頁(yè)，共128頁(yè)。Treatment of chronic heart failure Principle: alleviate symptoms ,improve life quality.treatment for primary disease and precipitating causesAntagonism of neurohumoral activationinhibition of progressive ventricular remodelingreduce mortality and extend life.第66頁(yè)，共128頁(yè)。Treatment of

33、 chronic heart failureGeneralPharmacologic treatmentNon-medicine treatment第67頁(yè)，共128頁(yè)。General treatment1.一般患者應(yīng)采取高枕位睡眠；較重者采取半臥位或坐位。2.限制體力活動(dòng)，心力衰竭較重的患者以臥床休息為主；心功能改善后，應(yīng)適當(dāng)下床活動(dòng)，以免下肢血栓形成和肺部感染。3.一定要戒煙、戒酒，保持心態(tài)平衡，同時(shí)還要保證充足的睡眠。4.少量多餐，低鹽飲食,每日食鹽不宜超過(guò)5克。5.按醫(yī)囑服藥；預(yù)防呼吸道感染；育齡婦女要做好避孕。第68頁(yè)，共128頁(yè)。General treatmentdecreased

34、 burdensincreased systole powerAnti-neurohumoral activation第69頁(yè)，共128頁(yè)。General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation1.Lifestyle managementEducationRegulate weightDietary management:salt take2.Rest and action3. Treatment for primary disease and precipitating 第70

35、頁(yè)，共128頁(yè)。General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation1.Rest2. Dietary management:salt take3. Diuretics furosemidedihydrochlorothiazide ( potassium-losing) antistone (potassium-sparing)第71頁(yè)，共128頁(yè)。The main point of diuretics application對(duì)于有癥狀的心衰，當(dāng)液體負(fù)荷過(guò)重已表現(xiàn)為肺淤血或外周

36、水腫時(shí)，利尿劑是基本的治療。應(yīng)用利尿劑可迅速改善呼吸困難并增加運(yùn)動(dòng)耐量（I類建議，證據(jù)級(jí)別A）尚無(wú)大型隨機(jī)對(duì)照試驗(yàn)評(píng)估這類藥物對(duì)癥狀和生存的影響。如能耐受，利尿劑始終應(yīng)與ACEI和-受體阻滯劑一起使用。（I類建議，證據(jù)級(jí)別C）。第72頁(yè)，共128頁(yè)。 襻利尿劑應(yīng)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(jí))。利尿劑通常從小劑量開始(氫氯噻嗪25 mg/d，呋塞米20 mg/d，托塞米10 mg/d),逐漸加量。一旦病情控制即以最小有效量長(zhǎng)期維持。每日體重變化是最可靠檢測(cè)利尿劑效果和調(diào)整利尿劑劑量的指標(biāo)。長(zhǎng)期服用利尿劑應(yīng)嚴(yán)密觀察不良反應(yīng)的出現(xiàn)如電解質(zhì)紊亂、癥狀

37、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(shí)（類，B級(jí)）。The main point of diuretics application第73頁(yè)，共128頁(yè)。General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation1.Rest2. Dietary management:salt take3. Diuretics4. Vasodilator sodium nitroprusside(SNP) Nitroglcerin（硝酸甘油）regitine(酚妥拉明)第74頁(yè)，共128

38、頁(yè)。The main point of Vasodilator application直接血管擴(kuò)張劑對(duì)于CHF的治療無(wú)特殊作用。（類，A級(jí)）血管擴(kuò)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(yīng)用（類，B級(jí)）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第75頁(yè)，共128頁(yè)。General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation1.Digitalis （1）effection:Positive inotropic： inhibit Na+

39、-K+-ATP enzyme introcellular Na+、K+ Na+-Ca2+exchange introcellular Ca2+ myocardial systole power introcellular K+ ，digitalis poisoning第76頁(yè)，共128頁(yè)。第77頁(yè)，共128頁(yè)。General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation1.Digitalis （1）effection:Positive inotropic：Electrophysiolo

40、gical Inhibit condution system, espicially atriventricular junction. Improve the autorhythmicty of atrium, junction region and ventricle.第78頁(yè)，共128頁(yè)。General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation1.Digitalis （1）effection:Positive inotropic：ElectrophysiologicalPar

41、asympathetic stimulating anti-sympathetic nerve exciting 第79頁(yè)，共128頁(yè)。General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation1.Digitalis （1）effection:Positive inotropic：ElectrophysiologicalParasympathetic stimulatingRole in the renal tubule cells reducing sodium reabsorpt

42、ion inhibit the secretion of renin 第80頁(yè)，共128頁(yè)。General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation1.Digitalis （2）application indication: chronic congestive heart failure complicated by atrail flutter and fibrillation and a rapid ventricular rate第81頁(yè)，共128頁(yè)。General tre

43、atmentdecreased burdensincreased systole powerAnti-neurohumoral activation1.Digitalis （2）application contraindication（禁忌癥）:WPW with AF degree AVB , degree AVBsick sinus syndrome(SSS)Hypertrophic cardiomyopathy (HOCM)severe mitral stenosis(SMS)acute myocardiac infarction(first 24 h第82頁(yè)，共128頁(yè)。General

44、treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation1.Digitalis (3) digitalis poisoningfactors： K+ ,O2 ,Clincal expression: gastric bowel reaction; arrhythmia; neurological and visual changeDiagnosis： 2.0 ng/ml第83頁(yè)，共128頁(yè)。Arrhythmia of digitalis poisoningVentricular Premature

45、 beatNonparoxysmal atrioventricular junctional tachycardia非陣發(fā)性房室交界性心動(dòng)過(guò)速Atrial Premature beatAtrial fibrillaton Atrioventricular block ST-T change like fishhookCharacteristic feature第84頁(yè)，共128頁(yè)。第85頁(yè)，共128頁(yè)。General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation1.Digitalis

46、Treatment of digitalis poisoningdrug withdrawaltachycadia:supply K+ , Lidocain ivbradicadia： atropin iv, not suitable for pacemaker not suitable for isoprenaline disable cardioerter第86頁(yè)，共128頁(yè)。General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation 1、 Digitalis2、-excitan

47、tDopamine： NE precursor2g/kg.min Dopamine -R(+) expand renal artery2-5 g/kg.min 1 2-R(+) myocardial contractility, Vasodilate5-10 g/kg.min -R(+) BP ,HR Dobutamine： Dopamine derivatives 2g/kg.min 10g/kg.min Vasodilate, HR -small effects第87頁(yè)，共128頁(yè)。General treatmentdecreased burdensincreased systole po

48、werAnti-neurohumoral activation 1、 Digitalis2、-excitant3、Phosphodiesterase inhibitors 1、effect: restrain activity of phosphodiesterase ， the degradation of cAMP(-) cAMP Ca2+ channel activation Ca2+ -inflowmyocardial contractility 第88頁(yè)，共128頁(yè)。General treatmentdecreased burdensincreased systole powerAn

49、ti-neurohumoral activation 1、 Digitalis2、-excitant3、Phosphodiesterase inhibitors 1、effect:2、indications ：refractory heart failureend-stage heart failure before heart transplantation 第89頁(yè)，共128頁(yè)。General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation 1、 Digitalis2、-excita

50、nt3、Phosphodiesterase inhibitors 1、effect:2、indications ：3、drugs： 氨力農(nóng)(Amrinone) VD 5-10 g/kg.min 米力農(nóng)(Milrinone) VD 0.5 g/kg.min第90頁(yè)，共128頁(yè)。General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation 1、 Digitalis2、-excitant3、Phosphodiesterase inhibitors 1、effect:2、indications

51、 ：3、drugs： 4、defect ： side-effect ; mortality 第91頁(yè)，共128頁(yè)。 AII 產(chǎn)生是通過(guò)多種通道 血管緊張素原腎素血管緊張素 I(1-10) Ang II（1-8）ACEAT1AT2血管收縮 增殖醛固酮增加血管擴(kuò)張 抗增殖Ang1-7Ang1-7受體激活血管擴(kuò)張 抗增殖ARB第92頁(yè)，共128頁(yè)。General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation 1、 RAAS inhibitorAngiotensin Converting En

52、zyme Inhibitors(ACEI) dilate blood vessels inhibit RAS, sympathetic system reverse the ventricular remodeling improve blood flow dynamics Improve endothelial function AT ,Inhibit the degradation of bradykinin第93頁(yè)，共128頁(yè)。General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activa

53、tion 1、 RAAS inhibitorAngiotensin Converting Enzyme Inhibitors(ACEI) Clinical status symptoms , exercise tolerance mortality delay the progress of heart failure reducing hospitalization rates prevent HF after myocardial infarction 第94頁(yè)，共128頁(yè)。General treatmentdecreased burdensincreased systole powerA

54、nti-neurohumoral activation 1、 RAAS inhibitorAngiotensin Converting Enzyme Inhibitors(ACEI) Captopril 6.2525mg 23/d Enalapril 10 mg 2/d Benazepril 510 mg/d Perindopril 24 mg/d Fosinopril 510 mg/d Ramipril 5 mg/d第95頁(yè)，共128頁(yè)。General treatmentdecreased burdensincreased systole powerAnti-neurohumoral act

55、ivation 1、 RAAS inhibitorAngiotensin Converting Enzyme Inhibitors(ACEI) application methods starting with small dosesif tolerated , gradually increase the dosemonitoring of renal function and ions renal function change, high potassium, dry cough, angioedema 第96頁(yè)，共128頁(yè)。General treatmentdecreased burd

56、ensincreased systole powerAnti-neurohumoral activation 1、 RAAS inhibitorAngiotensin Converting Enzyme Inhibitors(ACEI) Contraindication: anuric renal failure pregnancy and brest feeding woman allergeRelative Contraindication: renal artery stenosis bilaterally Cr225 mol/l k+5.5mmol/l hypotension第97頁(yè)，

57、共128頁(yè)。General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation 1、 RAAS inhibitorAngiotensin Converting Enzyme Inhibitors(ACEI) Angiotensin II receptor antagonist (ARB) AT-AT1 receptor Inhibit RAS No affecting the degradation of bradykinin第98頁(yè)，共128頁(yè)。General treatmentdecre

58、ased burdensincreased systole powerAnti-neurohumoral activation 1、 RAAS inhibitorAngiotensin Converting Enzyme Inhibitors(ACEI) Angiotensin II receptor antagonist (ARB)application methods less dry cough and angioedema when HF , first chose ACEIwhen HF , should not be combined application of ACEI and

59、 ARB Losartan 50mg/d;valsartan 80mg/d第99頁(yè)，共128頁(yè)。General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation 1、 RAAS inhibitorAngiotensin Converting Enzyme Inhibitors(ACEI) Angiotensin II receptor antagonist (ARB)Aldosteroneantagonists spironolactone(SPI)螺內(nèi)酯potassium-sparing

60、 diuretic reverse the ventricular remodeling improve prognosis第100頁(yè)，共128頁(yè)。General treatmentdecreased burdensincreased systole powerAnti-neurohumoral activation 1、 RAAS inhibitorAngiotensin Converting Enzyme Inhibitors(ACEI) Angiotensin II receptor antagonist (ARB)Aldosteroneantagonists renin inhibit