1 heart failure. 2 definition heart failure –the pathophysiological state in which the heart is...
TRANSCRIPT
2
DEFINITION
• HEART FAILURE – the pathophysiological state in which the heart is
unable to pump blood at a rate commensurate with the requirement of the metabolizing tissues or can do so only from an elevated filling pressure.
– Usually caused by a defect in myocardial contraction (myocardial failure).
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DEFINITION
• CONGESTIVE HEART FAILURE– Clinical manifested as
• Pulmonary congestion• Systemic congestion• Inadequate tissure blood perfusion
• HEMODYNAMICALLY heart failure (cardiac dysfunction) is diagnosed when – LVEDP>18mmHg or– RVEDP>10mmHg
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UNDERLYING CAUSES
• Primary myocardial dysfunction (systolic and/or diastolic)– Cardiomyopathy
– Primary or secondary metabolic disturbances of myocardium
• Overloading of heart – Pressure overloading
– Volume overloading
– limited diastolic function
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UNDERLYING CAUSES
Age Age 70.3±10.1 yr.70.3±10.1 yr.
Causes CHDCauses CHD 65.8% 65.8%
Hypertension 36.0%Hypertension 36.0%
Dila. Cardiomy. 11.9%Dila. Cardiomy. 11.9%
With 2°DM 14.9%With 2°DM 14.9%
Shanghai OPD, Shanghai OPD, Chin J Cardiol 2001;29:6442001;29:644
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Precipitating factors
• infection
• arrhythmias
• Pulmonary embolism
• overfatigue
• Pregnancy and delivery
• Anemia and hemorrhage
• others
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Pathophysiology
• Frank-Starling mechanism
• Activation of neurohormonal pathway (SAS and RAS)
• Myocardial damage and remodeling
• Diasatolic heart failure
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CLINICAL CLASSIFICATION
• A cute vs. chronic heart failure
• Right-sided vs. left-sided Heart failure
• Low-output vs high-output heart failure
• Systolic vs diastolic heart failure
• Asymptomatic vs congestive heart failure
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Chronic left-sided HF :symptoms
Respiratory distress Exertional dyspnea Paroxysmal nocturnal dyspnea Orthopnea Acute pumnonary edema Cough (nonproductive), and hemoptysis
Reduced exercise capacityFatigue and weaknessUrinary symptoms
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Chron. left-sided HF : Physi. findings
General appearance
Dyspnetic
Cyanosis, icterus, malar flush, diminished pulse pressure, reduced SBP, rapid, weak and thready pulse in severe HF
Evidence of ↑adrenergic activity
Peripheral vasoconstriction (pallor, coldness of extremities and cyanosis of the digits ).
Diaphoresis with sinus tachycardia
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Chron. left-sided HF : Physi. finding
Cardiac findings
Cardiomegaly
S3 gallops
Accentuation of P2
Systolic murmur
Pulsus alternans
Pulmonary rales
Moist rales over
the lung bases
Rhonchi wheezes
↓BS
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Chron. right-sided HF : symptoms
•Gastrointestinal symptoms •Symtoms of urinary system •Dull ache in right upper quadrant. •dyspnea
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Chron. right-sided HF : Physi. finding
• Cardiac findings
• Hepatojugular reflux
• Congetive hepatomegaly or tenderness
• Edema
• Hydrothorax and ascites• Others (cyanosis, and etc.)
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Chronic HF : labolaroty findings
• Routine lab. And serum electrolytes & liver function tests
• ECG • Echocardiography • Chest Roentgenogram
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ECG
• Suggesting basic presence of basic heart diseases
• Atrial and ventricular hypertrophy, myocardial ischemia or infarction , arrhythmia
• V1ptf <- 0.03mm / s , indicating left atrial overloading.
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Echocardiogram
• M mode, 2D echo and Dopler technique for systolic and diastolic function of LV
– LVDd and LVDs ( Dd and Ds )– LV fraction of shortening (△ D % =( Dd - Ds )/ Dd × 100 %)– mVCF =( Dd - Ds )/ Dd × LVET – SV– LVEF
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Chest X ray
Left-sided heart failure cardiomegaly (cardiothorax ratio > 50%) dilated pulmonary vein
pulmonary infiltrates.
prominent bronchovascular markings
Interstitial edema, Kerley.s B line, alveolar edema, pleural effusion when PCWP > 25 ~ 30mmHg.
Right-sided HFCardiomegaly
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Invasive hemodynamic monitoring
•Using Swan-Ganz cather and thermodilution method for measurement of– Intracardiac and vascular pre
ssure–Cardiac output
to asses cardiac function
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Invasive hemodynamic monitoring
• CVP (中心静脉压) 6 ~ 12cmH2O
• PAP (肺动脉压) 12 ~ 30/4 ~ l3mmHg
• PCWP (肺毛细血管楔嵌压) 6 ~ 12mmHg
• SV (心搏量) 60 ~ 70ml
• SI (心搏指数) 4l ~ 51ml/m2
• CO (心排血量) 5 ~ 6L/min
• CI (心排指数) 2.6 ~ 4.0L/min.m2
• EF (射血分数) 0.5 ~ 0.6
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Functional classification( NYHA)
• Class I-No limitation: Ordinary physical activity does not cause undue fatigue, dyspnea, or palpitation
• Class II-slight limitation of physical activity: Such patients are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or angina.
• Class III-marked limitation of physical activity: although patients are comfortable at rest, less than ordinary activity will lead to symptoms.
• Class IV-inability to carry on any physical activity without discomfort: symptoms of congestive failure are present even at rest.With any physical activity, increased discomfort is experience.
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Chronic HF : diff. diagnosis
Left-sided HF
With pulmonary dyspnea: COPD,asthma Metabolic acidosisCardiac neurosis
Right-sided HFPricarditis
Hepatic, renal edema.
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Functional classification( NYHA)
• Class I-No limitation: Ordinary physical activity does not cause undue fatigue, dyspnea, or palpitation
• Class II-slight limitation of physical activity: Such patients are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or angina.
• Class III-marked limitation of physical activity: although patients are comfortable at rest, less than ordinary activity will lead to symptoms.
• Class IV-inability to carry on any physical activity without discomfort: symptoms of congestive failure are present even at rest.With any physical activity, increased discomfort is experience.
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Chronic HF : diff. diagnosis
Left-sided HF
With pulmonary dyspnea: COPD, asthma Metabolic acidosis Cardiac neurosis
Right-sided HF Pricarditis Hepatic, renal edema.
Survival
Morbidity
Exercise capacity
Quality of life
Neurohormonal changes
Progression of CHF
Symptoms
TREATMENT OBJECTIVES
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Chronic HF: treatment
Reducing loadRest and tranquilizer
Control salt intake
Water intake
diuretics
Vasodilators
Improve CO digitalis non-digitalis posit
ive inotropic agents aldost. antagonist β-bloker
correcting PF and cause of HF
diastolic HF dificult HF cases
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Diuretics
ThiazidesHydrochlorothiazide
Potassium-sparing diureticsSpironolactone
amiloride
Loop diureticsFrusemide
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Vasodilators
Nitrates
Nitroglycerine
Isosorbide dinitrate
Mononitrates
Nitroprusside
ACE inhibitor
ARB (Angiotensin receptor blocker)
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Acute heart failure
• Definition
• Etioloogy and mechanism
• Clinical picture
• Diagnosis
• treatment