Heartfailure1

DEFINITIONHEARTFAILURE

thepathophysiologicalstateinwhichtheheartisunabletopumpbloodataratecommensuratewiththerequirementofthemetabolizingtissuesorcandosoonlyfromanelevatedfillingpressure.

Usuallycausedbyadefectinmyocardialcontraction(myocardialfailure).2 DEFINITIONCONGESTIVEHEARTFAILUREClinicalmanifestedasPulmonarycongestionSystemiccongestionInadequatetissurebloodperfusionHEMODYNAMICALLYheartfailure(cardiacdysfunction)isdiagnosedwhenLVEDP>18mmHgorRVEDP>10mmHg3UNDERLYINGCAUSES

Primarymyocardialdysfunction(systolicand/ordiastolic)CardiomyopathyPrimaryorsecondarymetabolicdisturbancesofmyocardiumOverloadingofheartPressureoverloadingVolumeoverloadinglimiteddiastolicfunction4UNDERLYINGCAUSESAge70.3±10.1yr.CausesCHD65.8%Hypertension36.0%

Dila.Cardiomy.11.9%With2°DM14.9%ShanghaiOPD,ChinJCardiol

2001;29:6445Precipitatingfactors

infectionarrhythmiasPulmonaryembolismoverfatiguePregnancyanddeliveryAnemiaandhemorrhageothers6PathophysiologyFrank-StarlingmechanismActivationofneurohormonalpathway(SASandRAS)MyocardialdamageandremodelingDiasatolicheartfailure7

“8CLINICALCLASSIFICATIONAcutevs.chronicheartfailureRight-sidedvs.left-sidedHeartfailureLow-outputvshigh-outputheartfailureSystolicvsdiastolicheartfailureAsymptomaticvscongestiveheartfailure9

Chronicleft-sidedHF：symptoms

Respiratorydistress

Exertionaldyspnea

ParoxysmalnocturnaldyspneaOrthopnea

Acutepumnonaryedema

Cough(nonproductive),andhemoptysisReducedexercisecapacityFatigueandweaknessUrinarysymptoms10Chron.left-sidedHF：Physi.findingsGeneralappearanceDyspneticCyanosis,icterus,malarflush,diminishedpulsepressure,reducedSBP,rapid,weakandthreadypulseinsevereHFEvidenceof↑adrenergicactivityPeripheralvasoconstriction(pallor,coldnessofextremitiesandcyanosisofthedigits).Diaphoresiswithsinustachycardia11Chron.left-sidedHF：Physi.findingCardiacfindingsCardiomegalyS3gallopsAccentuationofP2SystolicmurmurPulsus

alternansPulmonaryralesMoistralesoverthelungbasesRhonchiwheezes↓BS12Chron.right-sidedHF：symptomsGastrointestinalsymptomsSymtomsofurinarysystemDullacheinrightupperquadrant.dyspnea

13Chron.right-sidedHF：Physi.findingCardiacfindingsHepatojugularreflux

Congetive

hepatomegalyortenderness

Edema

HydrothoraxandascitesOthers(cyanosis,andetc.)14ChronicHF：labolarotyfindingsRoutinelab.Andserumelectrolytes&liverfunctiontestsECGEchocardiographyChestRoentgenogram15ECGSuggestingbasicpresenceofbasicheartdiseasesAtrialandventricularhypertrophy,myocardialischemiaorinfarction,arrhythmiaV1ptf＜－0.03mm／s，indicatingleftatrialoverloading.16EchocardiogramMmode,2DechoandDoplertechniqueforsystolicanddiastolicfunctionofLVLVDdandLVDs（Ddand

Ds）LVfractionofshortening（△D％＝（Dd-Ds）／Dd

×100％）mVCF＝（Dd-Ds）／Dd×LVETSVLVEF17ChestXrayLeft-sidedheartfailure

cardiomegaly(cardiothoraxratio＞50%)dilatedpulmonaryveinpulmonaryinfiltrates.prominentbronchovascularmarkingsInterstitialedema,Kerley.sBline,alveolaredema,pleuraleffusionwhenPCWP＞25～30mmHg.Right-sidedHFCardiomegaly1819InvasivehemodynamicmonitoringUsingSwan-Ganz

catherandthermodilutionmethodformeasurementofIntracardiacandvascularpressureCardiacoutputtoassescardiacfunction20InvasivehemodynamicmonitoringCVP（中心靜脈壓）6～12cmH2OPAP（肺動(dòng)脈壓）12～30/4～l3mmHgPCWP（肺毛細(xì)血管楔嵌壓）6～12mmHg

SV（心搏量）60～70mlSI（心搏指數(shù)）4l～51ml/m2

CO（心排血量）5～6L/minCI（心排指數(shù)）2.6～4.0L/min.m2

EF（射血分?jǐn)?shù)）0.5～0.6

21ChronicHF：diagnosis

causesanatomypathologyarrhythmiaFunctionalclassification22Functionalclassification（NYHA)ClassI-Nolimitation:Ordinaryphysicalactivitydoesnotcauseunduefatigue,dyspnea,orpalpitationClassII-slightlimitationofphysicalactivity:

Suchpatientsarecomfortableatrest.Ordinaryphysicalactivityresultsinfatigue,palpitation,dyspnea,orangina.ClassIII-markedlimitationofphysicalactivity:althoughpatientsarecomfortableatrest,lessthanordinaryactivitywillleadtosymptoms.ClassIV-inabilitytocarryonanyphysicalactivitywithoutdiscomfort:symptomsofcongestivefailurearepresentevenatrest.Withanyphysicalactivity,increaseddiscomfortisexperience.23ChronicHF：diff.diagnosisLeft-sidedHF

Withpulmonarydyspnea:COPD,asthma

MetabolicacidosisCardiacneurosisRight-sidedHFPricarditisHepatic,renaledema.24Functionalclassification（NYHA)ClassI-Nolimitation:Ordinaryphysicalactivitydoesnotcauseunduefatigue,dyspnea,orpalpitationClassII-slightlimitationofphysicalactivity:

Suchpatientsarecomfortableatrest.Ordinaryphysicalactivityresultsinfatigue,palpitation,dyspnea,orangina.ClassIII-markedlimitationofphysicalactivity:

althoughpatientsarecomfortableatrest,lessthanordinaryactivitywillleadtosymptoms.ClassIV-inabilitytocarryonanyphysicalactivitywithoutdiscomfort:

symptomsofcongestivefailurearepresentevenatrest.Withanyphysicalactivity,increaseddiscomfortisexperience.25ChronicHF：diff.diagnosisLeft-sidedHF

Withpulmonarydyspnea:COPD,asthmaMetabolicacidosisCardiacneurosisRight-sidedHF

Pricarditis

Hepatic,renaledema.26

Survival Morbidity Exercisecapacity Qualityoflife

Neurohormonalchanges ProgressionofCHF SymptomsTREATMENTOB