内科学心力衰竭范维琥课件.ppt
1,Heart failure,2,DEFINITION,HEART FAILURE A 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 constellation of clinical manifestations, including circulatory congestion, dyspnea, fatigue, and weakness.,3,FORMS OF HEART FAILURE,Systolic vs diastolic heart failure Low-output vs high-output heart failure Acute vs chronic heart failure Right-sided vs left-sided heart failure,4,UNDERLYING CAUSES,Ischemic heart diseaseCardiomyopathiesCongenital, valvular and hypertensive heart disease (potential treatable ),5,PRECIPITATING FACTORS,InfectionArrhythmiasPhysical, dietary, fluid, environmental, and emotional excessesMyocardial infarctionPulmonary embolism AnemiaThyrotoxicosis and pregnancyAggravation of hypertensionRheumatic, viral, and other forms of myocarditisInfective endocarditis,6,PATHOGENESIS,Chronic hemodynamic overloadeccentric ventricular hypertrophy Chronic pressure overload concentric ventricular hypertrophy Ventr. hypertrophy ventr. DilatationRemodeling of ventricle HFActivation of endogenous neurohormonal system and cytokines,7,“,8,CLINICAL MANIFESTATION OF HF,Primary Symptoms Dyspnea Orthopnea Paroxysmal (nocturnal) dyspnea Acute pumnonary edema,9,CLINICAL MANIFESTATION OF HF,Other symptomsFatigue and weaknessAbdominal symptomsCerebral symptoms,10,PHYSICAL FINDINGS OF HF,General findingsPulse pressure （severe HF) SBP with cool, diaphoretic extremities, and Cheyne -Stokes respirationCyanosis, sinus tachycardia,11,PHYSICAL FINDINGS OF HF,Cardiovascular findings S3 and S4 Cardiomegaly Murmurs Pulsus alternans Distention of j v. (systemic v. p),12,PHYSICAL FINDINGS OF HF,Pulmonary ralesCardiac edemaSymmetric and dependent in the legsMost prominet in eveningHydrothorax and ascitesCongestive hepatomegaly.,13,LABORATORY EXAMINATION,N-terminal-pro-BNP and BNPTwo-dimensioanl echocardiography with Doppler flow studiesChest roentgenogramECG,14,Echocardiogram,2D echo with Dopler technique for systolic and diastolic function of LV LVDd and LVDs（Dd and Ds）LVEF,15,DIAGNOSIS OF HF,Combination of the clinical manifestation of HF, together with the findings characteristic of one of the underlying forms of heart disease.,16,DIFF. DIAGNOSIS OF HF,Pulmonary diseasePulmonary embolismAnkle edemaEnlargement of the liver and ascites,17,TREATMENT OF HF,Correction of the underlying causeRemoval of the precipitating causePrevention of deterioration of cardiac functionControl of the congestive HF state,GENERAL MEASURES,Treating coronary risk factors Moderate dietary Na restriction Daily measurement of weight Prevent respiratory infection Avioding excessive alcohol, temperature extremes, and tiring trips,19,TREATMENT OF HF,Control of excessive fluidDietDiureticsThiazide diureticsMetolazoneFrusemideBumetanidetorsemidePotassium-sparing diuretics,20,TREATMENT OF HF,Blockade of renin-angiotensin-aldosterone and adrenergic systemACE inhibitorsAngiotensin receptor blockersBeta-adrenoceptor blockersAldosterone antagonist,21,TREATMENT OF HF,Enhancement of myocardial contractilityDigitalisSympathomimetic aminesPhosphodiesterase inhibitors,22,TREATMENT OF HF,VasodilatorsNitratesNitroglycerineIsosorbide dinitrateMononitratesNitroprussidenesiritide,23,TREATMENT OF HF,Ventricular resynchronizationManagement of arrhythmiaAnticoagulantsRefractory heart HFAssisted circulation/cardiac transplant.,24,STAGE A,At high risk for HF but without structural heart disease or symptoms of HF.Treat hypertensionEncourage smoking cessationTreat lipid disordersEncourage regular exerciseDiscourage alcohol intake, illicit drug useControl metabolic syndromeACEI or ARB in appropriate patients for vascular disease or diabetes,25,STAGE B,Structural heart disease but without signs or symptoms of HFAll measures under Stage AACEI or ARB in appropriate patients Beta-blockers in appropriate patients,26,STAGE C,Structural heart disease with prior or current symptoms of HF.All measures under Stages A and BDietary salt restrictionDRUGS FOR ROUTINE USEDiuretics for fluid retentionACEIBeta-blockersDRUGS IN SELECTED PATIENTSAldosterone antagonistARBsDigitalisHydralazine/nitratesDEVICES IN SELECTED PATIENTSBiventricular pacingImplantable defibrillators,27,STAGE D,Refractory HF requiring specialized interventions.Appropriate measures under Stages A, B, CDecision re: appropriate level of careOPTIONSCompassionate end of-life care/hospiceExtraordinary measuresheart transplantchronic inotropespermanentmechanical supportexperimentalsurgery or drugs,28,PROGNOSIS OF HF,Depend on Nature of the underlying heart disease Presence of a treatable precipitating factorThe response to treatment,谢 谢,docin/sanshengshiyuandoc88/sanshenglu,更多精品资源请访问,
