1、Objective:1.Mastering clinical manifestation,diagnosis and management of heart failure2.Grasping causes,pathophysiology of heart failure3.Understanding classification and investigation of heart failure 1.general concept 1)causes of heart failure 2)precipitating/aggravating factors 3)pathophysiology
2、4)type of heart failure2.chronic and acute heart failure 1)clinical manifestation 2)investigation 3)diagnosis and differential diagnosis 4)management Content Heart failure is an imprecise term used to describe the state that develops when the heart cannot maintain an adequate cardiac output or can d
3、o so only at the expense of an elevated filling pressure.Definition pulmonary congestion,systemic venous congestion,tissue perfusion deficiency due to low cardiac output.Clinical Features vleft ventricular end-diastolic pressure18mmHg,vright ventricular end-diastolic pressure10mmHg,heart failure=car
4、diac insuffiency.Hemodynamic FeaturesCauses of heart failure1.Reduced ventricular contractility a.Cardiomyopathy,myocardial infarction.b.Metabolic dysfunction 2.ventricular overload a.pressure overload-hypertension,aortic stenosis,pulmonary hypertension,pulmonary valve stenosis.b.volume overload-mit
5、ral regurgitation,aortic regurgitation,atrial septal defect,ventricular sepals defect,hyperthyroidism,artery-venous fistula.c.ventricular inflow obstruction-hypertrophy,mitral stenosis,tricuspid stenosis,restrictive cardiomyopathy,constrictive pericarditis.endocardial fibrosis and other disorders th
6、at cause a stiff myocardium.Precipitating/aggravating factors myocardial ischemia or infarction infection arrhythmia pulmonary embolism exertion pregnancy and parturition anemia intravenous fluid overload,electrolyte disturbance,acid-base imbalancePathophysiology 1.Frank-Starlings Law of the heart a
7、.The cardiac output is a function of the preload,the afterload,and myocardial contractility.b.Preload:the volume and pressure of blood in the ventricle at the end of diastole.c.Afterload:the arterial resistance.1 正常静息正常静息2 正常活动正常活动3 心衰活动心衰活动3 心衰静息心衰静息心肌收缩性心肌收缩性BADC左室舒张末容量左室舒张末容量图图321 正常和心力衰竭时对机体活动时的
8、代偿正常和心力衰竭时对机体活动时的代偿情况情况最 大 活最 大 活动动活动活动静息静息左室作功左室作功呼 吸 困呼 吸 困难难肺水肿肺水肿E4 静息静息 致死性心肌受损致死性心肌受损心肌细胞死亡心肌细胞死亡心力衰竭心力衰竭心肌细胞死亡心肌细胞死亡+心肌能量消耗心肌能量消耗后负荷后负荷血管收缩血管收缩心排血量心排血量神经体液兴奋神经体液兴奋RASSASInSP3循环循环心肌能量消耗心肌能量消耗胞浆胞浆Ca2+cAMP InSP3 心脏心脏心肌松弛性心肌松弛性变力效应变力效应+心律失常心律失常猝死猝死图图322 肾素肾素血管紧张素和交感血管紧张素和交感肾肾上腺素能系统激活时对心脏代偿功能的影响上腺
9、素能系统激活时对心脏代偿功能的影响 2.RAAS in Heart Failure 2.RAAS in Heart Failure 3.myocardium impaired and remodelinginitial myocardium impairedventricular overloadmyocardium infarctioninflammationdisease progressheart failurecomplicationdeathchamber enlargementmyocardial hypertrophyembryo gene phenotypeextracellu
10、lar matrix changesecondary conductfactorsympathetic nervoussystemRAASendothelinsTNF-,IL-6mechanical stressoxidative stress 4.Diastolic heart failure Heart failure may develop as a result of poor ventricular filling and high filling pressure caused by abnormal ventricular relaxation 顺应性顺应性顺应性顺应性正常正常压
11、压 力力图图324 心室舒张末期压力和容积的关系心室舒张末期压力和容积的关系舒张性心力衰竭时，心室顺应性降低，心室压力舒张性心力衰竭时，心室顺应性降低，心室压力容积曲线容积曲线向左上方移位，即在任何特定的舒张末期压时，心室末期向左上方移位，即在任何特定的舒张末期压时，心室末期容量小于正常人。容量小于正常人。容容 积积a.sarcoplasmic reticulum intake Ca2+free Ca2+in myocyte degrade slowly b.In CHD with obvious ischemia,before contractility dysfunction,have o
12、ccurred relaxation dysfunctionc.In hypertrophy and hypertrophic cardiomyopathy,left ventricular end-diastolic filling pressure pulmonary hypertension,pulmonary congestion diastolic heart failure relaxation dysfunction Type of heart failure Heart failure can be described or classified in several ways
13、.1.Acute and chronic heart failure 2.Left,right and biventricular heart failure 3.High and low output heart failure 4.Diastolic and systolic dysfunction 5.Asymptomatic and congestive heart failurevLow output heart failure:Clinical manifestation of abnormal peripheral circulation:vasoconstriction in
14、system,cold,pale,extremities cyanosis,in the late period,output per minute decrease and lead to difference of pulse pressure decrease,the above manifestation occur in the majority of CHF.vHigh output heart failure:Extremities warm,flush,difference of pulse pressure increase,seen in hyperthyroidism,a
15、nemia,pregnancy Systolic dysfunction Heart failure may develop as a result of impaired myocardial contraction.Diastolic dysfunction Heart failure can also be due to poor ventricular filling pressure caused by abnormal ventricular relaxation,which is commonly found in patients with left ventricular h
16、ypertrophy,hypertension and ischemic heart disease.1 Chronic heart failureDefinition same meaning as congestive heart failureclinical manifestation1.left ventricular heart failuremainly manifested with pulmonary congestion and reduction of cardiac output A symptom1.dyspnea1)breathlessness2)paroxysma
17、l nocturnal dyspnea:often with wheeze sound in both lung cardiogenic asthma3)Orthopnea:in decubitus,blood volume flow to heart increase elevated enddiastolic filling pressure pulmonary venous and capillary pressure increase interstitial pulmonary edema pulmonary compliance decrease respiratory resis
18、tance4)acute pulmonary edema2.cough and hemoptysis pink-tinged or brownish sputum3.fatigue on exertion 4.urinary system symptom in early period,nocturia increase in later period,oliguria B.Sign1.general sign dyspnea after activity,also cyanosis,jaundice,difference of pulse pressure decrease,SBp decr
19、ease,rapid heart rate,peripheral vasoconstriction ,extremities cyanosis,cold,sinus tachycardia.2.Heart sign diffuse and laterally displaced apical impulse gallop in early diastolic period,accentuated p2 systolic murmur at cardiac apex pulses alternans occur when left ventricular ejective impedance i
20、ncrease3.Lung sign moist rales in the base of lung CHF patients occur pleural fluid2.Right ventricular Failure systemic circulation congestionSymptom1)gastrointestinal tract symptom:anorexia,distention,nausea,vomiting,constipation2)kidney symptom kidney congestion renal function decrease3)hepatic re
21、gion pain:congestion,cardiac cirrhosis4)dyspnea Sign1.heart sign heart dilate when right heart failure is obvious,strong impulse occur in the systolic period at the left sternal border,obvious beat occur infraxiphoid diastolic gallop relative tricupid incompetence2.hepatic cervical reflux3.congestiv
22、e liver and tenderness occur before edema Acute:jaundice,ALT increase Long term:cardiac cirrhosis4.edema occur after cervical filling and liver large,is typical sign of right heart failure.at first occur in foot,ankle,anterior tibia.In the early period,edema occur in the morning,worse in the evening
23、,disappear after sleeping.In the late time,systemic,symmetric,pitting edema If complicated with malnutrition or hepatic dysfunction,face edema occur,prognosis is poor.5.pleural fluid and ascites 3.biventricular heart failure have clinical manifestation of left and right heart failure.Conditions with
24、 normal systolic function and decreased diastolic function include:(1)systemic arterial hypertension (2)myocarditis (3)hyretrophic cardiomyopathy (4)congestive cardiomyopathy In the setting of left ventricular dysfunction,which of following neurohormonal factors would be activated?(1)Norepinephrine
25、(2)Endothelin (3)Arginie vasopreein (4)Endothelial-derived relaxing factor Investigation 1.routine examination blood,urine,renal function,electrolyte,liver function 2.ECG a.no specific findings.b.Abnormalities may provide etiological clue(ventricular hypertrophy,AMI,bundle branch block)c.V1ptf25-30m
26、mHg(3.3-4KPa)interstitial edema occur.参参 数数正常值正常值临床意义临床意义中心静脉压（中心静脉压（CVP）612cmH2O（0.591.18KPa）说明血容量过多或右心衰竭说明血容量过多或右心衰竭肺动脉压（肺动脉压（PAP）1230/413mmHg（1.64.0/0.531.73KPa）说明肺动脉高压、左心衰竭说明肺动脉高压、左心衰竭肺毛细血管楔嵌压（肺毛细血管楔嵌压（PCWP）612mmHg（0.81.6KPa）说明肺淤血、左心衰竭说明肺淤血、左心衰竭心搏量（心搏量（SV）6070ml可由于前负荷不足、心包填塞、可由于前负荷不足、心包填塞、心肌收缩力下
27、降，心排阻力上升心肌收缩力下降，心排阻力上升心搏指数（心搏指数（SI）4151ml/m2同上同上心排血量（心排血量（CO）56L/min可由于正性肌力药物作用，可由于正性肌力药物作用，说明有心力衰竭说明有心力衰竭心排指数（心排指数（CI）2.64.0L/（minm2）说明收缩力减低或心力衰竭说明收缩力减低或心力衰竭射血分数（射血分数（EF）0.50.6说明心室收缩功能减低说明心室收缩功能减低左室每搏作功（左室每搏作功（LVSW）60123 左室每搏作功指数（左室每搏作功指数（LVSWI）5062 体循环血管阻力（体循环血管阻力（SVR）7701500dyness/cm5见于缺血、血管扩张剂，见
28、于缺血、血管扩张剂，高血压、血管活性药物高血压、血管活性药物体循环血管阻力指数（体循环血管阻力指数（SVRI）19702390dyness（cm5m2）同上同上肺血管阻力（肺血管阻力（PVR）37250 dyness/cm5毛细血管前肺小动脉收缩、肺栓塞、慢性毛细血管前肺小动脉收缩、肺栓塞、慢性肺疾病、肺间质水肿、肺小血管阻塞性病肺疾病、肺间质水肿、肺小血管阻塞性病变、二尖瓣狭窄变、二尖瓣狭窄肺血管阻力指数（肺血管阻力指数（PVRI）69177 dyness（cm5m2）同上同上增高增高 降低降低 Invasive homodynamic monitoringDiagnosis and dif
29、ferential diagnosis Clinical diagnosis include:etiology(basic cause and induce cause),pathoanatomy,pathophysiology,heart rhythm cardiac function NYHA classification no activity limit,daily activity dont lead to inertia,dyspnea,palpitation.slight activity limit,no symptom at rest ,daily activity lead
30、 to inertia,dyspnea,palpitation or angina pectoris.obvious activity limit,no symptom at rest,daily activity lead to inertia,dyspnea,palpitation or angina pectoris.cannot do any activity ,have symptom at rest.typeCI(L/minm2）PCWP（mmHg）Clinical manifestation2.218（2.4）No peripheral perfusion deficiency
31、and pulmonary congestion,no symptom and sign of heart failure 2.218（2.4）No peripheral perfusion deficiency,pulmonary congestion,no obvious clinical manifestation 2.218（2.4）peripheral perfusion deficiency,no pulmonary congestion,seen in right ventricular infarction and blood volume deficiency 2.218（2
32、.4）peripheral perfusion deficiency and pulmonary congestion,severe typeForrester classificationKillip classification no heart failure symptom,no moist rales,PCWP may elevate slight to moderate heart failure,50%lung field moist rales,may occur lung edema cardiac shock,Bp90mmHg,oliguria 18mmHg,pulmona
33、ry congestion2.clinical manifestation of peripheral circulatory perfusion deficiency CI2.2L/min.m23.valve insufficiency,ventricular septal defect pulmonary hypertension,valve regurgitation with cardiac dysfunction If blood volume deficiency,should fluid replacement at first,then use vasodilator drug
34、s.药物药物机制机制前负前负荷荷后负后负荷荷常用剂量常用剂量作用时间作用时间开始开始高峰高峰持续持续硝酸盐血管扩张剂硝酸盐血管扩张剂 硝酸甘油硝酸甘油NO供者供者+0.210g/（kgmin）iv56mg 经皮经皮2min515min10ug/Kg.min activate-receptor,vasoconstrict Dobutamine 2-7.5ug/Kg.min 2.Phosphodiesterase inhibitor Inhibit cAMP degrade increase intracellular cAMP Ca2+increase cardiac contraction i
35、ncrease Amrinone Milrione 3.Aldosterone antagonist Protect aldosterone escape.4.-adrenocepter antagonists Recent clinic trials have shown,when given in very small doses under carefully monitored conditions,they can increase ejection fraction,improve symptoms and reduce the frequency of hospitalizati
36、on in patient with chronic heart failure.Relieve toxiation of catecholamine .On the base of using ACE-I,diuretics,digitalis,using bloker.Given in very small incremental doses Bisoprool 1.25mg metoprolol 6.25mg 5.diastolic heart failure treatment treat primary disease relax myocardium revert myocardi
37、al hypertrophy decrease preload control tachycardia calcium channel blocker,and blocker can be useful.6.Refractory heart failure 1)Have the etiology and precipitating causes been established?2)Are drug dose optimal?3)Is the patient adhering to an adequate low-salt diet?4)Need another cardiac transpl
38、antation.7.Acute pulmonary edemaEmergency treatment1)position:Dont keep patient in a supine position2)Maintain oxygenation:high concentrations of O2 should be given by mask or nasal cannula.3)Morphine sulfate 3-5mg IV or 5-10mg IM can reduce agitation,reduce transient arterial and venous dilation,de
39、crease the respiratory rate,slow the heart rate,and reduce respiratory and cardiac work.4)Intravenous administration of a rapidly actig diuretic,eg.(furosemide 40mg IV)can be initiate a prompt diuresis in 15 to 20 min.5)Rotating tourniquets are effective with Bp cuff applied to 3 limbs,inflated midw
40、ay between diastolic and systolic pressure,deflated and rotated 10 to 20 min.6)Vasodilator drugs7)Digitalis8)Aminophylline9)others Pathophysiologic consequences of a myocardial infarction include:(1)increased systolic load due to the akinetic segment(2)decreased ejection fraction that approximates t
41、he amount of muscle loss.(3)hypertrophy of noninfarcted myocardium.(4)decreased end-diastoic volume Supportive evidence that left-sided failure is present includes all the following EXCEPT:A.abnormally elevated filling pressures as detected by right heart catheterizationB.a cardiac index of 3.5 liters/min/m2C.a reduction in maximum oxygen consumption determined noninvasively by exerciseD.the presence of pulmonary rales on physical examinationE.low left ventricular ejection fraction at rest on echocardiography
