循环系统内科学课件:Heart Failure-Dao Wen Wang.ppt
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1、1Congestive Heart FailureDao Wen Wang, MD, PhDDepartment of Internal Medicine, Tongji Hospital/Medical College, HUST2Basic Definition of Heart Failure(1) Heart failure is a medical term that describes an inability of the heart to keep up its work load of pumping blood to the lungs and to the rest of
2、 the body.http:/danilhammoudimd_ Heart (or Cardiac) Failure is the pathophysiological state which the heart is unable to pump blood at a commensurate with the requirements of the metabolizing tissues or can do so only from an elevated filling pressure. -Braunwards Heart Disease Chronic heart failure
3、 is complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. -JACC guidelineBasic Definition of Heart Failure(1)4Epidemiology It is estimated that as many as two million Americans suffer from c
4、ongestive heart failure (Morbidity: 1.2-2.0%) and that up to 29, 000 die annually from this chronic disorder. Cannobio, Mary. Cardiovascular Disorders. Missouri: C.V. Mosby Company, 1990. In the world, it is 2% Only in 35-74 years old people, it is estimated that as many as 3.6 million Chinese suffe
5、r from congestive heart failure (0.9%), Annual mortality is about 20%-50% and 5 year mortality is up to 67%. The morbidity increases as ages get older: such as the mortality in age 50 is 1%, but up to 10 times in 80. 5Etiology of Heart Failure Congestive heart failure is a syndrome that can be cause
6、d by multiple underlying diseases such as: Primary myocardial injury: (1) ischemic myocardial impairment-coronary heart disease or myocardial infarction (2) myocarditis and cardiomyopathy-hypertrophic, dilated cardiomyopathies, isolated left ventricular non-compaction and Arrhythmic right ventricle
7、cardiomyopathy (3) Metabolic disorders in myocardium-hypothyroidism, hyperthyroidism, diabetes Overload of heart: (1) pressure overload (afterload)-hypertension, aortic stenosis, pulmonary stenosis (2) volume overload (preload)-aortic or mitral regurgitation (insurficiency), congenital heart disease
8、s (left to right side fistula), over volume circulation status: chronic anemia, thyroidism6Population attributable risk for heart failure incidence Population attributable risk for heart failure incidence More cardiomyopathies in China: dilated or hypertrophic 7NT-proBNPOther disease8Predisposing fa
9、ctor of Heart FailureHeart failure patients usually have basic heart disease and heart failure occurs under following predisposing factors: Infection ! arrhythmias Elevated blood volume overfatigue or excited too much Progressing of heart disease9Pathophysiology1. Short-term adaptive mechanisms: Hem
10、odynomic and Circulatory Consequences of Heart failure10Frank-Starling CurveVascular Redistribution of Left Ventricular OutputEndothelial Dysfunction112. Chronic Myocardial Remodeling (1)Ventricular Remodeling, consisting of changes in mass, volume, shape, and composition, constitutes one of the pri
11、ncipal mechanisms by which the heart compensates for an increased load12 Patterns of Ventricular Remodeling: In early stage or compensatory phase, ventricle remodels and function can return to normal; In later stage or advanced phase (overload increases further), there is further aggravation in myoc
12、ardial function and later in “exhaustion” phase, several macroscopic events take place.2. Chronic Myocardial Remodeling (2)1314Structural changes in the left ventricle in systolic heart failure (SHF) and diastolic heart failure (DHF). AC, Autopsy examples of left ventricular (LV) remodeling that are
13、 common in patients with SHF (B) and DHF (C). D, Typical LV geometry with SHF or DHF. 15 Cellular Changes in myocardial remodeling (1) Cell size becomes larger (2) Mitochondria increases and expands decreases in number (3) Collagens in the extracellular matrix (ECM) increase (4) Apoptosis and necros
14、is of cardiomyocytes occurs, and cell number decreases2. Chronic Myocardial Remodeling (3)162. Chronic Myocardial Remodeling (4) Molecular Changes in myocardial remodeling (1) Myocytes loss: necrosis, apoptosis (classic apoptosis and endoplasmic reticulum (ER) Stress-induced apoptosis) (2) Changes i
15、n cardiac gene expression17183. Neurohormonal, Autocrine, and Paracrine Adjustments Autonomic nervous system: increased activation in sympathetic activity Change in Beta-receptor-G protein-adenylyl cyclase pathway: Beta-receptor, myocardial hypertrophy, attenuation of heart force Activation of renin
16、-angiotensin-aldosterone system (RAS): increase in vascular resistance, water and sodium re-absorption and ECM Inflammatory cytokines: TNF, IL-1,6, AngII192021Normal Heart and Circulation22How to Classify the Heart Failure23 Left-Sided Heart Failure? Involves the left ventricle of the heart Systolic
17、 failure The heart looses its ability to contract or pump blood into the circulation Diastolic failure The heart looses its ability to relax because it becomes stiff Heart cannot fill properly between each beat24 Left-Sided Heart Failure Systolic and diastolic heart failure are treated with differen
18、t types of medications In both types, blood may “back up” in the lungs causing fluid to leak into the lungs (pulmonary edema) Fluid may also build up in tissues throughout the body (edema)25 Right-Sided Heart Failure Usually occurs as a result of left heart failure The right ventricle pumps blood to
19、 the lungs for oxygen Occasionally isolated right heart failure can occur due to lung disease or blood clots to the lung (pulmonary embolism)26 How fast does heart failure develop? Usually a chronic disease The heart tries to compensate for the loss in pumping function by: Developing more muscle mas
20、s Enlarging Pumping faster Having more blood volume27Acute verse Chronic Heart Failure Acute heart failure: the syndrome develops very fast without enough time to compensate when the acute congestion occur after sudden attack such as acute massive infarction, acute myocarditis or acute aggravation o
21、f chronic heart failure because of infection or other reasons. Chronic heart failure: the heart failure develops for long time with compensation.28Low-output or High-output Heart Failure Low-output heart failure: cardiomyopathy, myocardial infarction, diabetic cardiomyopathy and so on. Low-output he
22、art failure is characterized by clinical evidence of systemic vasoconstriction with cold, pale and sometimes cyanotic extremities, reduction in pulse pressure with low stroke volume. High-output heart failure: such as hyperthyroidism, arteriovenous fistulas, anemia. The extremities are warm usually,
23、 and flushed and pulse pressure is widened or normal.29How to Assess Functional CapacityNew York Heart Association (NYHA) Functional ClassificationLimitations: this system is subject to considerable interobserver variability and is insensitive to important changes in exercise capacity. These limitat
24、ions may be overcome by formal tests of exercise tolerance. Measurement of the distance that a patient can walk in 6 minutes may have prognostic significance and may help to assess the level of functional impairment in the very sick, but serial changes in walking distance may not parallel changes in
25、 clinical status. Class% of patientsSymptoms I 35%No symptoms or limitations in ordinary physical activity II 35%Mild symptoms and slight limitation during ordinary activity III 25%Marked limitation in activity even during minimal activity. Comfortable only at rest IV 5%Severe limitation. Experience
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