心衰英文講稿課件

1、12Heart failure is the pathophysiological state in which the heart is unable to pump blood at a rate commensurate with the requirements of the metabolizing tissues or can do so only from an elevated filling pressure. Varying degrees of pulmonary and systemic vascular congestion and hypo perfusion. I

2、t is usually, but not always, Caused by a defect in myocardial contraction, i.e, by myocardial failure. 3 1 Causes primary disturbance in myocardial contractility myocardial infarction 節(jié)段性心肌損害 myocardial ischemic myocarditis 彌漫性心肌損害 cardiomyopathy connective tissue disease 4 Disorder of myocardial m

3、etabolism VitaminB1Deficiency high altitude heart diseasemyocardium amyloidosis5 Ventricle Overloadhypertensionaortic stenosis afterloadpulmonary hypertensionpulmonary stenosisMI、AI、TIASD、VSD、PDA preloadhyperthyridism、anemia、 arterio-venous fistula6Decompensation of chronic CHFCoronary ischemia/ inf

4、arctionSevere hypertensionValvular Heart DiseaseCardiomyopathy/ MyocarditisPericardial diseaseOther: Diastolic dysfunction, CHDUsual Cardiac Causes of CHF7 2 precipitating causesRecent infection especially pulmonary infectionInappropriate Reduction of Therapy arrhythmiasPulmonary embolismPhysical, E

5、nvironmental and emotional excessesInfective endocarditisDevelopment of an unrelated illnessAdministration of cardiac depressants or salt-re-tainting DrugsHigh-Output states pregnancyDevelopment of a second form of heart disease8 3 pathophysiology Hemodynamics abnormality 在心力衰竭時，心功能曲線向左下偏移normalHear

6、t failure心臟指數(shù)2.5-0.81.62.4肺淤血 低排左室收縮功能 left ventricular end-diastolic pressure9Adaptive mechanisms of neurohormonalIncreased Sympathetic ActivityActivation of the renin-angiotensin system(RAS)Arginine Vasopressin (AVP) is elevatedANP (atrial natriuretic peptide)BNP (brain natriuretic peptide) releas

7、edCNP (c-natriuretic peptide)Bradykinin 緩激肽Endothelin.10神經(jīng)內(nèi)分泌激活 排鈉利尿 早期 早期 心肌收縮力擴(kuò)血管 心房肽 心排血量 重要臟器血流抗腎素醛固酮 SNS 外周血管收縮 心衰 RAS 加壓素心衰惡化 心房肽 外圍阻力 耗竭 長期 水鈉潴留 心臟負(fù)荷 心衰惡化 長期 對心肌的直接毒性 11Ventricle remodeling初始心肌損傷心臟負(fù)荷過重心肌梗死炎 癥繼發(fā)性介導(dǎo)因素去甲腎上腺素 血管緊張素 內(nèi)皮素 炎癥細(xì)胞因子腫瘤壞死因子，白介素6醛固酮(交感激活)機(jī)械應(yīng)激氧化應(yīng)激(氧自由基 )疾病進(jìn)展心力衰竭并發(fā)癥死亡心肌重塑心肌細(xì)

8、胞肥大心肌細(xì)胞凋亡細(xì)胞外基質(zhì)變化作用于 心肌124 forms of heart failure Acute heart failure 按心衰發(fā)展速度 Chronic heart failure Left-sided heart failure根據(jù)心衰發(fā)生部位 Right-sided heart failure Biventricular failure根據(jù)心臟的收縮性 Systolic heart failure 舒張性可 分為 Diastolic heart failure 13 in addition；： Forward vs. backward heart failure Asymp

9、tomatic vs.congestive heart failure Low-output vs : Congenital, Valvular, Rheumatic, Hypertensive, Coronary, Cardiomyopathic high-output heart failure : Anemia, Systemic Arteriovenous Fistulas, Hyperthyroidism, Beriberi Heart Disease , Paget” Disease ,Fibrous dysplasia, etc145 Clinical manifestation

10、s left heart failure：Consequence of inadequate cardiac output and/or pulmonary congestion hypertension heart disease 多見于 coronary heart disease valvular heart disease AI MI 15 symptoms respiratory distress exertional dyspnea orthopnea the increased venous return when the patient lies flat paroxysmal

11、 nocturnal dyspnea offer being asleep for some time the patient is awakene by severe breathlessness. pulmonary edema due to gradual resorption of interstitial fluid overnight and aocturnal depression of respiratory function. 1617Cough Sputum production A nocturnal dry cough due to bronchial oedema o

12、r cardiac asthmaIncreased respiratory rate、 WheezingHemoptysis Frothy pink-tinged sputum due to pulmonary oedemaReduced exercise capacityFatigue and weakness , dizzy agrypnodePallor, cyanosis, tachycardiablood pressure decrease18physical findings 心臟方面體征 cardiomegaly 左心室大為主， 但AMI , 風(fēng)心病MS可無左室擴(kuò)大, Tachy

13、cardia Protodiastolic gallop sounds 1920Physical signAccentuation of p2 肺動脈瓣區(qū)第二心音亢進(jìn)Systolic murmurs 心尖區(qū)相對性收縮期雜音 pulsus alternans 交替脈21 base of lung moist rales wheezing in the chest breath sounds are diminished 在間質(zhì)性肺水腫時，肺部無干濕羅音 僅有肺呼吸音減低，如高原心臟病。2223right heart failure symptom and sign of systemic cir

14、culation congestion 多見于：chronic pulmonary heart diseaseright ventricular cardiomyopathyright ventricular myocardial infarctionMS TS TI 24 Symptom of right heart failure Gastrointestinal tractAnorexia ( which may be caused by oedema of the gut)Nausea and vomitingConstipation 便秘Superior belly ache ,Di

15、stention 上腹疼痛 25Urinary Symptoms renal function decline nocturia , oliguria Proteinuria granular cast ,26Hepatic region symptomcongestive hepatomegaly 肝淤血腫大abdominal distention 腹飽脹不適Hepatic region ache 肝區(qū)疼痛cardiogenic cirrhosis 心源性肝硬化2728physical findingsCardromegalyPalpable systolic movement in the

16、 left parasternal regionImpulse is accompanied by reciprocal systolic retraction of the apesGallop of diastole in the left parasternal regionThe systole murmurs of tricuspid regurgitation 29engorgement of neck veins 頸V充盈或怒張 hepatojugular reflux 肝頸返流征陽性congestive hepatomegaly 肝腫大和壓痛Peripheral edema水腫

17、 Descensus symmetry incisurehydrothorax and ascitea 胸水和腹水Cyanotic 紫紺30Biventricular heart failure The manifestation of left and right ventricular heart failure Complications: Acid-Base and Electrolyte Disorder Renal insufficience Cardiac cachexia 心源性惡液質(zhì)316 laboratory examination32The Chest Roentgeno

18、gramUsually demonstrates increased heart size cardiothoracic ratio0.50Interstitial pulmonary edema Kerley B lineAlveolar pulmonary edema , with a cloudlike appearance and concentration of the fluid around the hili in a butterfly pattern hydrothorax333435 electrocardiogram AnalysisPtfV1 50%，young peo

19、ple55%Percentage of fractional shortening(FS)normal 25% Youth30%abnormality EF50% FS1 abnormality: E/A2.5L/min.mPCWP 40歲 多見于兒童或青少年History 有高、冠、風(fēng)心病史 有家族史及過敏史Fit time 常夜間出現(xiàn) 多在寒冷季節(jié)發(fā)作expectoration 粉紅色泡沫痰 干咳或大量稀薄白痰Sign 心大 奔馬律 心臟雜 心肺方面僅有心率快 音雙肺底有較多干濕羅音 雙肺有彌漫性哮鳴音 胸叩診呈濁音 胸叩診呈高清音Treatment 嗎啡 腎上腺素類48Different

20、iation of righ heart failureis Hydropericardium, constrictive pericarditis Cardiogenic and renal edema portal cirrhosis cava Syndrome498 Management of heart failure To improve quality and length of life To prevent progression of heart failure50 Removal of the underlying cause To treat hypertension C

21、atheter-based intervention or coronary bypass surgery Repair structural abnormalities of congenital heart defects To treat hyperthyroid or hypothyroid51 Precipitating causes therapeuticsRest and Augmentation nutrienAnti-infection,pulmonary infection or infective endocarditisContrast arrhythmiaRedres

22、s electrolyte disturbance Redress anemiaRedress Acid-Base DisorderTo treat pulmonary Embolism52Therapeutic strategy for management of heart failure Supine restAugmentation nutrient Salt restriction Symptomatic treatmentSupplemental O2 provided Cardiac monitoring Initiate necessary supportive therapy

23、53DiureticsHydridiuril: Distal tubule, inhibit Na + CI- symport ,Na+, particulculy in elderly patientsLasix: Thick ascending limb of loop of Henle ,Inhibition of Na + /k+/CI- symport , Hypochloremic alkalosis HCO3 K+, Na + CI- , Mg+, Uric acldAldactone: Collecting duct: aldosterone antagonists K+, p

24、artiularly in patients54 利尿劑 diuretics 噻嗪類：作用于遠(yuǎn)曲腎小管近端，抑制Na+、CI-、K+ 重吸收 雙氫氯噻嗪 （DHCT）25 mg Qd 袢利尿劑：作用于亨利袢的上升支，抑制Na+、CI-、K+ 重吸收 速尿 20-40 mg Qd 潴鉀利尿劑：作用于遠(yuǎn)曲腎小管遠(yuǎn)端，排Na+、CI-，但 不排K+ 氨苯喋啶 50 mg Bid 醛固酮拮抗劑：作用于集合管，排Na+保K+（抑制H+- K+ 交換并有抗醛固酮的作用， 如安體舒通20mg 40mg Qd55 vasodilators Afterload reduction Hydralazing ,Ph

25、enolamine Preload reduction Nitroglycerin ,Isosorbide dinitrate potent preload and afterload reducer Sodium nitroprusside dose 0.5 - 2 ug/kg/min useful in acute mitral regurgitation56 Renin-Angiotensin System AntagonistsAngiotensin Converting Enzyme Inhibitor Angiotensin receptor antagonistRenin inh

26、ibitor57 ACEI的基本作用圖解 血管緊張素原血管緊張素 I腎素旁路系統(tǒng)胰蛋白酶組織蛋白酶血管緊張素 IIACE緩激肽P物質(zhì)腦啡肽I 型受體無活性片段II 型受體血管擴(kuò)張腎血漿流量腎小球內(nèi)壓動力學(xué)改變非-動力學(xué)改變 蛋白尿 ECM 降解 M 浸潤動力學(xué)改變動力學(xué)改變非-動力學(xué)改變非-動力學(xué)改變血管收縮 腎血漿流量 腎小球內(nèi)壓 鈉/水重吸收醛固酮TGF-細(xì)胞外基質(zhì)PAI-1M 激活血管擴(kuò)張BP腎臟發(fā)育 細(xì)胞增殖抗纖維化效應(yīng)壓力性利鈉NOPGE2PGF25859ACEI對緩激肽的影響及其病生理意義ACEI（+）內(nèi)皮細(xì)胞NO合成酶表達(dá)NO釋放PGE2、PGI合成EDHF酶解組織局部緩激肽堆積

27、抑制血小板凝集tPA合成阻斷氧化型LDL的毒性反應(yīng)擴(kuò)血管、抗增殖效應(yīng)抗血栓形成平衡效應(yīng)內(nèi)皮細(xì)胞氧化應(yīng)切力無活性片段606162 Shortness Captopril ACEI lente Enalaprol ultralente Ramipril ANG receptor antagonist Losartan 50mg Qd , Jiesartan 80mg Qd63 Digitalis Positive inotropic Negative frequency Negative conduction64 digitalis glycosidesImprovement of myocard

28、ial contractilityIncreases cardiac outputPromotes diuresis Reduces the filling pressure of ventricle Reduction of pulmonary vascular congestion Reduction of central venous pressure 65 抑制 機(jī)理：洋地黃Na+_K+ATP酶 Na+內(nèi)流 細(xì)胞內(nèi)Na+-Na+_ Ca+交換 K+ 細(xì)胞內(nèi)Ca+ 正性肌力作用66Adaptation Systolic heart failure ischemic, valvular,h

29、ypertensive, congenital heart disease, dilated cardiomyopathies, cor pulmonaleAf:Atrial fibrillationAF:Atrial flutter67Contraindication Digitalism Preexcitation syndrome combine Af AFAtrioventricular blockSick sinus syndrome;SSS Diastolic heart failureHypertrophic obstructive cardiomyopathy Isolated

30、 MS with normal sinus rhythm Acute myocardial infarction in a 24h68 Clinical application Cedilanid 0.4 mg iv ， Strophanthin 0.25mg iv， Digoxin 0.25mg po Qd 69 Digitalis toxicity:Gastrointestinal tract sympt Nausea, Vomiting, Anorexia nervous system Blurred vision, opto -chryso, Lassitude, depression

31、, Sleeplessness, Headache symptom of heart rhythm disturbances Ectopic beats of junctional or ventrcular orijin Accelerated AV junctional pacemaker Bradycardia, AV block, sinus arrest Excessively slow ventricular rate response to AfWorsening heart failure70Treatment of digitalis toxicityadjustment D

32、osageMonitoring as clinically appropriate or AVB respond to atropine or temporary ventricular pacingPotassium or MagnesiumLidocaine or phenytoinElectrical cardioversion can precipitate severe rhvthm distrbances should be used with particular caution71 Adrenoreceptor Agonists and Phosphodiesterase Inhibitors A T P 腺 磷 兒苯酚胺 興奮 激活 苷 酸 抑制多巴胺 受體酸 二 磷酸二酯酶抑制劑 環(huán) 酯 化 酶 激 酶 活 心肌細(xì)胞血管平滑肌細(xì)胞 酶 C