心臟衰竭課件

1、心臟衰竭心輸出量不足以供應體內器官血流需求心輸出量減低體內器官血流需求增加綱要（1）心臟衰竭是一個普遍、嚴重、且耗費金錢，但可治療的疾病。每一個心臟衰竭的病人均應接受心臟超音波的檢查。研究證實，不論是初級或次級的致病因素，對心臟衰竭都是非常重要的。The Epidemiology of Congestive Heart Failure in the United StatesPrognosis Related to Severity of Heart Failure心臟衰竭的原因（1）冠狀動脈心臟病高血壓瓣膜性心臟病毒素：酒精，古柯鹼，化學治療藥物，感染（心肌炎，敗血癥）浸潤性疾?。貉爻林?/p>

2、癥，類澱粉沉著癥心臟衰竭的原因（2）非特異性心肌病變：包括遺傳性，擴張性，限制性和肥厚性先天性心臟病自體免疫性疾?。河财ぐY，紅斑性狼瘡內分泌疾?。禾悄虿。谞钕贆C能障礙，嗜鉻性細胞瘤Left VentricleRight Ventricle心臟衰竭的型態(tài)Left vs. Right heart failureForward vs. Backward heart failureSystolic vs. Diastolic heart failureLow vs. High cardiac output heart failureChronic vs. Acute heart failureCau

3、ses of Left Heart FailureCauses of Right Heart Failure Consequence of Left Heart Failure Right Ventricular Infarction Pulmonary Hypertension & Disease Congenital Heart Disease Infective EndocarditisCauses of Low Cardiac Output Heart Failure心肌收縮功能不良心臟Preload 不足心臟Afterload 過高Causes of High Cardiac Out

4、put Heart Failure甲狀腺機能障礙貧血發(fā)燒Vit B1 缺乏 (Beri Beri disease)AV fistula / shuntCommon Causes of Chronic Heart FailureCommon Causes of Acute Heart Failure暫時性或急性心肌缺氧 (包括心肌梗塞或外傷)突發(fā)性心律不整急性瓣膜失常（包括人工瓣膜）心包膜填塞急性肺動脈栓塞合併肺臟疾病（包括睡眠呼吸中止）合併腎臟疾病未服藥或藥物中毒（包括換藥及不按醫(yī)囑服藥）心臟衰竭之臨床癥狀（1）心輸出量減少倦怠週邊循環(huán)變差出現第三心音心搏過速腎功能不全心臟衰竭之臨床癥狀（2）

5、鬱血咳嗽氣喘- DOE, PND肺囉音水腫- Peripheral, Sacral腹水頸靜脈怒張肝臟充血New York Heart Association Classification, 1964心臟衰竭之臨床癥狀（3）心律不整頭暈心悸昏厥心臟衰竭之處理步驟臨床診斷 (心臟衰竭之癥狀及型態(tài))基本檢查（CxR, ECG, Echo.）找出病因或可能之原因評估危險因子心臟衰竭 心輸出量相對不足Normal vs. Enlarged Heart FailureDiastolic vs. Systolic Heart FailureCongestive Heart Failure with Left

6、 Ventricular HypertrophyCongestive Heart Failure with Bi-ventricular Dilatation and Bilateral Pleural EffusionAims of Treatment for CHF心臟衰竭之治療原則不同型態(tài)心臟衰竭之治療急性期 vs. 慢性期 藥物 vs. 非藥物之處置進一步特殊處置心臟衰竭之治療 - Systolic CHFTo improve心臟Preload 不足心肌收縮功能不良心臟Afterload 過高心臟衰竭之治療 - Diastolic CHFTo improve心律不整或心跳過快心肌缺氧心

7、肌舒張功能不良心臟Afterload 過高心臟衰竭之治療 急性期限水及足夠劑量之利尿劑增強左心室收縮力之藥物 (Dobutamine & Dopamine & 毛地黃 )其他血管擴張劑考慮使用抗心律不整藥物心臟衰竭之治療 慢性期使用最大劑量之ACEI利尿劑病情穩(wěn)定後使用大劑量之乙型阻斷劑毛地黃其他血管擴張劑考慮使用抗凝血藥物心臟衰竭之治療 非藥物處置控制危險因子（吸煙，喝酒，血脂代謝異常，糖尿病，高血壓） 限制鹽分及水分攝取過多，並監(jiān)測體重適度運動改善營養(yǎng)狀況建議注射流行感冒及肺炎球菌之疫苗Non-pharmacological Treatment of CHF心臟衰竭之藥物治療 (1)利尿劑

8、毛地黃 - Cardiomegaly & Atrial fibrillation增強左心室收縮力之藥物 - Dobutamine & Dopamine ACEI乙型阻斷劑 Normal cardiac size or Rapid heart rate心臟衰竭之藥物治療 (2)抗心律不整藥物抗凝血藥物Autonomic System( Norepinephrine )Renin-Angiotensin System( Angiotensin II )Hypertrophy, Apoptosis, Remodelling, Fibrosis, Ischemia, ArrhythmiaNeuro-H

9、ormonal Activation in CHFACE inhibitors in heart failureApproximately 7,000 patients evaluated in placebo-controlled clinical trialsConsistent improvement in cardiac function, symptoms and clinical statusDecrease in all-cause mortality by 20-25% (p0.001)Decrease in combined risk of death and hospita

10、lisation by 20-25% (p0.001)SOLVD Prevention(enalapril)Class IClass IVSOLVD Treatment (enalapril)V-HeFT II (enalapril)CONSENSUS(enalapril)Class IIClass IIIUS Consensus Recommendations (1996)Consensus recommendationsAll patients with heart failure (NYHA Fc I-IV) due to left ventricular systolic dysfun

11、ction should receive an ACE inhibitor unless they have a contraindication to its use or cannot tolerate treatment with the drugACE inhibitors in heart failureb1 receptorsb2 receptorsMyocyte hypertrophy & death,dilatation, ischaemia & arrhythmiasa1 receptorsCardiacsympathetic activitySympatheticactiv

12、ity to kidneys& blood vesselsVasoconstrictionSodium retentionCNS sympatheticoutflowAdrenergic activationAdapted from M Packerb1 receptorsa1 receptorsCARDIOTOXICITYb2 receptorsSympathetic activationBisoprololMetoprololPropranololCarvedilolAntiadrenergic therapy by blockadeAdapted from M PackerCompreh

13、ensive Adrenergic BlockadeAdapted from M Packera1 blockadea1 blockadeb blockadeCardiac output Renal blood flowWorsening heart failureSodium retentionCarvedilol (n=696)Placebo (n=398)SurvivalDays0501001502002503003504001.0 0.9 0.8 0.7 0.6 0.5Risk reduction = 65%p0.001Packer et al (1996)The MERIT-HF S

14、tudy Group (1999)Months of follow-upMortality %03691215182120151050PlaceboMetoprolol CR/XLp=0.0062Risk reduction = 34%US Carvedilol Study blockers in heart failure -all-cause mortalityMERIT-HFLancet (1999)0 200 400 600 8001.00.80.60BisoprololPlaceboTime after inclusion (days)p0.0001SurvivalRisk redu

15、ction = 34%CIBIS-IIOver 13,000 patients evaluated in placebo-controlled clinical trialsConsistent improvement in cardiac function, symptoms and clinical statusDecrease in all-cause mortality by 3035% (p0.0001) (up to 65% with carvedilol)Decrease in combined risk of death and hospitalisation by 2530%

16、 (p0.0001) blockers in heart failureCAPRICORN (carvedilol)?Class IClass IVUS Carvedilol (carvedilol)CIBIS II (bisoprolol)MERIT-HF (metoprolol)COPERNICUS(carvedilol)Class IIClass III blockers in heart failureConsensus recommendationsAll patients with stable class II or III heart failure due to left v

17、entricular systolic dysfunction should receive a blocker (in addition to an ACE inhibitor) unless they have a contraindication to its use or cannot tolerate treatment with the drugWhy are the recommendations more restrictive than for ACE inhibitors despite the available evidence?心臟衰竭之藥物治療 急性期足夠劑量之利尿劑使用最大劑量之ACEI增強左心室收縮力之藥物 (Dobutamine & Dopamine)毛地黃 - Cardiomegaly & Atrial fibrillation低劑量乙型阻斷劑 Normal cardiac size or Rapid heart rate考慮使用抗凝血藥物心臟衰竭之藥物