1、8 肺心病英文 中山大学 内科学Mechanism and Pathology（一）Pulmonary hypertension：Definition：mean pulmonary artery pressure（mPAP）25 mmHg at rest or 30 mmHg during exercise.Functional changes in pulmonary vascular Hypoxia,Hypercapnia,Respiratory acidosis,vasoconstriction substancesPulmonary vasoconstrictionPulmonary
2、hypertension Hypoxia is the most important factor leads to pulmonary hypertension Anatomic changes in pulmonary vascular Remodeling of pulmonary vesselsIncreased blood viscosity and blood volumeMechanism and Pathology（二）Dysfunction of right heart Pulmonary hypertension Afterload of right ventricular
3、,Oxygen supply of myocardium Hypertrophy and dilatation of the right ventricle Right heart failure(三）Damages to other vital organs：Multiple organ dysfunctionClinical ManifestationsCompensation stage of cardiac and lung function Symptoms:cough,sputum,short of breath;dyspnea and palpitation on exertio
4、n;fatigue and decrease of exercise tolerance;exacerbated by acute infection.Signs:cyanosis,signs of emphysema,moist rales and/or rhonchi;P2A2,systolic murmur of tricuspid area,subxiphoid visible/palpable cardiac impulse,distended jugular venous.Clinical ManifestationsDecompensation stage of cardiac
5、and lung function Respiratory failure Symtoms:severe dyspnea,especially at night,headache,insomnia,inappetence,somnolence,dizziness,confusion,even delirium.Signs:conjunctiva congestion and edema,retinal vasodilatation,optic papillary edema;weakness or disappear of deep reflexes,pathological reflexes
6、.Clinical ManifestationsDecompensation stage of cardiac and lung function Right heart failure Symtoms:dyspnea aggravated,palpitation,inappetence,abdominal distention,nausea.Signs:cyanosis,arrhythmia,tachycardia,subxiphoid systolic murmur or even diastolic murmur.Tender hepatomegaly,Hepatojugular ref
7、lux,lower extremity edema,ascites.Chest radiography：Enlarged right descending pulmonary artery diameter 15mm;The ratio of diameter of right descending pulmonary artery to trachea1.07;Right descending pulmonary artery broadens2mm during dynamic observation Bulge of the middle segment of pulmonary art
8、ery or with the height3mmEnlargement of the pulmonary arteries and the major branches,with marked tapering of peripheral arteries Pulmonary cone protrudes or with the height7mmRight ventricular hypertrophyLaboratory assessmentElectrocardiography：Main criteria:Mean frontal plane electrical axis 90 V1
9、 R/S1 Marked clockwise rotation of the electrical axis：V5 R/S1 Rv1+Sv5 1.05mV aVR R/S or R/Q1 V:QS,Qr,qr（excluding myocardial infarction）P-pulmonale (tall peaked P waves in lead II)Secondary criteria:Low voltage QRS waveforms in limb leads Right bundle branch block Laboratory assessment Echocardiogr
10、aphy The inner diameter of right ventricular outflow 30 mm The right ventricular internal dimension 20mm Anterior right ventricular wall thickened,or with the pulsation amplitude increase Ratio of left to right ventricular internal dimension 2 Increased inner diameter of right pulmonary artery 18mm
11、or pulmonary artery trunk20mm Ratio of right ventricular outflow inner diameter to left atrium internal dimension 1.4 Pulmonary valve curve shows the hypertention of pulmonary circulation Laboratory assessmentVectorcardiogram More sensitive than ECG：positive rate 80-95%Graphic show the hypertrophy o
12、f right heart Arterial blood gas analysis:Hypoxemia and/or hypercapnia Respiratory failure:PaO260mmHg PaCO2 50mmHg Blood test:Acid-base and electrolyte imbalance Blood viscosity RBC count and hemoglobin WBC count and neutrophilic ratio when infection occursLaboratory assessmentMedical history of COP
13、D and other lung or pulmonary vascular diseases.Symptoms and signs of primary disease,pulmonary hypertension,right ventricular hypertrophy or dysfunction of right heartLab findings:EKG;X-ray;UCG,et al.DiagnosisDifferential diagnosisCoronary heart disease Primary cardiomyopathy Rheumatic heart diseas
14、eCyanotic congenital heart diseaseCompensation stage Treatment of primary disease Eliminate the predisposing factors,avoid the acute exacerbation to restore the heart and lung function TreatmentDecompensation stage Treatment of respiratory failure Treatment of right heart failureTreatment Treatment
15、of respiratory failure lAntimicrobial treatmentlBronchodilators,expectorantslSputum aspiration,airway maintenance lOxygen therapylCorrect the acid-base and electrolyte imbalanceTreatment Treatment of right heart failurelOxygen therapy,infection control and the measures to improve respiratory functio
16、n can ameliorate the the symptoms of heart failure in most cases lAppropriate diuretics,cardiotonics and vasodilators can be chosen when the treatments mentioned above failsTreatmentTreatment of right heart failureDiuretics:Principle:Combine potassium-sparing diuretics and the diuretics that dischar
17、ges potassium;Low dosage,short period and intermittent use.Treatment of right heart failureCardiotonics:Principle:Low dosage,rapid effect and excreted(cedilanid,strophanthin K),correction of hypoxia and hypokalemia before use.Indications:Heart failure cant be improved after infection controled,respi
18、ratory function improved and diuretics used supraventricular tachyarrhythmia Right heart failure without acute infection Acute left heart failureTreatment of right heart failureVasodilators Dilates the pulmonary atery pressure of pulmonary atery load of the right heart improve the right heart functi
19、on Adverse effect:blood pressure,blood flow of coronary atery,ventilation/perfusion ratio hypoxemia Treatment of ComplicationsPulmonary encephalopathy Acid-base and electrolyte disturbance Arrhythmia：atrial premature contractions,paroxysmal supraventricular tachycardia,chaotic atrial tachycardia is the most specificShockGastrointestinal hemorrhageDIC谢谢！谢谢！
