内科学心力衰竭范维琥课件.ppt

1、1Heart failure 2DEFINITIONn HEART FAILURE nA clinical syndrome in which an abnormality of cardiac structure or function is responsible for the inability of the heart to eject or fill with blood at a rate commensurate with the requirements of the metabolizing tissues.Heart failure results in a conste

2、llation of clinical manifestations,including circulatory congestion,dyspnea,fatigue,and weakness.3FORMS OF HEART FAILUREnSystolic vs diastolic heart failure nLow-output vs high-output heart failure nAcute vs chronic heart failure nRight-sided vs left-sided heart failure 4UNDERLYING CAUSES nIschemic

3、heart diseasenCardiomyopathiesnCongenital,valvular and hypertensive heart disease(potential treatable)5PRECIPITATING FACTORS n Infectionn Arrhythmiasn Physical,dietary,fluid,environmental,and emotional excessesn Myocardial infarctionn Pulmonary embolism n Anemian Thyrotoxicosis and pregnancyn Aggrav

4、ation of hypertensionn Rheumatic,viral,and other forms of myocarditisn Infective endocarditis6PATHOGENESIS Chronic hemodynamic overloadeccentric ventricular hypertrophy Chronic pressure overload concentric ventricular hypertrophy Ventr.hypertrophy ventr.Dilatation Remodeling of ventricle HF Activati

5、on of endogenous neurohormonal system and cytokines 7“8 CLINICAL MANIFESTATION OF HF Primary Symptoms Dyspnea Orthopnea Paroxysmal(nocturnal)dyspnea Acute pumnonary edema9CLINICAL MANIFESTATION OF HFnOther symptomsnFatigue and weaknessnAbdominal symptomsnCerebral symptoms10PHYSICAL FINDINGS OF HF Ge

6、neral findingsPulse pressure（severe HF)SBP with cool,diaphoretic extremities,and Cheyne-Stokes respirationCyanosis,sinus tachycardia11PHYSICAL FINDINGS OF HF Cardiovascular findings S3 and S4 Cardiomegaly Murmurs Pulsus alternans Distention of j v.(systemic v.p)12PHYSICAL FINDINGS OF HF Pulmonary ra

7、les Cardiac edema Symmetric and dependent in the legs Most prominet in evening Hydrothorax and ascites Congestive hepatomegaly.13LABORATORY EXAMINATIONnN-terminal-pro-BNP and BNPnTwo-dimensioanl echocardiography with Doppler flow studiesnChest roentgenogramnECG14Echocardiogram n2D echo with Dopler t

8、echnique for systolic and diastolic function of LV nLVDd and LVDs（Dd and Ds）nLVEF15DIAGNOSIS OF HF nCombination of the clinical manifestation of HF,together with the findings characteristic of one of the underlying forms of heart disease.16DIFF.DIAGNOSIS OF HF Pulmonary disease Pulmonary embolism An

9、kle edema Enlargement of the liver and ascites17TREATMENT OF HF Correction of the underlying cause Removal of the precipitating cause Prevention of deterioration of cardiac function Control of the congestive HF state GENERAL MEASURES n Treating coronary risk factorsn Moderate dietary Na restrictionn

10、 Daily measurement of weight n Prevent respiratory infectionn Avioding excessive alcohol,temperature extremes,and tiring trips19TREATMENT OF HFn Control of excessive fluidn Dietn Diureticsn Thiazide diureticsn Metolazonen Frusemiden Bumetaniden torsemiden Potassium-sparing diuretics20TREATMENT OF HF

11、n Blockade of renin-angiotensin-aldosterone and adrenergic systemn ACE inhibitorsn Angiotensin receptor blockersn Beta-adrenoceptor blockersn Aldosterone antagonist21TREATMENT OF HFn Enhancement of myocardial contractilityn Digitalisn Sympathomimetic aminesn Phosphodiesterase inhibitors22TREATMENT O

12、F HFnVasodilatorsNitrates Nitroglycerine Isosorbide dinitrate Mononitrates Nitroprussidenesiritide23TREATMENT OF HF Ventricular resynchronization Management of arrhythmia Anticoagulants Refractory heart HF Assisted circulation/cardiac transplant.24STAGE An At high risk for HF but without structural

13、heart disease or symptoms of HF.nTreat hypertensionnEncourage smoking cessationnTreat lipid disordersnEncourage regular exercisenDiscourage alcohol intake,illicit drug usenControl metabolic syndromenACEI or ARB in appropriate patients for vascular disease or diabetes25STAGE BnStructural heart diseas

14、e but without signs or symptoms of HFnAll measures under Stage AnACEI or ARB in appropriate patients nBeta-blockers in appropriate patients26STAGE Cn Structural heart disease with prior or current symptoms of HF.n All measures under Stages A and Bn Dietary salt restrictionn DRUGS FOR ROUTINE USEnDiu

15、retics for fluid retentionnACEInBeta-blockersn DRUGS IN SELECTED PATIENTSnAldosterone antagonistnARBsnDigitalisnHydralazine/nitratesn DEVICES IN SELECTED PATIENTSnBiventricular pacingnImplantable defibrillators27STAGE Dn Refractory HF requiring specialized interventions.nAppropriate measures under S

16、tages A,B,CnDecision re:appropriate level of carenOPTIONSnCompassionate end of-life care/hospicenExtraordinary measuresnheart transplantnchronic inotropesnpermanentnmechanical supportnexperimentalnsurgery or drugs28PROGNOSIS OF HFnDepend on nNature of the underlying heart disease nPresence of a treatable precipitating factornThe response to treatmentdocin/sanshengshiyuandoc88/sanshenglu 更多精品资源请访问更多精品资源请访问