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1、深度和节律的改变Dyspneaonexertion劳力性呼吸困难Orthopnea端Background背景背景Definitionandexplainingthedefinition定义定义pathogenesis机制机制Content内容内容 心为君主之官，脏腑百骸，惟所是命，聪明智慧，莫不由之心为君主之官，脏腑百骸，惟所是命，聪明智慧，莫不由之 The heart is more deceitful than anything. It is incurable who can know it? Jeremiah17:9-10Heartfailure心衰心衰-BackgroundHeart
2、failure心衰心衰-Background Cats look down on us. Dogs look up to us. Pigs treat us as equalsHeartfailure心衰心衰-BackgroundWhatkillus?Background 2010年中国心血管病报告年中国心血管病报告1/5adultssufferfromcardiovasculardisease3milliondiefromcardiovasculardiseaseaccountfor41%ofdeathnumberChinadeath1/11.6sAmericadeath1/34.0sequ
3、ivalenttoonceWenchuanbigearthquakeBackgroundthereportofcardiovasculardiseaseinchina2010hypertension高血压高血压2亿人亿人myocardialinfarction心肌梗心肌梗200万人万人pulmonaryheartdisease肺心病肺心病500万人万人rheumaticheartdisease风心病风心病250万人万人congenitalheartdisease先心病先心病200万人万人heartfailure心衰竭心衰竭420万人万人2010年中国心血管病报告年中国心血管病报告therepo
4、rtofcardiovasculardiseaseinchina2010BackgroundWeFaceanepidemicofHF Affecting0.4-2%oftotalpopulation，8-10%ofelderly TheglobalHFpatientshaveupto2250million，increasingat200millionperyear TheprognosisofHFsimilartocancerorevenworse The20%patientswithHFreadmissionafterdischargedfromhospitalin30days Lessth
5、an50%patientssurvival5yearsfromthediagnosisofheartfailure Averagesurvivaltimeis16month，inhospitalonly25%survival5yearsBackground0 02020404060608080100100HeartdiseaseCerebrovascularmalignancyaccidentalrespiratorygastrointestinalcommunicableUrinarysystemNeuropsychosisEndocrinosisLifestyleBiogenticsEnv
6、ironmentalfactorsHealthcareTop10causeofdeathinChinaandthemainriskfactors%ForecastingthefutureofcardiovasculardiseaseintheUnitedStatesCirculation2011;123(8):933-944EstimateddirectandindirectcostofmajorcordialdiseaseInunitedstatein2010TheEconomicBurdenOfCardiovascularDiseasesCoronaryheartdiseaseHypert
7、ensivediseaseStrokeHeartfailure$53.9$34.4Costinbillion$105.9$93.5Clinicalintervention 生生 死死LowriskstateDangerousstateEarlychangeDifferentprognosisClinicdiseaseSub-clinicsymptomsPreventinterventionHypertensionhyperlipidmiasmokingdiabetesobeyhereditarypsychologicalinterventionNationalstandardlifestyle
8、drugoperationphysicsBackgroundheathsub-healthsub-clinicdiseaseRiskFactorsEndothelialDysfunctionAtherosclerosisCoronaryarterydiseaseMyocardialIschemiaCoronaryThrombosisMyocardialInfarctionArrhythmia&LossofMuscleRemodelingVentricularDilationCongestiveHeartFailureEndstageHeartDisease TheProgressiveDeve
9、lopmentofChronicCardiovascularDisease 慢性心血管疾病渐进式发展慢性心血管疾病渐进式发展心功不全心功不全insufficiencyHeartfunctionPhysicalActivitylimitationSymptomsatrestDescriptionINonoalmostasnormalpersonIIMildSlightnoCanwithstandheavierphysicalactivityIIImoderateobviousnoCanwithlighterphysicalactivityIVsevereobviousyesLoselaborab
10、ilitycompletelyLife-threating分级分级:TheNewYorkHeartAssociationFunctionalClass (NYHA-FC)心肌收缩力因各种心肌收缩力因各种病因病因减弱（原发或继发），不能将减弱（原发或继发），不能将静脉回心血量等量搏出，因而使静脉回心血量等量搏出，因而使心输出量心输出量绝对或相对绝对或相对减少，减少，使体循环和使体循环和/或肺循环静脉系统或肺循环静脉系统淤血淤血，动脉系统，动脉系统供血不足供血不足，不能满足人体在静息状态或一般活动时代谢的的需要，从而不能满足人体在静息状态或一般活动时代谢的的需要，从而出现一系列的心脏循环障碍的出现
11、一系列的心脏循环障碍的症状和体征症状和体征。大循环大循环心功心功临床临床 心肌衰竭心肌衰竭：原发性心肌病变，如心肌炎，心肌梗塞：原发性心肌病变，如心肌炎，心肌梗塞 Myocardialfailure：primarymyocardiallesions，myocarditiis 心力衰竭心力衰竭：不仅仅是心脏问题，如缩窄性心包炎：不仅仅是心脏问题，如缩窄性心包炎Heartfailure：notonlyheartproblem，contractivepericarditis 充血性心衰充血性心衰： 慢性经过，血容量增加，出现水肿慢性经过，血容量增加，出现水肿 Congestiveheartfailu
12、re：chronic，blood，edema心肌收缩力因各种心肌收缩力因各种病因病因减弱（原发或继发）减弱（原发或继发）ExpoundingMyocardialcontractilityisimpairedbyvariouscauses（primaryorsecondary).fibrinouspericarditis心肌收缩力因各种心肌收缩力因各种病因病因减弱（原发或继发）减弱（原发或继发）ExpoundingThefactorsinfluenceCOBasiccausesExampleContractility收缩性（力收缩性（力)Myocardialabnormalitiescorona
13、ryheartdiseaseload负荷负荷OverloadValvularstenosis,valvularinsufficiencySynergy协同性协同性DisharmonyRhythm节律节律ArrhythmiaUnderlyingCausesofHF心衰的基本病因心衰的基本病因CADthecommonest2/3Hypertensionin4%Toxicinjuryin2%-4%Valvediseasesin4%Unknownin20%CommonCausesofHF心衰的常见病因心衰的常见病因诱因诱因诱因诱因precipitationcauseprecipitationcause
14、（AggravatingFactorsAggravatingFactors）3 3InfectionsInfections3 3Arrhythmias(AF)Arrhythmias(AF)3 3PregnancyandchildbirthPregnancyandchildbirth3 3beheatedwithpassionbeheatedwithpassion3 3toofasttotransfusiontoofasttotransfusion3 3panyfactorthatincreasecordialloadorinjureheartpprecipitationisnotalwaysp
15、recipitationAttentionExpounding 心输出量绝对或相对降低心输出量绝对或相对降低A AV V瘘瘘 贫贫血血 甲甲亢亢 脚脚气气病病HyperdynamicstatusIncreasedventricularpreloadATPconsumptionincreasedandproductiondecreasedhighcardiacoutputHF（1%）lowcardiacoutputHFnotes：otherclassificationself-studycardiacoutputreduceabsolutelyorrelatively,dermatophytos
16、isbarbiers=beriberipanneuritisepidemicadieteticneuritisendemicneuritis脚气与脚气病脚气与脚气病香港脚香港脚HongKongfoot运动员脚运动员脚athletefootburning,itching，cracking糖代谢脱羧酶的辅酶糖代谢脱羧酶的辅酶CoenzymeofdecarboxylaseinSugarmetabolism参与参与 -酮酸的氧化脱羧酮酸的氧化脱羧Participatein -ketoacidoxidativedecarboxylationVitB1(thiamin硫胺素硫胺素)：葡萄糖葡萄糖gluco
17、se酵解酵解glycolysis乳酸乳酸Lacticacid丙酮酸丙酮酸pyruvicacidTCA循环循环乙酰辅酶乙酰辅酶A丙酮酸丙酮酸NADHNAD+NADHNAD+发酵发酵ferment呼吸链递氢呼吸链递氢NADHNAD+VitB1丙酮酸脱氢酶系丙酮酸脱氢酶系参与参与 -酮酸的氧化脱羧酮酸的氧化脱羧丙酮酸丙酮酸乳酸堆积乳酸堆积CO2,H+Beriberi：comesfromaSinhalesephraseMeaning：“weak,weak”or“Icannot,Icannot”,备急千金要方备急千金要方考诸经方往往有考诸经方往往有脚弱脚弱之论，而古人之论，而古人少有此疾。自永嘉南渡，衣
18、缨士人，少有此疾。自永嘉南渡，衣缨士人，多有遭者。风毒中人，随处皆得，多有遭者。风毒中人，随处皆得，作病何偏着于脚也？答曰作病何偏着于脚也？答曰 夫人有夫人有五脏，心肺二脏，经络所起在手十五脏，心肺二脏，经络所起在手十指；肝肾与脾三脏，经络所起在足指；肝肾与脾三脏，经络所起在足十趾。夫十趾。夫风毒之气，皆起于地风毒之气，皆起于地。地。地之寒暑风湿皆作蒸气，足常履之，之寒暑风湿皆作蒸气，足常履之，所以风毒之中人也所以风毒之中人也必先中脚必先中脚；久而；久而不瘥，遍及四肢腹背头项也；微时不瘥，遍及四肢腹背头项也；微时不觉，痼滞乃知。经云不觉，痼滞乃知。经云 次传、间次传、间传是也。传是也。东晋、六
19、朝时叫脚弱东晋、六朝时叫脚弱孙思邈称为风毒脚气孙思邈称为风毒脚气内经诸病源候论脚气病治法总要内经诸病源候论脚气病治法总要DryberiberiWasteberiberiDifficultyinwalkingPeripheraledemaTinglingornumbnessIncreasedheartrateparalysisofthelowerlegsDyspneaonexertionMentalconfusion/speechdifficultiesParoxysmalnocturnaldyspneanystagmusVasodilationleadingtoincreasedarterio
20、venousshuntPeripheralorcenterlesionCardiovascularsysteminfantberibericrying,butnotloudlyandwithouttears.Maybefatal.TypesofberiberiExpounding 心功下降，静脉淤血，动脉缺血心功下降，静脉淤血，动脉缺血 CausesCardiacfunctionimpairment代代偿偿CardiacoutputVenouscongestion引起病理性损害，出现临床症状和体征引起病理性损害，出现临床症状和体征Arterialsischemiavenoussystemcon
21、gestionarterialsysteminsufficientbloodsupplyCardiacoutputIschemiaandHypoxia heartRatesympathetic strokesympatheticFrank-Starlinglawhypertrophy-remodeling Bloodredistributionneurohumoral(NE,RAAS)心衰时机体的适应和代偿心衰时机体的适应和代偿adaptionandcompensationCardiacoutputCO=stroke/minXheartRateCardiac（ventricular）remod
22、eling心肌重塑（构）心肌重塑（构）心肌受损，代偿与适应心肌受损，代偿与适应出现结构、代谢和功能改变出现结构、代谢和功能改变生物学：心肌细胞，非心肌细胞、细胞外基质生物学：心肌细胞，非心肌细胞、细胞外基质基因表达基因表达？几何学：心肌肥大，心室扩大等几何学：心肌肥大，心室扩大等NormalCentripetalCentrifugalLoadpostloadpreloadMyofibershyperplasiaparalleltandemVentricularWallthicknessthickeningslightthickeningHeartChamberexpansionnoobviou
23、sobviousMyocardialhypertrophy significant myofibre disarray and interstitial fibrosis in HCM.HeartRate180Scarometers2.2Excessivehypertrophyorganinterstitiumtissuecap,sympatheticdensitycellsurfacearea,mitochondriamolecularV3imbalancegrowthandincreaseLimitationofmyocardialcompensationAbstractIthasbeen
24、difficulttoestablishwhetherwearelimitedtotheheartmusclecellswearebornwithorifcardiomyocytesaregeneratedalsolaterinlife.Wehavetakenadvantageoftheintegrationof14C,generatedbynuclearbombtestsduringtheColdWar,intoDNAtoestablishtheageofcardiomyocytesinhumans.Wereportthatcardiomyocytesrenew,withagradualde
25、creasefrom1%turningoverannuallyattheageof20to0.3%attheageof75.Lessthan50%ofcardiomyocytesareexchangedduringanormallifespan.Thecapacitytogeneratecardiomyocytesintheadulthumanheartsuggeststhatitmayberationaltoworktowardsthedevelopmentoftherapeuticstrategiesaimingtostimulatethisprocessincardiacpatholog
26、ies.weremyocardialcellspost-mitoticcells?Science 324: 98, 2009.Expounding4：症状和体征：症状和体征signsandsymptomsCardiacoutputArterialsperfusionVenousstagnationrenalFatigueCardiacshockSuddendeathliver-gutlungskinEdemaDyspneaCyanosisDyspnea呼吸困难呼吸困难Respiratorybecomelabored呼吸费力呼吸费力Respiratoryfrequencydepthandrhyt
27、hm呼吸频率、深度和节律的改变呼吸频率、深度和节律的改变Dyspneaonexertion劳力性呼吸困难劳力性呼吸困难Orthopnea端坐呼吸端坐呼吸Paroxysmalnocturnaldyspnea夜间阵发性呼吸困难夜间阵发性呼吸困难Dyspnea呼吸困难呼吸困难 Fatigue Activities limited Chest congestion Edema or ankle swelling Shortness of breathTheMajorsignsandsymptomsofCHF?Think FACES.疲乏疲乏 活动受限活动受限 胸闷胸闷 水肿或脚踝肿胀水肿或脚踝肿胀 气
28、促气促“Evolution”ofOurUnderstandingofCHF慢性心衰的认识演变慢性心衰的认识演变 cardio-renalmodel心肾模型心肾模型Na-waterretention Hemodynamicdisorder血流动力学紊乱血流动力学紊乱reducedcardiacoutputandexcessivevasoconstriction Neurohormonalmodel神经体液模型神经体液模型ActinmyosintroponinThick&thinmyofilament10-5 10-7 Tropomyosin肌球蛋白肌球蛋白肌动蛋白肌动蛋白肌纤蛋白肌纤蛋白肌凝蛋白
29、肌凝蛋白阻凝蛋白阻凝蛋白亲凝蛋白亲凝蛋白原肌球蛋白原肌球蛋白原肌凝蛋白原肌凝蛋白向肌球蛋白向肌球蛋白Woe？！？！“pump”BasicmechanismsCell1.Systole proteinsCa+transferATP1.Contraclityabnormalitiesdegeneration,necrosis,apoptosis excitationconstrationCainflux(channel)CabindingtotroponinSRleaseATPproduction/utilization2.Diastole 2.Disorderdiastolicpropertie
30、s Ca+restorationeffluxandSRActin&myosindissociationgross3.Synergy Anatomies Compliance Coordinationsynchronismsymmetry3dysynergy GrossanatomyanomaliesVentricularwallthick？!AlteredComplianceChangedinCoordinationParadoxical:？!asynchronismasymmetry “pump”Basicmechanisms图图3-1-4 心脏反常收缩示意图心脏反常收缩示意图 正常心脏正常心脏 受损心脏变薄受损心脏变薄 室压室压，膨突，膨突此课件下载可自行编辑修改，仅供参考！此课件下载可自行编辑修改，仅供参考！感谢您的支持，我们努力做得更好！谢谢感谢您的支持，我们努力做得更好！谢谢
