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1、HEART FAILURE,Management of Heart Failure,Treatment Strategies:Ameliorate symptomsMaintain cardiac functional stateReduce mortality rateReduce hospitalization,Treatment,1. The cause must be removed2. General management: bed rest, mitigate，oxygen inhalation， reduction of salt intake 3. Drug Treatment
2、,Drug Treatment,Positive inotropic agentscardiac glycosides, phosphodiesterase inhibitors Vasodilators Diuretics Angiotensin converting enzyme inhibitors (ACEI) Beta-blockers,治疗,洋地黄类药物：正性肌力，负性传导，负性心率；直接抑制过度的神经内分泌系统。 临床常用制剂：地高辛；西地兰。 常用剂量：地高辛口服化量：2岁0.05-0.06mg/kg，2岁0.03-0.05mg/kg，维持量为化量的1/5。西地兰静注化量：2岁
3、0.03-0.04mg/kg，2岁0.02-0.03mg/kg。新生儿用量更少，取婴儿量的1/2至2/3。,治疗-洋地黄类药物,使用方法化量（饱和量）：适用于急性心衰或重症心衰，首次用化量的1/2量，余量分2次（1/4、1/4）， q4h-q6h或q8h。维持量：适用于慢性心衰或轻症心衰，维持量为化量的1/5量，分2次口服；或者化量后需继续维持者，于化量后12小时开始予维持量。,治疗-洋地黄类药物,注意事项：用药前了解洋地黄情况；避免用钙剂；注意纠正低血钾。 洋地黄中毒表现：心律失常；消化道症状；神经系统症状等。处理：停用洋地黄及利尿剂；口服补钾；必要时用抗心律失常药。,Diuretics,R
4、elieve the congestion status by elimination of sodium and water. Indicated in pulmonary congestion with dyspnea and rales and generalized edema ,ascites Agents used: Thiazideschlorothiazide , chlothalidone Loop diureticsfurosimide, bumetanide, ethacrynic acid Potassium-sparing diureticsspirolectone,
5、 triamterene, amiloride Side effects: hypokalemia, hyperglycemia,ACE-Inhibitors,Rationales of the ACEI treatment for heart failure: Decreases peripheral circulatory resistance Decreases the blood volume Decreases the sympathetic activity Inhibition of the remodeling process,ACE-Inhibitors,Short-term
6、 effects Symptomatic improvement: approximately 2/3 of cases with severe heart failure show diurea, improvement in dyspnea and less edema. Hemodynamic improvement:increased cardiac output by 25%-30%reduction of PCWP by 20%decreased peripheral resistance by 30%BPdrop 10%-15%Heart rateslightly reducse
7、d N.B. 1st dose hypotension, transient elevation of BUN and creatinin,ACEI treatment of H.F.,Long-term effects : Reduction of mortality and preservation of cardiac function. SAVE study:Cases: post acute myocardial infarction with EF40%Captopril Control P Case No. 1115 1116 Mortality rate (42months)
8、RR 21% 0.014 Development Of severe H.F. RR 37% 0.001,SOLVE study:,1) Cases of H.F.with symptoms, EF35%Enalapril ControlCase No. 2111 2117Follow up for 37.4 monthsReduction of the death or development of H.F.by 37% (P0.001),Conclusion of ACEI treatment of heart failure:,ACEI should be used in patient
9、s with heart failure irrespective to their underlying causes, if not contra-indicated. Early application of ACEI can postpone the development of congestive heart failure Attention should be paid to hypotension, increased blood Cr content and the side effect of cough. Agent used: Captopril, Enalapril
10、, Perindopril, Lisinopril etc.,Beta-blocker in treatment of H.F.,Adverse effects induced by prolonged excessive sympathetic activity: Increases peripheral resistance-after-load Increases heart rate Increases excitability-arrhythmias Elevation of NE cAMP intracellular Ca+ overload precipitation of ap
11、optosis and cell deathBeta-blockers can induce negative inotropic response,Clinical Trial: US Carvedilol Heart Hailure Study,Carvedilol Placebo RR P No.of cases 696 398 Mortality rate (%) 3.2 7.8 65% 0.001 Hospitalization (%) 14.1 19.6 27% 0.036Agents proved to be effective in major clinical trails:
12、Carvedilol, Metaprolol, Bisoprolol,Indications of Beta-blockers in CHF,Beta-blocker is indicated in CHF grade II,III and IV irrespective to its cause if not contraindicated Used on top of ACEI and diuretics Preferably initiate the treatment in hospital especially for severe cases Start with a very s
13、mall dose (usually 1/8 of the target dose), and increase gradually in 1-2 week interval. Watch carefully, adjust the dosage of ACEI or diuretics if necessary,Summary of management of H. F.,Treating the underlying cause and associated diseases General care daily life adjustments Drug therapy: ACEI Di
14、uretics in case presence of congestionBeta-blockers Digoxin if necessary,Acute Left Heart FailurePulmonary edema,Etiological causes: Acute myocardial infarction, Hypertension, Mitral stenosis, etc. Pathophysiology marked increase of the pulmonary blood volume and capillary pressure resulting exudati
15、on in alveoli. Clinical features:Severe dyspneaCough with frothy sputum,blood tingedFull of lung ralesRestlessness to mental retardation,Management of Acute Left Heart Failure,Oxygen therapy. Positive pressure oxygenation if necessary Vasodilator therapy: Nitroglycerin,nitropruside I.V. Diuretics: F
16、urosemide I.V. Positive inotropic therapy: Dobutamine, milrinone (N.B. cardiac glycoside is contraindicated in the first 24 hr. of AMI) Sedatives: Morphine in small dosage may help the restlessness state,进展,1.急性心衰治疗顺序：强心、利尿、扩管2.慢性心衰治疗顺序：神经内分泌疗法、强心、利尿。心功能 I：ACEI；II：ACEI+ 受体阻滞剂+洋地黄类；III： ACEI+ 受体阻滞剂+洋地黄类+利尿剂；： ACEI+ 洋地黄类+利尿剂。基因治疗；心肺移植等,
