1 / 110

心力衰竭 Heart Failure

心力衰竭 Heart Failure. 浙江大学医学院附属第一医院 陶谦民. 定义. 心力衰竭是心脏各种疾病发展到中、末期导致心脏功能障碍，出现心功能不全（ cardiac insufficiency ）的一组临床综合征，多指临床出现心肌收缩力下降使心排血量不能满足机体代谢的需求，器官、组织血液灌注不足，同时出现肺循环和 / 或体循环淤血的表现。. 病因. 心肌本身病变 —— 原发性心肌损害 1. 缺血性心肌损害：冠心病心肌缺血（长期）和 / 或心肌梗死 2. 心肌炎和心肌病，以病毒性心肌炎和原发性扩张性心肌病最为常见

ranit
Download Presentation

心力衰竭 Heart Failure

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. 心力衰竭Heart Failure 浙江大学医学院附属第一医院 陶谦民

  2. 定义 • 心力衰竭是心脏各种疾病发展到中、末期导致心脏功能障碍，出现心功能不全（cardiac insufficiency）的一组临床综合征，多指临床出现心肌收缩力下降使心排血量不能满足机体代谢的需求，器官、组织血液灌注不足，同时出现肺循环和/或体循环淤血的表现。

  3. 病因 • 心肌本身病变——原发性心肌损害 1.缺血性心肌损害：冠心病心肌缺血（长期）和/或心肌梗死 2.心肌炎和心肌病，以病毒性心肌炎和原发性扩张性心肌病最为常见 3.心肌代谢障碍性疾病：如糖尿病性心肌病、心肌淀粉样变性等

  4. 病因 • 心脏负荷过重，心肌本身功能无异常，但因长期的高强负荷致心脏功能受损 1.压力负荷（后负荷）过重，如高血压、主动脉瓣狭窄、肺动脉高压、肺动脉瓣狭窄等 2.容量负荷（前负荷）过重，因大量的血液回流长期造成心脏功能损害，可见于：⑴心脏瓣膜关闭不全，如主动脉瓣关闭不全、二尖瓣关闭不全等；⑵先天性心脏病如间隔缺损、动脉导管未闭、动静脉瘘等；⑶慢性重度贫血、甲状腺功能亢进等伴有全身血容量增多或循环血量增多等 • 心脏扩张受到限制，如大量心包积液或心包缩窄

  5. 诱因 • 有基础心脏病的患者，其心力衰竭的症状通常由一些增加心脏负荷的因素所诱发，这些常见的诱发心力衰竭的因素有： 1.感染，以呼吸道感染最为常见，感染性心内膜炎和风湿活动也是诱发心力衰竭常见而隐匿的原因 2.心律失常，心房颤动是器质性心脏病常见的心律失常，也是诱发心力衰竭最重要的因素 3.血容量增，如摄入钠盐过多，静脉输入液体过多、过快等 4.过度体力活动，劳累或情绪激动，如妊娠后期及分娩过程，情绪波动如暴怒等 5.治疗不当，所谓医源性因素，如不恰当停用洋地黄类药物或降压药物，某些心脏功能抑制性药物 6.原有心脏疾病加重或并发加重心脏负担的疾病，如冠心病发生心肌梗死，风湿性心瓣膜病出现风湿活动，合并甲状腺功能亢进或贫血等

  6. 类型 • 左心衰、右心衰和全心衰 左心衰以肺循环淤血为特征，临床主要表现为呼吸困难；右心衰主要见于肺源性心脏病和某些先天性心脏病，以体循环淤血为特征，临床出现浮肿、腹水和肝肿大等；全心衰则综合左右心衰的临床表现 • 急性和慢性心衰 • 收缩性和舒张性心衰

  7. Heart Failure (HF) Definition A complex clinical syndrome in which the heart is incapable of maintaining a cardiac output adequate to accommodate metabolic requirements and the venous return.

  8. HF Incidence and Prevalence • Prevalence • Worldwide, 22 million1 • United States, 5 million2 • Incidence • Worldwide, 2 million new cases annually1 • United States, 500,000 new cases annually2 • HF afflicts 10 out of every 1,000 over age 65 in the U.S.2 1 World Health Statistics, World Health Organization, 1995. 2 American Heart Association, 2002 Heart and Stroke Statistical Update.

  9. Prevalence of HF by Age and Gender United States: 1988-94 Source: NHANES III (1988-94), CDC/NCHS and the American Heart Association

  10. New York Heart Association Functional Classification Class I:No symptoms with ordinary activity Class II:Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, dyspnea, or angina Class III:Marked limitation of physical activity. Comfortable at rest, but less than ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain Class IV:Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency may be present even at rest

  11. HF Classification: Evolution and Disease Progression • Four Stages of HF (ACC/AHA Guidelines): Stage A: Patient at high risk for developing HF with no structural disorder of the heart Stage B: Patient with structural disorder without symptoms of HF Stage C: Patient with past or current symptoms of HF associated with underlying structural heart disease Stage D: Patient with end-stage disease who requires specialized treatment strategies Hunt, SA, et al ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult, 2001

  12. Severity of Heart FailureModes of Death NYHA II NYHA III CHF CHF 12% Other 26% Other 59% Sudden 24% Sudden Death 64% 15% Death n = 103 n = 103 NYHA IV CHF Other 33% 56% Sudden Death 11% n = 27 MERIT-HF Study Group. Effect of Metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL randomized intervention trial in congestive heart failure (MERIT-HF). LANCET. 1999;353:2001-07.

  13. Etiology of Heart Failure What causes heart failure? • The loss of a critical quantity of functioning myocardial cells after injury to the heart due to: • Ischemic Heart Disease • Hypertension • Idiopathic Cardiomyopathy • Infections (e.g., viral myocarditis, Chagas’ disease) • Toxins (e.g., alcohol or cytotoxic drugs) • Valvular Disease • Prolonged Arrhythmias

  14. The Donkey Analogy Ventricular dysfunction limits a patient's ability to perform the routine activities of daily living…

  15. Left Ventricular Dysfunction • Systolic: Impaired contractility/ejection • Approximately two-thirds of heart failure patients have systolic dysfunction1 • Diastolic: Impaired filling/relaxation 30% (EF > 40 %) (EF < 40%) 70% Diastolic Dysfunction Systolic Dysfunction 1 Lilly, L. Pathophysiology of Heart Disease. Second Edition p 200

  16. Cardiac Output • Cardiac output is the amount of blood that the ventricle ejects per minute Cardiac Output = HR x SV

  17. Determinants of Ventricular Function Contractility Preload Afterload Stroke Volume • Synergistic LV Contraction • Wall Integrity • Valvular Competence Heart Rate Cardiac Output

  18. Left Ventricular Dysfunction Volume Overload Pressure Overload Loss of Myocardium Impaired Contractility LV Dysfunction EF < 40%  End Systolic Volume  Cardiac Output  End Diastolic Volume Hypoperfusion Pulmonary Congestion

  19. Hemodynamic Basis for Heart Failure Symptoms

  20. Hemodynamic Basis forHeart Failure Symptoms LVEDP  Left Atrial Pressure  Pulmonary Capillary Pressure  Pulmonary Congestion

  21. Symptoms Dyspnea on Exertion Paroxysmal Nocturnal Dyspnea Tachycardia Cough Hemoptysis Physical Signs Basilar Rales Pulmonary Edema S3 Gallop Pleural Effusion Cheyne-Stokes Respiration Left Ventricular DysfunctionSystolic and Diastolic

  22. Symptoms Abdominal Pain Anorexia Nausea Bloating Swelling Physical Signs Peripheral Edema Jugular Venous Distention Abdominal-Jugular Reflux Hepatomegaly Right Ventricular FailureSystolic and Diastolic

  23. Consequences of DecreasedMean Arterial Pressure  Mean Arterial Pressure (BP) =  Cardiac Output x Total Peripheral Resistance

  24. Compensatory Mechanisms • Frank-Starling Mechanism • Neurohormonal Activation • Ventricular Remodeling

  25. Compensatory Mechanisms Frank-Starling Mechanism a. At rest, no HF b. HF due to LV systolic dysfunction c. Advanced HF

  26. Compensatory Mechanisms Neurohormonal Activation Many different hormone systems are involved in maintaining normal cardiovascular homeostasis, including: • Sympathetic nervous system (SNS) • Renin-angiotensin-aldosterone system (RAAS) • Vasopressin (a.k.a. antidiuretic hormone, ADH)

  27. Compensatory Mechanisms: Sympathetic Nervous System Decreased MAP Sympathetic Nervous System  Contractility Tachycardia Vasoconstriction MAP = (SV x HR) x TPR

  28. Cardiac sympatheticactivity Sympathetic activity to kidneys + peripheral vasculature 1- receptors 2- receptors 1- receptors Activation of RAS 1- b1- Myocardial toxicity Increased arrhythmias Vasoconstriction Sodium retention Sympathetic Activation in Heart Failure CNS sympathetic outflow Disease progression Packer. Progr Cardiovasc Dis. 1998;39(suppl I):39-52.

  29. Compensatory Mechanisms: Renin-Angiotensin-Aldosterone (RAAS) Angiotensinogen Renin Angiotensin I Angiotensin Converting Enzyme Angiotensin II AT I receptor Vasoconstriction Vascular remodeling Oxidative Stress LV remodeling Cell Growth Proteinuria

  30. Compensatory Mechanisms: Renin-Angiotensin-Aldosterone (RAAS) Renin-Angiotensin-Aldosterone ( renal perfusion) Salt-water retention Thirst Sympathetic augmentation Vasoconstriction MAP = (SV x HR) x TPR

  31. Compensatory Mechanisms: Neurohormonal Activation – Vasopressin Decreased systemic blood pressure Central baroreceptors - Increased systemic blood pressure Stimulation of hypothalamus, which produces vasopressin for release by pituitary gland Vasoconstriction Release of vasopressin by pituitary gland

  32. Compensatory Neurohormonal Stimulation: Summary Decreased Cardiac Output ­Renin-angiotensinsystem ­Sympatheticnervous system ­Antidiuretic hormone(vasopressin) ­Contractility Vasoconstriction ­Circulating volume ­Heartrate Anteriolar Venous Maintainbloodpressure ­Venous return to heart(­preload) Cardiacoutput + - Peripheral edemaand pulmonarycongestion + ­Strokevolume

  33. Compensatory Mechanisms Ventricular Remodeling Alterations in the heart’s size, shape, structure, and function brought about by the chronic hemodynamic stresses experienced by the failing heart. Curry CW, et al. Mechanical dyssynchrony in dilated cardiomyopathy with intraventricular conduction delay as depicted by 3D tagged magnetic resonance imaging. Circulation 2000 Jan 4;101(1):E2.

  34. Other Neurohormones • Natriuretic Peptides: Three known types • Atrial Natriuretic Peptide (ANP) • Predominantly found in the atria • Diuretic and vasodilatory properties • Brain Natriuretic Peptide (hBNP) • Predominantly found in the cardiac ventricles • Diuretic and vasodilatory properties • C-type Natriuretic Peptide (CNP) • Predominantly found in the central nervous system • Limited natriuretic and vasodilatory properties

  35. Pharmacological Actions of hBNP Hemodynamic (balanced vasodilation) • veins • arteries • coronary arteries Neurohormonal aldosterone norepinephrine Renaldiuresis & natriuresis Abraham WT and Schrier RW, 1994

  36. Endothelium-Derived Vasoactive Substances Produced by a thin lining of cells within the arteries and veins called the endothelium Endothelium-derived relaxing factors (EDRF) – Vasodilators: • Nitric Oxide (NO) • Bradykinin • Prostacyclin Endothelium-derived constricting factors (EDCF) – Vasoconstrictors: • Endothelin I

  37. Mediators of Heart Failure Cytokines • Small protein molecules produced by a variety of tissues and cells • Negative inotropes • Elevated levels associated with worse clinical outcomes • Examples: • Tumor necrosis factor (TNF)-alpha • Interleukin 1-alpha • Interleukin-2 • Interleukin-6 • Interferon-alpha

More Related