【正文】 Heart Failure _ZhangQing Heart Failure 上海交通大學(xué)醫(yī)學(xué)院 附屬仁濟(jì)醫(yī)院心內(nèi)科 張 清 副教授 Heart Failure _ZhangQing ?Heart failure is the pathophysiological state in which the heart is unable to pump sufficient blood to satisfy the metabolic demands of the body with enough preload. Heart Failure _ZhangQing The Progressive Development of Cardiovascular Disease Endstage Heart Disease Congestive Heart Failure Ventricular Dilation Remodeling Arrhythmia amp。 Loss of Muscle Myocardial Infarction Myocardial Ischemia CAD Atherosclerosis Endothelial Dysfunction Risk Factors Coronary Thrombosis Heart Failure _ZhangQing For progressive duration ? Congestive heart failure is classified into acute and chronic heart failure ? Congestive heart failure is classified into left side, right side and biventricular heart failure For anatomical type Heart Failure _ZhangQing Heart Failure _ZhangQing Chronic heart failure Heart Failure _ZhangQing Causes Fundamental causes: ? impairment of myocardium, such as AMI,cardiomyopathy,myocarditis ? overloading of the heart, such as hypertension, aortic stenosis, mitral stenosis,emphysema,aortic insufficiency,mitral insufficiency,VSD,PDA,ASD. ? diminished LV pliance, such as ventricular hypertrophy Precipitating factors ? infection,especially pulmonary infection, fever ? physical,environmental,or emotional stress ? increased sodium load ? arrhythmia, ? pulmonary emboli ? pregnancy and delivery ? anemia,bleeding,excessive transfusion Heart Failure _ZhangQing Pathophysiology of heart failure ? Impaired myocardium ? ↓ ? Cardiac output ↓, heart failure ? ↓ ? Neurohumoral stimulation ? RAS and sympatheticadrenergic↑ ? ↓ ↓ ? Vasoconstriction increased heart rate ? Salt and water retention increased energy ? (augments preload) expenditure ? Hypertrophy ? ↓ ? Leads to deterioration and death of cardiac cell Heart Failure _ZhangQing Effects of Neurohormonal Stimulation in Heart Failure Heart ? Heart rate ? Contractility ? Stroke volume ? Cardiac output ? Conduction velocity ? Myocardial oxygen consumption Peripheral Circulation ? Arterial vasoconstriction ? Venoconstriction ? Systemic vascular resistance ? Redistribution of blood flow ? Renal vasoconstriction Heart Failure _ZhangQing Pathophysiology of Heart Failure: Left Ventricular Remodeling Leftventricular (LV) remodeling is defined as a change in LV geometry, mass and volume that occurs over a period of time Heart Failure _ZhangQing Heart Failure _ZhangQing Ventricular Remodeling: Compensatory Mechanism Dilation Hypertrophy ? Globular shape Short term: Compensatory Long term: Harmful Heart Failure _ZhangQing DETERMINANTS OF VENTRICULAR FUNCTION STROKE VOLUME PRELOAD CONTRACTILITY CARDIAC OUTPUT HEART RATE Synergistic LV contraction LV wall integrity Valvular petence AFTERLOAD Heart Failure _ZhangQing Vicious Cycle of Heart Failure Myocardial dysfunction Diminished Cardiac output Diminished renal blood flow Renin release Angiotensin II Aldosterone Increased Sympathetic Activity Vasoconstriction Increased force and rate of myocardial contraction Increased cardiac workload Renal retention of sodium and water Increased venous return Edema Heart Failure _ZhangQing Pathophysiology and Therapeutic Approaches to Heart Failure ?LV Function ?Cardiac Output Neurohormonal Activation Salt and Water Retention ?Peripheral vasoconstriction ?Blood flow Vasodialtors ACE Inhibitors Diuretics ACE Inhibitors 223。 Blockers Digoxin Heart Failure _ZhangQing Common Symptoms of Heart Failure ? Dyspnea on exertion ? Paroxysmal nocturnal dyspnea ? Orthopnea ? Fatigue ? Lower extremity edema ? Cough, usually worse at night ? Nausea, vomiting, anorexia, RUQ pain, ascites ? Nocturia ? Sleep disorders ? Increased abdominal girth Heart Failure _ZhangQing Common Physical Findings of Heart Failure ? Elevated jugular venous pressure ? Hepatojugular reflux ? Displaced apical impulse ? S3 gallop ? Pulmonary rales ? Hepatomegaly ? Peripheral edema ? Ascites Heart Failure _ZhangQing Clinical manifestation ? Left heart failure:SOB,cough,rales,gallop ? Right heart failure:gastrointestinal congestion,anorexia,nausea,a sense of fullness after meals,hepatojugular reflux,swelling of feet or ankles ? Low cardiac output:fatigue and weakness,oliguria ? Biventricular heart failure:both clinical manifestation of left and right heart failure,one of which maybe predominant. Heart Failure _ZhangQing Functional Classification ? A classification of patients with heart disease based on the relation between symptoms and the amount of effort required to provoke them has been developed by the New York Heart Association. Heart Failure _ZhangQing ? Class 1No limitation Ordinary physical activity does not cause undue fatigue,dyspnea,or palpitation ? Class 2Slight limitation of physical activity Such patients are fortable at physical activity results in fatigue,palpitation,dyspnea,or angina Heart Failure _ZhangQing ? Class 3Marked limitation of physical activity Although patients are fortable at rest,less than ordinary activity will lead to symptoms. ? Class 4Inability to carry on any physical activity Symptoms of congestive failure are present even at any physical activity,increased disfort is experienced. Heart Failure _ZhangQing Heart Failure _ZhangQing Complication ? Pulmonary em