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1、福建医科大学附属第一医院福建医科大学附属第一医院晋学庆晋学庆重症心衰治疗指南与临床实践指南与临床实践的关系Evidence-BasedMedicineProblem-BasedMedicine心脏重症特点1.心衰合并多器官功能衰竭，心、肺、肾2.心衰心脏受损严重为突出表现，大面积心梗，心脏手术，重症心肌炎3.心衰特殊原因，少见，特别是一些新的药品，器械Yourheartisanamazingpowerhousethatpumpsandcirculates5or6gallonsofbloodeachminutethroughyourentirebody.Understandinghowthehe
2、artworksTounderstandheartdisease,youmustfirstknowhowtheheartworks.Theheartislikeanyothermuscle,requiringbloodtosupplyoxygenandnutrientsforittofunction.Itbeatsabout100,000timesaday,pumpingbloodthroughyourcirculatorysystem.Thecycleofpumpingbloodthroughoutyourbodycarriesfreshoxygentoyourlungsandnutrien
3、tstoyourbodystissues.Bloodalsotakeswaste,suchascarbondioxide,awayfromyourtissues,.Withoutthisprocess,wecouldnotlive.Heartdisease:thenumber-onekillerHeartdiseaseaffectsabout14millionmenandwomenintheUnitedStates,andithasahighmortalityrateOneofthemostdevastatingconsequencesofheartdiseasecanbesuddencard
4、iacarrest.Blockageofthecoronaryarteriesbyplaquemaycauseaheartattack(myocardialinfarction)orafatalrhythmdisturbance(suddencardiacarrest).Suddencardiacdeath-afatalconsequenceofheartdiseaseEveryonesexperiencewithheartdiseaseisdifferent.Somepeopleexperienceshortnessofbreathorchestpainandmakeittothehospi
5、talintimetobetreated.Othersarenotaslucky.Forsomepeople,suddencardiacarrestcanbethefirstsymptomtheyexperience,anditisoftendeadlyunlesstreatedimmediately.Besideschestpain(angina)andshortnessofbreath,someothercommonsymptomsofheartdiseaseincludejawpain,backpain,andheartpalpitations.Whatarecommonsymptoms
6、ofheartdisease?Symptomsofheartdiseaseusuallyoccurduringexerciseoractivity.Thatsbecausetheheartexperiencesincreaseddemandfornutrientsandoxygenthatcannotbemetbecausethecoronaryarteriesareblocked.Othersymptomsofheartdiseaseincludechestpain(angina),shortnessofbreath,jawpain,andbackpain,especiallyonthele
7、ftside.Doctorsuseavarietyofteststodetectheartdisease.Onecommontestistheelectrocardiogram(ECGorEKG).Whatisanelectrocardiogram(EKG)?Ahealthyheartworksasanelectricalpumpandneedsastrongbloodsupplytoconductelectricity.Peoplewithheartdisease,however,haveaweakbloodsupply,sotheirheartsconductelectricitypoor
8、ly.Anelectrocardiogram(EKG)isanoninvasivetestthatmeasurestheelectricalactivityoftheheart.AnEKGtakesapproximatelyfiveminutesandispainless.ManyotherheartconditionscanbediagnosedwithanEKG,forexampleabnormalheartrhythms,evidenceofpriorheartattack,evidenceofanevolvingheartattack,unstableangina,congenital
9、heartabnormalities,evidenceofabnormalbloodelectrolytes,andevidenceofinflammationoftheheart(myocarditis,pericarditis).Sometimes,ifanelectrocardiogramcomesbacknormal,doctorswillusestressteststodetectheartdisease.Anothertestoptionisechocardiography,whichusessoundwavestogenerateimagesoftheheart.Computer
10、izedtomography(CT)scansareusedtoshowthatheartdiseaseisnotpresentandthatthecoronaryarteriesarenormal.Coronaryangiographyviacardiaccatheterizationisconsideredthegoldstandardofheartdiseasetests.Heartdiseasetreatmentisdifferentforeveryone.Forsomepatientswithheartdisease,medicationsmaybenecessary.Whenmed
11、icationsarentenough,sometimesinvasiveproceduresareusedtohelptreatheartdisease.Heartdiseaseisahighlypreventableandreversibledisease.Ahealthydietisamajorfactorincontrollingheartdisease.Otherlifestylechangesthatcanbemadetohelppreventheartdiseaseincludedrinkingalcoholinmoderationandquittingsmoking.Exerc
12、ise,controllinghighbloodpressureanddiabetes,andtakingdailyaspirinaremorewaystoreduceyourchancesofdevelopingheartdisease. 心脏重症病房的治疗手段进展心脏重症病房的治疗手段进展3.1呼吸机辅助通气3.2肾脏替代治疗3.3主动脉内球囊反搏术(IABP)和左心辅助装置(LVAD)3.4ECMO（体外膜肺氧合）在国外，特别是欧美发达国家，心脏重症医学的诞生起源于心肺复苏术的开始，要早于真正的综合性ICU的建立。从1962年开始，MelterHe和Day分别创立冠心病监护病房，从此心脏
13、重症医学在世界发达国家特别是欧美地区迅速发展，以CCU或CICU为代表的心脏重症监护病房已经成为心脏医疗中心中不可缺少的组成部分，代表了一家中心的心脏医疗水平，救治水平和管理水平，更与医疗单位或中心的现代化水平挂钩定义心力衰竭是由于任何心脏结构或功能异常导致心室充盈或射血功能受损的一组临床综合征，其主要临床表现为呼吸困难和乏力（活动耐量受限），以及液体潴留（肺淤血和外周水肿）。心衰为各种心脏疾病的眼中和终末阶段，发病率高，是当今最重要的心血管病之一。心衰发展分为4个阶段根据心衰发生发展的过程，从心衰的危险因素进展成结构性心脏病，出现心衰症状，直至难治性终末期心衰,可分成4个阶段。前心衰(A)前
14、临床心衰(B)临床心衰(C)难治性终末期心衰(D)这4个阶段不同于纽约心脏协会(NYHA)的心功能分级。心衰阶段的划分正是体现了重在预防的概念，其中预防患者从阶段A进展至阶段B，即防止发生结构性心脏病，以及预防从阶段B进展至阶段C,以至于进展到D阶段。依据左室射血分数(LVEF),心衰可分为LVEF降低的心衰(heartfailurereducedleftventricularejectionfraction,HF-REF)LVEF保留的心衰(heartfailurewithpreservedleftventricularejectionfraction,HF-PEF).LVEF是心衰患者分类
15、的重要指标，也与预后及治疗反应相关。LVEF保留或正常的情况下收缩功能仍可能是异常的。CASE1女性，83岁反复活动后气喘5年，加重1月5年来反复活动后气喘，发作时端坐呼吸，咳白色泡沫样痰，夜间阵发性加剧，经治疗后好转。近1月来症状加剧，不能平卧，双下肢浮肿。既往有高血压病，糖尿病病史20多年。入院肺部CT扫描入院诊断，心功能衰竭，心功能IV级。肺部感染冠状动脉粥样硬化性心脏病，急性冠脉综合症高血压病糖尿病入院后治疗方案抗感染纠正心衰（强心、利尿、扩血管）治疗后症状改善，但反复发作左室内径在正常上限，室壁未见增厚，心腔形态失常、心尖部圆钝，前壁、室间隔中段以下及整个心尖部运动减弱或无运动，余室
16、壁运动未见明显异常，整体收缩不协调；二维法LVEF30。右心大小正常，室壁运动未见明显异常估计肺动脉收缩压至少57-62mmHg；讨论病人下一步治疗方案病人冠心病，引起心衰，继发肺部感染，明确。但病人83岁，年龄大，不能平卧，是否因该PCI。PCI的风险：病人不能耐受手术，手术风险大。Someoftheriskfactorsforheartdiseaseincludesmoking,highbloodpressure,highcholesterol,diabetes,andobesityWhataretheriskfactorsforheartdisease?Someofthecommonri
17、skfactorsforheartdiseaseincludesmoking,highbloodpressure(hypertension),highcholesterol,diabetes,familyhistoryofheartdisease,peripheralarterydisease,andobesity.Additionalheartdiseaseriskfactorsincludelackofexercise,anunhealthydiet,stress,andatypeApersonalityWhatarelifestyleriskfactorsforheartdisease?
18、Lifestyleriskfactorsthatcontributetoheartdiseaseincludelackofexercise,high-fatdiet,emotionalstress,andhavingatypeApersonality(aggressive,impatient,competitive).CASE2男性，30岁胸闷，气喘，浮肿1月，加剧1周既往无高血压病，糖尿病病史个人史：烟，20-40支/天X10年，酒，白酒6-7两/次X4-5次/周X5-6年每天3-4餐职业：刑警大队队长。体格检查BP192/116mmHgHR106bpmIBM40.1（Height170cm
19、，WT116kg）急性痛苦病容，端坐呼吸，双肺满布湿性罗音，哮鸣音。下肢可凹水肿。EchocardiogramComputedTomographyofChestElectriocardiogram入院诊断1.扩张型心肌病(原发性、酒精性、缺血性、心律失常，肥胖型）？心律失常快速性心房扑动肺部感染胸腔积液，心包积液左心室内占位性病变（血栓、粘液瘤）2.肥胖3.高血压病。治疗策略1.保守药物治疗降压，利尿，抗菌素，低分子肝素钙，呼吸机，倍他乐克，23.75mgQD2.介入，冠脉造影3.心脏移植左心室附壁血栓左心室附壁血栓左室附壁血栓的形成多是继发于急性心梗之后，是急性心梗的常见并发症之一。附壁血栓
20、形成后反过来引起急性心梗的可能很小，主要是可能会出现血栓的脱落，从而出现体循环动脉栓塞的可能性加大，最常见的栓塞部位就是脑。所以目前的主要矛盾并不是并发心梗的风险，而是并发脑栓塞的风险较大.讨论病人通过正规的心衰药物治疗，以及抗菌素，低分子肝素钙的治疗，病人症状改善不明显，BP130-140/90-100mmHgWeight108kg.房扑射频消融术？控制体重措施每日三餐，2两/餐两个月体重11682kg。病人呼吸困难症状明显改善，UCG提示EF从18%增加到30%左心室血栓消失。下肢水肿消失。心电图仍然房扑。病人出院，门诊随访。静息心肌灌注显像：左室心腔明显扩大，后壁心肌血流灌注轻度减低。随
21、访6个月后病人一般情况稳定，无心悸胸闷，气喘等症状，已经开始正常工作。思考病人的主要病因是肥胖，因此控制体重是主要的，开始阶段对体重控制没有重视，病人症状控制不好，症状反复，从控制体重开始，病情逐步好转并趋于稳定。在之后的随访过程中，继续控制体重，心脏结构与功能明显好转。房扑转为窦律。说明，对于肥胖型心肌病的治疗，预后要比原发性扩张型心肌病要好。ShouldWeTargetObesityinAdvancedHeartFailure?Obesityisariskfactorforthedevelopmentofheartfailure(HF),buthasbeenassociatedwithim
22、provedsurvivalinpatientswithestablishedHF.Morbidlyobeseindividuals(BMI40kg/m2)aged50yearswithseverelydepressedsystolicfunctionandNYHAclassIII-IVsymptomsshouldbeconsideredformalabsorptivebariatricsurgeryatanexperiencedcenter.TranslRes.2014Apr18.Obesityandheartfailure:epidemiology,pathophysiology,clin
23、icalmanifestations,andmanagement.Obesityisariskfactorforheartfailure(HF)inbothmenandwomen.Severeobesityproduceshemodynamicalterationsthatpredisposetochangesincardiacmorphologyandventricularfunction,asobesitycardiomyopathy.Substantialweightlossinseverelyobesepersonsiscapableofreversingmostobesity-relatedabnormalitiesofcardiacperformanceandmorphologyandimprovingtheclinicalmanifestationsofobesitycardiomyopathy.Follow-upfor7monthslater小结1.如何从复杂的病情中找出清晰的思路2.病因治疗始终都是心脏重症的根本3.多器官功能衰竭，一定不能忽视万恶之源的寻找4.指南要灵活运用5.心衰的治疗一定要考虑病人预后
