心力衰竭诊断新技术的临床评价施仲伟会议课件教学幻灯PPT.ppt
心力衰竭诊断新技术的临床评价,上海交通大学医学院瑞金医院心脏科 施仲伟,ESC 2008 心力衰竭：新的定义,心力衰竭是一种临床综合征，患者有以下三类特点：典型症状（呼吸困难、乏力或疲乏、踝部肿胀）典型体征（心动过速、呼吸急促、肺部啰音、胸腔积液、颈静脉压力升高、外周水肿、肝大）休息时心脏结构或功能异常客观证据（心脏增大、第三心音、心杂音、超声心动图异常、BNP增高）,上海瑞金医院施仲伟,Dickstein K,et al.Eur Heart J 2008,29:2388,Two-dimensional echocardiography with Doppler should be performed during initial evaluation of patients presenting with HF to assess left ventricular ejection fraction(LVEF),left ventricle size,wall thickness,and valve function.Radionuclide ventriculography can be performed to assess LVEF and volumes.心力衰竭患者的初次评价应包括二维超声心动图和多普勒检查，评估左室射血分数、左室大小、室壁厚度和瓣膜功能。核素心室造影术可用于估计左室射血分数及容量。,Initial Clinical Assessment of Patients Presenting With Heart Failure,上海瑞金医院施仲伟,ACC Heart Failure Guidelines 2009,超声心动图异常与心力衰竭（1）,上海瑞金医院施仲伟,Echocardiographic Tissue Doppler Imaging Is a Powerful Independent Prognosticator of Mortality in the General Population,Rasmus Mogelvang,MD,PhDThe Copenhagen City Heart Study&Department of Cardiology,Gentofte University Hospital,Denmark,Copenhagen City Heart Study,Results from the Fourth Copenhagen City Heart Study,Characteristics of the Study Population,1036例社区成人，平均随访5.3年，90例死亡,s,e,a,Eas index=e/(as),Eas-index:An Estimator of CombinedSystolic and Diastolic Performance,上海瑞金医院施仲伟,Kaplan-Meier Survival Plot for the Eas-index,1,2,3,4,5,Follow-up in years,6,1.tertile,Survival-%,100,95,90,85,2.tertile,3.tertile,Adjusted for age and sex,Multivariate analysis 3.tertile vs.1.tertile,Relative Risk 2.5(1.44.7);P0.005,上海瑞金医院施仲伟,Mogelvang R,et al.Circulation 2009,119:2679,Patients with LVEF 35%,sinus rhythm,and NYHA functional class III or ambulatory class IV symptoms despite recommended,optimal medical therapy and who have cardiac dyssynchrony,which is currently defined as a QRS duration 0.12 seconds,should receive cardiac resynchronization therapy,with or without an ICD,unless contraindicated.接受最佳药物治疗而LVEF 35%、窦性心律、心功能级、心脏不同步（QRS 0.12s）的患者，应接受CRT治疗（安装或不装心内除颤器），除非有禁忌证。,Cardiac Resynchronization Therapy(CRT),ACC Heart Failure Guidelines 2009,上海瑞金医院施仲伟,498例有CRT适应证的患者,12项左室不同步的超声心动图指标,没有一项左室不同步的超声心动图指标能帮助更好地选择CRT患者,PROSPECT:Modest Sensitivity and Specificity and Great Variability,上海瑞金医院施仲伟,Resynchronization Therapy in Normal QRS(RethinQ)Study,2030%of patients do not respond to CRT despite application of established selection criteriaPatients with normal conduction or a slightly prolonged QRS duration also exhibit mechanical abnormalities due to intraventricular dyssynchronyWe hypothesized that patients with NYHA class III,LVEF 35%,QRS 130 ms,and evidence of mechanical dyssynchrony on echocardiography may benefit from cardiac resynchronization therapy,Beshai JF,for the RethinQ study investigators,上海瑞金医院施仲伟,Patients Baseline Characterizatics,RethinQ Study,上海瑞金医院施仲伟,Results:Peak VO2 by Sub-Group,RethinQ Study,超声难以准确评价心脏不同步时的复杂畸变过程1例扩张性心肌病患者：TDI未见不同步、应变显示不同步,上海瑞金医院施仲伟,心力衰竭的生物标志物,定义：能反映心脏应激、功能异常或心肌损伤状态的酶、激素、生物学物质及其他标志物分类及举例：炎症标志物（C-反应蛋白、肿瘤坏死因子-）氧化应激标志物（氧化型LDL、髓性过氧化物酶）细胞外基质重构标志物（基质金属蛋白酶、胶原前肽）神经激素（去甲肾上腺素、血管紧张素）心肌损伤标志物（肌钙蛋白I 和T、心脏型脂肪酸蛋白）心肌应激标志物（BNP、NT-proBNP、ST2）新型生物标志物（嗜铬素、半乳糖凝集素-3、脂联素）,上海瑞金医院施仲伟,786例不同程度的慢性心力衰竭患者心功能级，LVEF 5%65%（平均2510%）BNP38536 pg/ml（平均688948 pg/ml），接受标准抗心力衰竭治疗随访24个月，研究终点为任何原因的死亡评价和肽素的预测价值、并与BNP和NT-proBNP相比较,Neuhold S,et al.JACC 2008,52:266,上海瑞金医院施仲伟,从加压素到和肽素：应激反应的指标,和肽素：加压素激素原的C端部分肽段,上海瑞金医院施仲伟,Kaplan-Meier plots:survival in patients grouped according to quartiles of plasma copeptin,上海瑞金医院施仲伟,心力衰竭的临床诊断,症状和体征是提示和诊断心力衰竭的基本要素超声心动图提供心脏结构或功能异常的客观证据生物标志物辅助心力衰竭诊断、鉴别诊断、预后评估,上海瑞金医院施仲伟,
