教学课件 心力衰竭VIP免费

HeartFailureXiaojuanBai7yearsprogramofChinaMedicalUniversityObjective:1.Masteringclinicalmanifestation,diagnosisandmanagementofheartfailure2.Graspingcauses,pathophysiologyofheartfailure3.Understandingclassificationandinvestigationofheartfailure1.generalconcept1)causesofheartfailure2)precipitating/aggravatingfactors3)pathophysiology4)typeofheartfailure2.chronicandacuteheartfailure1)clinicalmanifestation2)investigation3)diagnosisanddifferentialdiagnosis4)managementContentHeartfailureisanimprecisetermusedtodescribethestatethatdevelopswhentheheartcannotmaintainanadequatecardiacoutputorcandosoonlyattheexpenseofanelevatedfillingpressure.Definition•pulmonarycongestion,•systemicvenouscongestion,•tissueperfusiondeficiencyduetolowcardiacoutput.ClinicalFeaturesleftventricularend-diastolicpressure>18mmHg,rightventricularend-diastolicpressure>10mmHg,heartfailure=cardiacinsuffiency.HemodynamicFeaturesCausesofheartfailure1.Reducedventricularcontractilitya.Cardiomyopathy,myocardialinfarction.b.Metabolicdysfunction2.ventricularoverloada.pressureoverload----hypertension,aorticstenosis,pulmonaryhypertension,pulmonaryvalvestenosis.b.volumeoverload----mitralregurgitation,aorticregurgitation,atrialseptaldefect,ventricularsepalsdefect,hyperthyroidism,artery-venousfistula.c.ventricularinflowobstruction----hypertrophy,mitralstenosis,tricuspidstenosis,restrictivecardiomyopathy,constrictivepericarditis.endocardialfibrosisandotherdisordersthatcauseastiffmyocardium.Precipitating/aggravatingfactors•myocardialischemiaorinfarction•infection•arrhythmia•pulmonaryembolism•exertion•pregnancyandparturition•anemia•intravenousfluidoverload,electrolytedisturbance,acid-baseimbalancePathophysiology•1.Frank-Starling’sLawofthehearta.Thecardiacoutputisafunctionofthepreload,theafterload,andmyocardialcontractility.b.Preload:thevolumeandpressureofbloodintheventricleattheendofdiastole.c.Afterload:thearterialresistance.1正常静息2正常活动3’心衰活动3心衰静息心肌收缩性BADC左室舒张末容量图3–2–1正常和心力衰竭时对机体活动时的代偿情况最大活动活动静息左室作功呼吸困难肺水肿E4静息致死性心肌受损心肌细胞死亡心力衰竭心肌细胞死亡++↑心肌能量消耗↑后负荷血管收缩↓心排血量神经体液兴奋RASSASInSP3循环↑心肌能量消耗↑胞浆Ca2+cAMPInSP3心脏↓心肌松弛性↑变力效应+－—心律失常猝死图3–2–2肾素—血管紧张素和交感—肾上腺素能系统激活时对心脏代偿功能的影响2.RAASinHeartFailure•2.RAASinHeartFailure•3.myocardiumimpairedandremodelinginitialmyocardiumimpairedventricularoverloadmyocardiuminfarctioninflammationdiseaseprogressheartfailurecomplicationdeathchamberenlargementmyocardialhypertrophyembryogenephenotypeextracellularmatrixchange•secondaryconductfactor•sympatheticnervoussystem•RAAS•endothelins•TNF-α,IL-6•mechanicalstress•oxidativestress•4.DiastolicheartfailureHeartfailuremaydevelopasaresultofpoorventricularfillingandhighfillingpressurecausedbyabnormalventricularrelaxation顺应性↓顺应性↑正常压力图3–2–4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–容积曲线向左上方移位，即在任何特定的舒张末期压时，心室末期容量小于正常人。容积a.sarcoplasmicreticulumintakeCa2+freeCa2+inmyocytedegradeslowlyb.InCHDwithobviousischemia,beforecontractilitydysfunction,haveoccurredrelaxationdysfunctionc.Inhypertrophyandhypertrophiccardiomyopathy,leftventricularend-diastolicfillingpressurepulmonaryhypertension,pulmon...