心力衰竭

nullnull Heart failure DEFINITION DEFINITIONHEART FAILURE the pathophysiological state in which the heart is unable to pump blood at a rate commensurate with the requirement of the metabolizing tissues or can do so only from an elevated filling pressure. Usually caused by a defect in myocardial contraction (myocardial failure). DEFINITION DEFINITIONCONGESTIVE HEART FAILURE Clinical manifested as Pulmonary congestion Systemic congestion Inadequate tissure blood perfusion HEMODYNAMICALLY heart failure (cardiac dysfunction) is diagnosed when LVEDP>18mmHg or RVEDP>10mmHgUNDERLYING CAUSES UNDERLYING CAUSES Primary myocardial dysfunction (systolic and/or diastolic) Cardiomyopathy Primary or secondary metabolic disturbances of myocardium Overloading of heart Pressure overloading Volume overloading limited diastolic function UNDERLYING CAUSESUNDERLYING CAUSESAge 70.3±10.1 yr. Causes CHD 65.8% Hypertension 36.0% Dila. Cardiomy. 11.9% With 2°DM 14.9% Shanghai OPD, Chin J Cardiol 2001;29:644 Precipitating factors Precipitating factors infection arrhythmias Pulmonary embolism overfatigue Pregnancy and delivery Anemia and hemorrhage others PathophysiologyPathophysiologyFrank-Starling mechanism Activation of neurohormonal pathway (SAS and RAS) Myocardial damage and remodeling Diasatolic heart failure null “ CLINICAL CLASSIFICATIONCLINICAL CLASSIFICATIONA cute vs. chronic heart failure Right-sided vs. left-sided Heart failure Low-output vs high-output heart failure Systolic vs diastolic heart failure Asymptomatic vs congestive heart failure Chronic left-sided HF ：symptoms Chronic left-sided HF ：symptoms Respiratory distress Exertional dyspnea Paroxysmal nocturnal dyspnea Orthopnea Acute pumnonary edema Cough (nonproductive), and hemoptysis Reduced exercise capacity Fatigue and weakness Urinary symptoms Chron. left-sided HF ：Physi. findingsChron. left-sided HF ：Physi. findingsGeneral appearance Dyspnetic Cyanosis, icterus, malar flush, diminished pulse pressure, reduced SBP, rapid, weak and thready pulse in severe HF Evidence of ↑adrenergic activity Peripheral vasoconstriction (pallor, coldness of extremities and cyanosis of the digits ). Diaphoresis with sinus tachycardiaChron. left-sided HF ：Physi. findingChron. left-sided HF ：Physi. findingCardiac findings Cardiomegaly S3 gallops Accentuation of P2 Systolic murmur Pulsus alternansPulmonary rales Moist rales over the lung bases Rhonchi wheezes ↓BS Chron. right-sided HF ：symptomsChron. right-sided HF ：symptomsGastrointestinal symptoms Symtoms of urinary system Dull ache in right upper quadrant. dyspnea Chron. right-sided HF ：Physi. findingChron. right-sided HF ：Physi. findingCardiac findings Hepatojugular reflux Congetive hepatomegaly or tenderness Edema Hydrothorax and ascites Others (cyanosis, and etc.)Chronic HF ：labolaroty findingsChronic HF ：labolaroty findingsRoutine lab. And serum electrolytes & liver function tests ECG Echocardiography Chest RoentgenogramECGECGSuggesting basic presence of basic heart diseases Atrial and ventricular hypertrophy, myocardial ischemia or infarction , arrhythmia V1ptf＜－0.03mm／s，indicating left atrial overloading. Echocardiogram Echocardiogram M mode, 2D echo and Dopler technique for systolic and diastolic function of LV LVDd and LVDs（Dd and Ds） LV fraction of shortening （△D％ ＝（Dd - Ds ）／Dd × 100％） mVCF ＝（Dd - Ds）／Dd × LVET SV LVEF Chest X ray Chest X rayLeft-sided heart failure cardiomegaly (cardiothorax ratio＞50%) dilated pulmonary vein pulmonary infiltrates. prominent bronchovascular markings Interstitial edema, Kerley.s B line, alveolar edema, pleural effusion when PCWP＞25～30mmHg. Right-sided HF Cardiomegalynull Invasive hemodynamic monitoringInvasive hemodynamic monitoring Using Swan-Ganz cather and thermodilution method for measurement of Intracardiac and vascular pressure Cardiac output to asses cardiac functionInvasive hemodynamic monitoringInvasive hemodynamic monitoringCVP（中心静脉压）6～12cmH2O PAP（肺动脉压）12～30/4～l3mmHg PCWP（肺毛细血管楔嵌压）6～12mmHg SV（心搏量）60～70ml SI（心搏指数）4l～51ml/m2 CO（心排血量）5～6L/min CI（心排指数）2.6～4.0L/min.m2 EF（射血分数）0.5 ～ 0.6 Chronic HF ：diagnosis Chronic HF ：diagnosis causes anatomy pathology arrhythmia Functional classificationFunctional classification（NYHA)Functional classification（NYHA) Class I-No limitation: Ordinary physical activity does not cause undue fatigue, dyspnea, or palpitation Class II-slight limitation of physical activity: Such patients are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or angina. Class III-marked limitation of physical activity:　although patients are comfortable at rest, less than ordinary activity will lead to symptoms. Class IV-inability to carry on any physical activity without discomfort: symptoms of congestive failure are present even at rest.With any physical activity, increased discomfort is experience.Chronic HF ：diff. diagnosisChronic HF ：diff. diagnosisLeft-sided HF With pulmonary dyspnea: COPD,asthma Metabolic acidosis Cardiac neurosis Right-sided HF Pricarditis Hepatic, renal edema. Functional classification（NYHA)Functional classification（NYHA) Class I-No limitation: Ordinary physical activity does not cause undue fatigue, dyspnea, or palpitation Class II-slight limitation of physical activity: Such patients are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or angina. Class III-marked limitation of physical activity:　although patients are comfortable at rest, less than ordinary activity will lead to symptoms. Class IV-inability to carry on any physical activity without discomfort: symptoms of congestive failure are present even at rest.With any physical activity, increased discomfort is experience.Chronic HF ：diff. diagnosisChronic HF ：diff. diagnosisLeft-sided HF With pulmonary dyspnea: COPD, asthma Metabolic acidosis Cardiac neurosis Right-sided HF Pricarditis Hepatic, renal edema. null Survival Morbidity Exercise capacity Quality of life Neurohormonal changes Progression of CHF SymptomsTREATMENT OBJECTIVESChronic HF: treatmentChronic HF: treatmentReducing load Rest and tranquilizer Control salt intake Water intake diuretics Vasodilators Improve CO digitalis non-digitalis positive inotropic agents aldost. antagonist β-bloker correcting PF and cause of HF diastolic HF dificult HF casesDiureticsDiureticsThiazides Hydrochlorothiazide Potassium-sparing diuretics Spironolactone amiloride Loop diuretics FrusemideVasodilatorsVasodilatorsNitrates Nitroglycerine Isosorbide dinitrate Mononitrates Nitroprusside ACE inhibitor ARB (Angiotensin receptor blocker)Acute heart failureAcute heart failureDefinition Etioloogy and mechanism Clinical picture Diagnosis treatmentnull谢 谢