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1、Heart Failure (HF) 李纯Heart failure (HF) Meaning of HF 1.Conception :heart failure is a final common pathway for many cardiac disorders of diverse etiology and pathogenic mechanisms. It is a clinical syndrome, manifested as a result of the inability of the heart to match its output to the metabolic n
2、eeds of the body even though the filling pressure of the heart is adequate.中国心力衰竭流行 病学l推算我国目前成年人中约400万心衰患者l随着年龄增加，心力衰竭患病率显著上升l城市农村，北方南方，与我国冠心病和高血压的地 区分布一致l冠心病和高血压是心力衰竭的主要病因1. 中华华心血管病杂杂志 2007; 35(12): 1076-95. 2. 顾东风顾东风 等. 中华华心血管病杂杂志 2003; 31(1): 3-6.心力衰竭预后l过去40年，心衰导致的死亡增加6倍（AHA 2005）l2007年中国心衰诊疗指南指出
3、，有临床症状的 患者5年生存率与恶性肿瘤相仿l25% 新发心力衰竭患者在1年内死亡 (ESC 1999）l心力衰竭反复入院治疗很常见，超过50% 患者 半年内即再入院治疗 (Krumholz et al. 1997, Vinson et al. 1990, Burns et al. 1997)狄兰.托马斯蒋介石伊丽莎白.泰勒聂荣臻叶利钦詹姆斯.门罗詹姆斯.布朗”Two new epidemics of cardiovascular disease are emerging: heart failure and atrial fibrillation.” Eugene BraunwaldNEJM
4、Now 1997心力衰竭 心脏 疾病的最 后战场E Braunwald ACC 20032.HF=systolic HF and/or diastolic HF3.HF and cardiac dysfunction(1) cardiac dysfunction = systolic dysfunction or diastolic dysfunction via instrumental examination without signs (2)HF= cardiac dysfunction +signsThe Donkey Analogy Ventricular dysfunction l
5、imits a patients ability to perform the routine activities of daily livingLets compare our heart to this donkey, and our body to the wagon that this donkey has to pullevery day. Fundamental causes1. primary decreased myocardial contractility such ascoronar heart disease (hungry) myocarditis ,cardiom
6、yopathy. (injury)治疗 Fundamental causes2. increased burdens to the heartincreased afterload (pressure load): hypertension aortic stenosispulmonary stenosis pulmonary hypertension . Fundamental causesincreased preload (volume load): mitral incompetence aortic incompetence tricuspid incompetence atrial
7、 septal defect (ASD) ventricul ar septal defect (VSD)(PDA)hyperthyr oidismanemia心脏功能的生 理基础心排血量心肌收缩力前负荷 （舒张期容量）后负荷 （射血阻抗）心率房室收缩 协调性心脏机械结 构完整性原发性心肌损害：缺血性心肌损害心肌炎或心肌病心肌代谢障碍 （糖尿病性心肌病等）高血压、瓣膜狭窄（半月瓣）心脏瓣膜关闭不全、血液返流左、右心分流或动静脉分流全身血容量增加，如贫血、甲亢心力衰竭的基本病因心力衰竭的基本病因 Precipitating causes1. infection ,especially respi
8、ratory infection2.arrhythmias3.physical or emotional excesses e.g. pregnancy and delivery4.rapid intravenous infusion ,excessive salt taking 5.electrolyte imbalance6.primary disease deterioration or a new disease happens Pathogenesis and pathophysiology1.Compensate heart failure 2.some cytofactors t
9、ake part in heart failure 3.about diastolic insufficiency 4.ventricular remodeling1.Compensate heart failurecardiac dilatation, by way of the Frank- Starling principle ,contractile force increases. cardiac hypertrophy neurohumoral activationa. Increase in sympathetic nervous activityb. RAAS activate
10、d (rennin angiotension aldosterone system)N Engl J Med 2003;348:2007-18收缩性 vs 舒张性 急性心梗后的心室重建开始心梗心梗持续 （几小时至几天）全面重建 （几天至几月） 在舒张性和收缩性心力衰竭中 的心室重建正常的心脏心脏肥厚 （舒张性心衰）心脏扩大 （收缩性心衰）高血压和心梗后的心室重构浓度水平血浆 去甲肾上腺素 (pg/mL)NLNLHFHF血浆 肾素激活 (ng/mL/h)15129630NLNLHFHF精氨酸 血管加压素 (pg/mL)126420NLNLHFHF心房钠尿肽 (pg/mL)300250200150
11、100500NLNLHFHF内皮素-1 (pg/mL)86420NLNLHFHF6005004003002001000Adapted from Cohn JN. Cardiology. 1997;88:26.neurohumoralneurohumoral activation activation累计死亡率(%)月NE 900pg/ml 10080604020001224364860总 体 P50%b. function of relaxation: E / A1.2 Diagnosis and differential diagnosis2. Differential diagnosis:
12、Bronchial asthma : youngallergichistorytypical wheezing (哮鸣音)alleviate symptoms of dyspnea after cough out sputum Diagnosis and differential diagnosis Pericardial effusion, Constrictive pericarditis: medical historysigns of heart and perivascularechocardiogram the most sensitive and specific noninva
13、sive method Diagnosis and differential diagnosis Hepatocirrhosis with ascites and edema of lower extremitydistention of jugular veinshepatojugular reflux(+).Treatment of chronic heart failurePrinciple: alleviate symptoms ,improve life quality. inhibition of progressive ventricular remodeling. reduce
14、 mortality and extend life.Treatment of chronic heart failuretreatment of the underlying causes and precipitating causes2. rest and restriction of salt take(1.5-2.5g/d)3. pharmacologic treatmentNon- pharmacological managementnA strong relationship between healthcare professionals and patients as wel
15、l as sufficient social support from an active social network has been shown to improve adherence to treatment. It is recommended that family members be invited to participate in education programmes and decisions regarding treatment and careSabate E. Adherence to Long-term Therapies. Evidence for Ac
16、tion. Geneva: WHO;2003.People involved in careThe Players调整生活方式1限钠：轻度心衰患者23g/d，中到重度心衰患者2 g/d。2限水：低钠血症，血钠225 mol/lk+5.5mmol/lhypotensionACEI不良反应低血压。肾功能恶化。高血钾。咳嗽：干咳。血管性水肿。Treatment of chronic heart failure3) the agent of improving myocardial contractility digitalis:Digoxin(0.125mg qd po) , Cedilanid(0.2-0.4mg st iv) indication:chronic congestive heart failure complicated by atrail flutter and fibrillation and a rapid vent
