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1、急性失代偿性心力衰竭治疗温州医学院附属第一医院心内科 张怀勤,急性心力衰竭急性心力衰竭（根据不同的病理生理及发作时间可以分为三类：1.新发生的AHF2.急性失代偿性心力衰竭3.晚期或终末期HF,心力衰竭的分类,New onset first presentationacute or slow onsetTransient recurrent or episodicChronic persistent stable, worsening , or decompensated,Esc guideline for HF 2008,急性失代偿性心力衰竭 （Acute Decompensaed Hear
2、t Failure, ADHF）通常是在原有慢性HF的基础上出现急性失代偿而发生的。 50%为缺血性心脏病,其他有瓣膜性心脏病、高血压。血压控制不好、严重心律失常、感染、液体控制不良为常见诱因。 占HF住院患者的75%，通常是在原有慢性HF的基础上出现急性失代偿而发生的。 ADHF患者相当于2005年 ACC/AHA指南 HF分期的 C期，既往曾有一 次或多次住院史。,ADHF时的病理生理学特征ADHF多数为低EF，也可以正常EF。当发生急性失代偿时，慢些症状异常增重 ，LVFP升高，血液动力学恶化，神经内分泌系统包括SNS，RAAS，精氨酸血管加压素，细胞因子，内皮素等的激活加剧，导致全身及
3、肺血管收缩， 水钠潴留， 病情发展，由代偿至失代偿，由适应至适应不良。,Median length of hospital stay: 6 days Hospital readmissions:2% within 2 days20% at 30 days50% at 6 months Mortality:11.6% at 30 days33.1% at 12 months50% at 5 years1. Aghababian RV. Rev Cardiovasc Med. 2002;3(suppl 4):S3 S9. 2. Jong P et al. Arch Intern Med. 2002
4、;162:1689 1694.,Outcomes of Acute decompensaed heart failure,ADHF的临床症状和评估,CLINICAL PRESENTATION OF PATIENTSHOSPITALIZED WITH ADHF,（1）颈静脉怒张 （2）心音及呼吸音异常 （3）心尖搏动移位 （4）体液潴留 （5）低CO表现（心动过速，低血压，四肢冷，精神状态变化）大多数患者出现容量负荷增加伴周围水肿及颈静脉怒张，肺部可有啰音。根据ADHERE注册，约65%入院时诊断为ADHF的患者有肺部啰音，奔马律及二尖瓣返流杂音常可听到，心尖搏动弥散、移位。,ADHF的体征,A
5、DHF 的 诊 断,1. 既往病史 2. 临床症状及体征 3. ECG 4. 胸片、CT 5. 实验室检查：血常规、电解质、血糖、尿素氮、Cr 6. BNP及心脏生物标志物 7. 心超,1. 血管扩张剂硝酸甘油硝普钠奈西立肽 2. 正性肌力药多巴酚丁胺米立农左西孟旦 3. 血管加压药多巴胺去甲肾上腺素和肾上腺素血管加压素 4. 利尿药呋塞米布美他尼托拉塞米氢氯噻嗪,5. 尚在研究中新药 血管加压素受体拮抗剂tolvaptan (ACTIV CHF, EVEREST)托伐普坦 conivaptan康尼伐普坦 Lixivaptan利希普坦 内皮素受体拮抗剂bosentan(REACH-1, ENA
6、BLE-1, -2) 腺苷A-1受体拮抗剂,AHF的药物治疗,Oxygen therapy should be administered to relieve symptoms related to hypoxemia.,The Hospitalized Patient,Whether the diagnosis of HF is new or chronic, patients who present with rapid decompensation and hypoperfusion associated with decreasing urine output and other ma
7、nifestations of shock are critically ill and rapid intervention should be used to improve systemic perfusion.,Oxygen Therapy and Rapid Intervention,Patients admitted with HF and with evidence of significant fluid overload should be treated with intravenous loop diuretics. Therapy should begin in the
8、 emergency department or outpatient clinic without delay, as early intervention may be associated with better outcomes for patients hospitalized with decompensated HF (Level of Evidence: B). If patients are already receiving loop diuretic therapy, the initial intravenous dose should equal or exceed
9、their chronic oral daily dose. Urine output and signs and symptoms of congestion should be serially assessed, and diuretic dose should be titrated accordingly to relieve symptoms and to reduce extracellular fluid volume excess. (Level of Evidence: C).,The Hospitalized Patient,Treatment With Intraven
10、ous Loop Diuretics,DIURATIC FOR ADHF,The Hospitalized Patient,Intensifying the Diuretic Regimen,When diuresis is inadequate to relieve congestion, as evidence by clinical evaluation, the diuretic regimen should be intensified using either:a. higher doses of loop diuretics;b. addition of a second diu
11、retic (such as metolazone, spironolactone or intravenous chlorthiazide) orc. Continuous infusion of a loop diuretic.,The Hospitalized Patient,Urgent Cardiac Catheterization and Revascularization,When patients present with acute HF and known or suspected acute myocardial ischemia due to occlusive cor
12、onary disease, especially when there are signs and symptoms of inadequate systemic perfusion, urgent cardiac catheterization and revascularization is reasonable where it is likely to prolong meaningful survival.,In patients with evidence of severely symptomatic fluid overload in the absence of syste
13、mic hypotension, vasodilators such as intravenous nitroglycerin, nitroprusside or neseritide can be beneficial when added to diuretics and/or in those who do not respond to diuretics alone.,The Hospitalized Patient,Severe Symptomatic Fluid Overload,Ultrafiltration is reasonable for patients with ref
14、ractory congestion not responding to medical therapy.,The Hospitalized Patient,Intravenous inotropic drugs such as dopamine, dobutamine or milrinone might be reasonable for those patients presenting with documented severe systolic dysfunction, low blood pressure and evidence of low cardiac output, w
15、ith or without congestion, to maintain systemic perfusion and preserve end-organ performance.,Ultrafiltration and Intravenous Inoptropic Drugs,Routine use of invasive hemodynamic monitoring in normotensive patients with acute decompensated HF and congestion with symptomatic response to diuretics and
16、 vasodilators is not recommended.,Use of parenteral inotropes in normotensive patients with acute decompensated HF without evidence of decreased organ perfusion is not recommended.,The Hospitalized Patient,Parenteral Inotropes,奈西立肽（重组人脑钠肽 rhBNP） 治疗ADHF的疗效及安全性奈西立肽（rhBNP, Nesiritide）为重组人B-型利钠肽（脑钠肽），作用与内源性BNP相似，能迅速改善血液动力学 状态及呼吸困难等症状。有明显的排钠利尿作用，降低醛固酮和去甲肾上腺素水平，抑制肾素活性和内皮素分泌。半衰期约18min，其副作用与其血管扩张作用有关，可出现剂量依赖性低血压，奈西立肽一般不会发生快速耐药性，也无毒性代谢产物，不引起心律失常。,
