重癥心衰治療指南與臨床實(shí)踐課件

重癥心衰治療指南與臨床實(shí)踐重癥心衰治療指南與臨床實(shí)踐指南與臨床實(shí)踐的關(guān)系Evidence-BasedMedicineProblem-BasedMedicine指南與臨床實(shí)踐的關(guān)系Evidence-BasedMedic心臟重癥特點(diǎn)1.心衰合并多器官功能衰竭，心、肺、腎2.心衰心臟受損嚴(yán)重為突出表現(xiàn)，大面積心梗，

心臟手術(shù)，重癥心肌炎3.心衰特殊原因，少見，特別是一些新的藥品，

器械心臟重癥特點(diǎn)重癥心衰治療指南與臨床實(shí)踐課件Yourheartisanamazingpowerhousethatpumpsandcirculates5or6gallonsofbloodeachminutethroughyourentirebody.YourheartisanamazingpowerUnderstandinghowtheheartworksTounderstandheartdisease,youmustfirstknowhowtheheartworks.Theheartislikeanyothermuscle,requiringbloodtosupplyoxygenandnutrientsforittofunction.Itbeatsabout100,000timesaday,pumpingbloodthroughyourcirculatorysystem.Thecycleofpumpingbloodthroughoutyourbodycarriesfreshoxygentoyourlungsandnutrientstoyourbody'stissues.Bloodalsotakeswaste,suchascarbondioxide,awayfromyourtissues,.Withoutthisprocess,wecouldnotlive.UnderstandinghowtheheartwoHeartdisease:thenumber-onekillerHeartdiseaseaffectsabout14millionmenandwomenintheUnitedStates,andithasahighmortalityrateHeartdisease:thenumber-oneOneofthemostdevastatingconsequencesofheartdiseasecanbesuddencardiacarrest.OneofthemostdevastatingcoBlockageofthecoronaryarteriesbyplaquemaycauseaheartattack(myocardialinfarction)orafatalrhythmdisturbance(suddencardiacarrest).BlockageofthecoronaryarterSuddencardiacdeath-afatalconsequenceofheartdiseaseEveryone'sexperiencewithheartdiseaseisdifferent.Somepeopleexperienceshortnessofbreathorchestpainandmakeittothehospitalintimetobetreated.Othersarenotaslucky.Forsomepeople,suddencardiacarrestcanbethefirstsymptomtheyexperience,anditisoftendeadlyunlesstreatedimmediately.Suddencardiacdeath-afatalBesideschestpain(angina)andshortnessofbreath,someothercommonsymptomsofheartdiseaseincludejawpain,backpain,andheartpalpitations.Besideschestpain(angina)anWhatarecommonsymptomsofheartdisease?Symptomsofheartdiseaseusuallyoccurduringexerciseoractivity.That'sbecausetheheartexperiencesincreaseddemandfornutrientsandoxygenthatcannotbemetbecausethecoronaryarteriesareblocked.Othersymptomsofheartdiseaseincludechestpain(angina),shortnessofbreath,jawpain,andbackpain,especiallyontheleftside.WhatarecommonsymptomsofheDoctorsuseavarietyofteststodetectheartdisease.Onecommontestistheelectrocardiogram(ECGorEKG).DoctorsuseavarietyoftestsWhatisanelectrocardiogram(EKG)?Ahealthyheartworksasan"electricalpump"andneedsastrongbloodsupplytoconductelectricity.Peoplewithheartdisease,however,haveaweakbloodsupply,sotheirheartsconductelectricitypoorly.Anelectrocardiogram(EKG)isanoninvasivetestthatmeasurestheelectricalactivityoftheheart.AnEKGtakesapproximatelyfiveminutesandispainless.ManyotherheartconditionscanbediagnosedwithanEKG,forexampleabnormalheartrhythms,evidenceofpriorheartattack,evidenceofanevolvingheartattack,unstableangina,congenitalheartabnormalities,evidenceofabnormalbloodelectrolytes,andevidenceofinflammationoftheheart(myocarditis,pericarditis).Whatisanelectrocardiogram(Sometimes,ifanelectrocardiogramcomesbacknormal,doctorswillusestressteststodetectheartdisease.Sometimes,ifanelectrocardioAnothertestoptionisechocardiography,whichusessoundwavestogenerateimagesoftheheart.AnothertestoptionisechocarComputerizedtomography(CT)scansareusedtoshowthatheartdiseaseisnotpresentandthatthecoronaryarteriesarenormal.Computerizedtomography(CT)sCoronaryangiographyviacardiaccatheterizationisconsideredthe"goldstandard"ofheartdiseasetests.CoronaryangiographyviacardiHeartdiseasetreatmentisdifferentforeveryone.HeartdiseasetreatmentisdifForsomepatientswithheartdisease,medicationsmaybenecessary.ForsomepatientswithheartdWhenmedicationsaren'tenough,sometimesinvasiveproceduresareusedtohelptreatheartdisease.Whenmedicationsaren'tenoughHeartdiseaseisahighlypreventableandreversibledisease.Ahealthydietisamajorfactorincontrollingheartdisease.HeartdiseaseisahighlyprevOtherlifestylechangesthatcanbemadetohelppreventheartdiseaseincludedrinkingalcoholinmoderationandquittingsmoking.OtherlifestylechangesthatcExercise,controllinghighbloodpressureanddiabetes,andtakingdailyaspirinaremorewaystoreduceyourchancesofdevelopingheartdisease.Exercise,controllinghighblo

心臟重癥病房的治療手段進(jìn)展3.1

呼吸機(jī)輔助通氣

3.2

腎臟替代治療

3.3

主動(dòng)脈內(nèi)球囊反搏術(shù)(IABP)和左心輔助裝置(LVAD)3.4

ECMO（體外膜肺氧合）

心臟重癥病房的治療手段進(jìn)展3.1

呼吸機(jī)輔助通氣

在國外，特別是歐美發(fā)達(dá)國家，心臟重癥醫(yī)學(xué)的誕生起源于心肺復(fù)蘇術(shù)的開始，要早于真正的綜合性ICU的建立。從1962年開始，MelterHe和Day分別創(chuàng)立冠心病監(jiān)護(hù)病房，從此心臟重癥醫(yī)學(xué)在世界發(fā)達(dá)國家特別是歐美地區(qū)迅速發(fā)展，以CCU或CICU為代表的心臟重癥監(jiān)護(hù)病房已經(jīng)成為心臟醫(yī)療中心中不可缺少的組成部分，代表了一家中心的心臟醫(yī)療水平，救治水平和管理水平，更與醫(yī)療單位或中心的現(xiàn)代化水平掛鉤在國外，特別是歐美發(fā)達(dá)國家，心臟重癥醫(yī)學(xué)的誕生起源于心肺復(fù)蘇定義心力衰竭是由于任何心臟結(jié)構(gòu)或功能異常導(dǎo)致心室充盈或射血功能受損的一組臨床綜合征，其主要臨床表現(xiàn)為呼吸困難和乏力（活動(dòng)耐量受限），以及液體潴留（肺淤血和外周水腫）。心衰為各種心臟疾病的眼中和終末階段，發(fā)病率高，是當(dāng)今最重要的心血管病之一。定義心力衰竭是由于任何心臟結(jié)構(gòu)或功能異常導(dǎo)致心室充盈或重癥心衰治療指南與臨床實(shí)踐課件重癥心衰治療指南與臨床實(shí)踐課件心衰發(fā)展分為4個(gè)階段根據(jù)心衰發(fā)生發(fā)展的過程，從心衰的危險(xiǎn)因素進(jìn)展成結(jié)構(gòu)性心臟病，出現(xiàn)心衰癥狀，直至難治性終末期心衰,可分成4個(gè)階段。前心衰(A)前臨床心衰(B)臨床心衰(C)難治性終末期心衰(D)這4個(gè)階段不同于紐約心臟協(xié)會(huì)(NYHA)的心功能分級。心衰階段的劃分正是體現(xiàn)了重在預(yù)防的概念，其中預(yù)防患者從階段A進(jìn)展至階段B，即防止發(fā)生結(jié)構(gòu)性心臟病，以及預(yù)防從階段B進(jìn)展至階段C,以至于進(jìn)展到D階段。心衰發(fā)展分為4個(gè)階段根據(jù)心衰發(fā)生發(fā)展的過程，從心衰的危險(xiǎn)因素重癥心衰治療指南與臨床實(shí)踐課件重癥心衰治療指南與臨床實(shí)踐課件依據(jù)左室射血分?jǐn)?shù)(LVEF),心衰可分為LVEF降低的心衰(heartfailurereducedleftventricularejectionfraction,HF-REF)

LVEF保留的心衰(heartfailurewithpreservedleftventricularejectionfraction,HF-PEF).LVEF是心衰患者分類的重要指標(biāo)，也與預(yù)后及治療反應(yīng)相關(guān)。LVEF保留或正常的情況下收縮功能仍可能是異常的。依據(jù)左室射血分?jǐn)?shù)(LVEF),心衰可分為重癥心衰治療指南與臨床實(shí)踐課件CASE1女性，83歲反復(fù)活動(dòng)后氣喘5年，加重1月5年來反復(fù)活動(dòng)后氣喘，發(fā)作時(shí)端坐呼吸，咳白色泡沫樣痰，夜間陣發(fā)性加劇，經(jīng)治療后好轉(zhuǎn)。近1月來癥狀加劇，不能平臥，雙下肢浮腫。既往有高血壓病，糖尿病病史20多年。CASE1女性，83歲入院肺部CT掃描入院肺部CT掃描重癥心衰治療指南與臨床實(shí)踐課件重癥心衰治療指南與臨床實(shí)踐課件重癥心衰治療指南與臨床實(shí)踐課件入院診斷，心功能衰竭，心功能IV級。肺部感染

冠狀動(dòng)脈粥樣硬化性心臟病，急性冠脈綜合癥高血壓病糖尿病入院診斷，入院后治療方案抗感染糾正心衰（強(qiáng)心、利尿、擴(kuò)血管）治療后癥狀改善，但反復(fù)發(fā)作入院后治療方案抗感染重癥心衰治療指南與臨床實(shí)踐課件左室內(nèi)徑在正常上限，室壁未見增厚，心腔形態(tài)失常、心尖部圓鈍，前壁、室間隔中段以下及整個(gè)心尖部運(yùn)動(dòng)減弱或無運(yùn)動(dòng)，余室壁運(yùn)動(dòng)未見明顯異常，整體收縮不協(xié)調(diào)；二維法LVEF30％。

右心大小正常，室壁運(yùn)動(dòng)未見明顯異常

估計(jì)肺動(dòng)脈收縮壓至少57-62mmHg；左室內(nèi)徑在正常上限，室壁未見增厚，心腔形態(tài)失常、心尖部圓鈍，重癥心衰治療指南與臨床實(shí)踐課件重癥心衰治療指南與臨床實(shí)踐課件討論病人下一步治療方案病人冠心病，引起心衰，繼發(fā)肺部感染，明確。但病人83歲，年齡大，不能平臥，是否因該P(yáng)CI。PCI的風(fēng)險(xiǎn)：病人不能耐受手術(shù)，手術(shù)風(fēng)險(xiǎn)大。討論病人下一步治療方案重癥心衰治療指南與臨床實(shí)踐課件重癥心衰治療指南與臨床實(shí)踐課件重癥心衰治療指南與臨床實(shí)踐課件重癥心衰治療指南與臨床實(shí)踐課件重癥心衰治療指南與臨床實(shí)踐課件

Someoftheriskfactorsforheartdiseaseincludesmoking,highbloodpressure,highcholesterol,diabetes,andobesity

SomeoftheriskfactorsforWhataretheriskfactorsforheartdisease?Someofthecommonriskfactorsforheartdiseaseincludesmoking,highbloodpressure(hypertension),highcholesterol,diabetes,familyhistoryofheartdisease,peripheralarterydisease,andobesity.

WhataretheriskfactorsforAdditionalheartdiseaseriskfactorsincludelackofexercise,anunhealthydiet,stress,anda"typeA"personalityAdditionalheartdiseaseriskWhatarelifestyleriskfactorsforheartdisease?Lifestyleriskfactorsthatcontributetoheartdiseaseincludelackofexercise,high-fatdiet,emotionalstress,andhavinga"typeA"personality(aggressive,impatient,competitive).WhatarelifestyleriskfactorCASE2男性，30歲胸悶，氣喘，浮腫1月，加劇1周既往無高血壓病，糖尿病病史個(gè)人史：煙，20-40支/天X10年，

酒，白酒6-7兩/次X4-5次/周X5-6年每天3-4餐職業(yè)：刑警大隊(duì)隊(duì)長。CASE2男性，30歲體格檢查BP192/116mmHgHR106bpmIBM40.1（Height170cm，WT116kg）急性痛苦病容，端坐呼吸，雙肺滿布濕性羅音，哮鳴音。下肢可凹水腫。體格檢查BP192/116mmHgEchocardiogramEchocardiogram重癥心衰治療指南與臨床實(shí)踐課件ComputedTomographyofChestComputedTomographyofChestElectriocardiogramElectriocardiogram入院診斷1.擴(kuò)張型心肌病(原發(fā)性、酒精性、缺血性、心律失常，肥胖型）？心律失常快速性心房撲動(dòng)

肺部感染胸腔積液，心包積液左心室內(nèi)占位性病變（血栓、粘液瘤）2.肥胖3.高血壓病。入院診斷1.擴(kuò)張型心肌病治療策略1.保守藥物治療

降壓，，利尿，抗菌素，低分子肝素鈣，呼吸機(jī)，倍他樂克，23.75mgQD2.介入，冠脈造影3.心臟移植治療策略1.保守藥物治療左心室附壁血栓左室附壁血栓的形成多是繼發(fā)于急性心梗之后，是急性心梗的常見并發(fā)癥之一。附壁血栓形成后反過來引起急性心梗的可能很小，主要是可能會(huì)出現(xiàn)血栓的脫落，從而出現(xiàn)體循環(huán)動(dòng)脈栓塞的可能性加大，最常見的栓塞部位就是腦。所以目前的主要矛盾并不是并發(fā)心梗的風(fēng)險(xiǎn)，而是并發(fā)腦栓塞的風(fēng)險(xiǎn)較大.左心室附壁血栓左室附壁血栓的形成多是繼發(fā)于急性心梗之后，是急重癥心衰治療指南與臨床實(shí)踐課件重癥心衰治療指南與臨床實(shí)踐課件討論病人通過正規(guī)的心衰藥物治療，以及抗菌素，低分子肝素鈣的治療，病人癥狀改善不明顯，BP130-140/90-100mmHgWeight108kg.房撲射頻消融術(shù)？討論病人通過正規(guī)的心衰藥物治療，以及抗菌素，低分子肝素鈣的治重癥心衰治療指南與臨床實(shí)踐課件控制體重措施每日三餐，2兩/餐兩個(gè)月體重11682kg。病人呼吸困難癥狀明顯改善，UCG提示EF從18%增加到30%左心室血栓消失。下肢水腫消失。心電圖仍然房撲。病人出院，門診隨訪。控制體重措施每日三餐，2兩/餐重癥心衰治療指南與臨床實(shí)踐課件靜息心肌灌注顯像：左室心腔明顯擴(kuò)大，后壁心肌血流灌注輕度減低。靜息心肌灌注顯像：左室心腔明顯擴(kuò)大，后壁心肌血流灌注輕度減低重癥心衰治療指南與臨床實(shí)踐課件重癥心衰治療指南與臨床實(shí)踐課件隨訪6個(gè)月后病人一般情況穩(wěn)定，無心悸胸悶，氣喘等癥狀，已經(jīng)開始正常工作。隨訪6個(gè)月后病人一般情況穩(wěn)定，無心悸胸悶，氣喘等癥狀，已經(jīng)開思考病人的主要病因是肥胖，因此控制體重是主要的，開始階段對體重控制沒有重視，病人癥狀控制不好，癥狀反復(fù)，從控制體重開始，病情逐步好轉(zhuǎn)并趨于穩(wěn)定。在之后的隨訪過程中，繼續(xù)控制體重，心臟結(jié)構(gòu)與功能明顯好轉(zhuǎn)。房撲轉(zhuǎn)為竇律。說明，對于肥胖型心肌病的治療，預(yù)后要比原發(fā)性擴(kuò)張型心肌病要好。思考病人的主要病因是肥胖，因此控制體重是主要的，開始階段對體重癥心衰治療指南與臨床實(shí)踐課件ShouldWeTargetObesityinAdvancedHeartFailure?Obesityisariskfactorforthedevelopmentofheartfailure(HF),buthasbeenassociatedwithimprovedsurvivalinpatientswithestablishedHF.ShouldWeTargetObesityinAdMorbidlyobeseindividuals(BMI≥40kg/m2)aged<50yearswithseverelydepressedsystolicfunctionandNYHAclassIII-IVsymptomsshouldbeconsideredformalabsorptivebariatricsurgeryatanexperiencedcenter.Morbidlyobeseindividuals(BMTranslRes.

2014Apr18.

Obesity

andheartfailure:epidemiology,pathophysiology,clinicalmanifestations,andmanagement.Obesity

isariskfactorforheartfailure(HF)inbothmenandwomen.Severe

obesityproduceshemodynamicalterationsthatpredisposetochangesincardiacmorphologyandventricularfunction,as

obesity

cardiomyopathy.Substantialweightlossinseverelyobesepersonsiscapableofreversingmost

obesity-relatedabnormalitiesofcardiacperformanceandmorphologyandimprovingtheclinicalmanifestationsof

obesitycardiomyopathy.TranslRes.

2014Apr18.

ObesiFollow-up

for7monthslaterFollow-upfor7monthslater重癥心衰治療指南與臨床實(shí)踐課件小結(jié)1.如何從復(fù)雜的病情中找出清晰的思路2.病因治療始終都是心臟重癥的根本3.多器官功能衰竭，一定不能忽視萬惡之源的尋找4.指南要靈活運(yùn)用5.心衰的治療一定要考慮病人預(yù)后小結(jié)1.如何從復(fù)雜的病情中找出清晰的思路重癥心衰治療指南與臨床實(shí)踐重癥心衰治療指南與臨床實(shí)踐指南與臨床實(shí)踐的關(guān)系Evidence-BasedMedicineProblem-BasedMedicine指南與臨床實(shí)踐的關(guān)系Evidence-BasedMedic心臟重癥特點(diǎn)1.心衰合并多器官功能衰竭，心、肺、腎2.心衰心臟受損嚴(yán)重為突出表現(xiàn)，大面積心梗，

心臟手術(shù)，重癥心肌炎3.心衰特殊原因，少見，特別是一些新的藥品，

器械心臟重癥特點(diǎn)重癥心衰治療指南與臨床實(shí)踐課件Yourheartisanamazingpowerhousethatpumpsandcirculates5or6gallonsofbloodeachminutethroughyourentirebody.YourheartisanamazingpowerUnderstandinghowtheheartworksTounderstandheartdisease,youmustfirstknowhowtheheartworks.Theheartislikeanyothermuscle,requiringbloodtosupplyoxygenandnutrientsforittofunction.Itbeatsabout100,000timesaday,pumpingbloodthroughyourcirculatorysystem.Thecycleofpumpingbloodthroughoutyourbodycarriesfreshoxygentoyourlungsandnutrientstoyourbody'stissues.Bloodalsotakeswaste,suchascarbondioxide,awayfromyourtissues,.Withoutthisprocess,wecouldnotlive.UnderstandinghowtheheartwoHeartdisease:thenumber-onekillerHeartdiseaseaffectsabout14millionmenandwomenintheUnitedStates,andithasahighmortalityrateHeartdisease:thenumber-oneOneofthemostdevastatingconsequencesofheartdiseasecanbesuddencardiacarrest.OneofthemostdevastatingcoBlockageofthecoronaryarteriesbyplaquemaycauseaheartattack(myocardialinfarction)orafatalrhythmdisturbance(suddencardiacarrest).BlockageofthecoronaryarterSuddencardiacdeath-afatalconsequenceofheartdiseaseEveryone'sexperiencewithheartdiseaseisdifferent.Somepeopleexperienceshortnessofbreathorchestpainandmakeittothehospitalintimetobetreated.Othersarenotaslucky.Forsomepeople,suddencardiacarrestcanbethefirstsymptomtheyexperience,anditisoftendeadlyunlesstreatedimmediately.Suddencardiacdeath-afatalBesideschestpain(angina)andshortnessofbreath,someothercommonsymptomsofheartdiseaseincludejawpain,backpain,andheartpalpitations.Besideschestpain(angina)anWhatarecommonsymptomsofheartdisease?Symptomsofheartdiseaseusuallyoccurduringexerciseoractivity.That'sbecausetheheartexperiencesincreaseddemandfornutrientsandoxygenthatcannotbemetbecausethecoronaryarteriesareblocked.Othersymptomsofheartdiseaseincludechestpain(angina),shortnessofbreath,jawpain,andbackpain,especiallyontheleftside.WhatarecommonsymptomsofheDoctorsuseavarietyofteststodetectheartdisease.Onecommontestistheelectrocardiogram(ECGorEKG).DoctorsuseavarietyoftestsWhatisanelectrocardiogram(EKG)?Ahealthyheartworksasan"electricalpump"andneedsastrongbloodsupplytoconductelectricity.Peoplewithheartdisease,however,haveaweakbloodsupply,sotheirheartsconductelectricitypoorly.Anelectrocardiogram(EKG)isanoninvasivetestthatmeasurestheelectricalactivityoftheheart.AnEKGtakesapproximatelyfiveminutesandispainless.ManyotherheartconditionscanbediagnosedwithanEKG,forexampleabnormalheartrhythms,evidenceofpriorheartattack,evidenceofanevolvingheartattack,unstableangina,congenitalheartabnormalities,evidenceofabnormalbloodelectrolytes,andevidenceofinflammationoftheheart(myocarditis,pericarditis).Whatisanelectrocardiogram(Sometimes,ifanelectrocardiogramcomesbacknormal,doctorswillusestressteststodetectheartdisease.Sometimes,ifanelectrocardioAnothertestoptionisechocardiography,whichusessoundwavestogenerateimagesoftheheart.AnothertestoptionisechocarComputerizedtomography(CT)scansareusedtoshowthatheartdiseaseisnotpresentandthatthecoronaryarteriesarenormal.Computerizedtomography(CT)sCoronaryangiographyviacardiaccatheterizationisconsideredthe"goldstandard"ofheartdiseasetests.CoronaryangiographyviacardiHeartdiseasetreatmentisdifferentforeveryone.HeartdiseasetreatmentisdifForsomepatientswithheartdisease,medicationsmaybenecessary.ForsomepatientswithheartdWhenmedicationsaren'tenough,sometimesinvasiveproceduresareusedtohelptreatheartdisease.Whenmedicationsaren'tenoughHeartdiseaseisahighlypreventableandreversibledisease.Ahealthydietisamajorfactorincontrollingheartdisease.HeartdiseaseisahighlyprevOtherlifestylechangesthatcanbemadetohelppreventheartdiseaseincludedrinkingalcoholinmoderationandquittingsmoking.OtherlifestylechangesthatcExercise,controllinghighbloodpressureanddiabetes,andtakingdailyaspirinaremorewaystoreduceyourchancesofdevelopingheartdisease.Exercise,controllinghighblo

心臟重癥病房的治療手段進(jìn)展3.1

呼吸機(jī)輔助通氣

3.2

腎臟替代治療

3.3

主動(dòng)脈內(nèi)球囊反搏術(shù)(IABP)和左心輔助裝置(LVAD)3.4

ECMO（體外膜肺氧合）

心臟重癥病房的治療手段進(jìn)展3.1

呼吸機(jī)輔助通氣

在國外，特別是歐美發(fā)達(dá)國家，心臟重癥醫(yī)學(xué)的誕生起源于心肺復(fù)蘇術(shù)的開始，要早于真正的綜合性ICU的建立。從1962年開始，MelterHe和Day分別創(chuàng)立冠心病監(jiān)護(hù)病房，從此心臟重癥醫(yī)學(xué)在世界發(fā)達(dá)國家特別是歐美地區(qū)迅速發(fā)展，以CCU或CICU為代表的心臟重癥監(jiān)護(hù)病房已經(jīng)成為心臟醫(yī)療中心中不可缺少的組成部分，代表了一家中心的心臟醫(yī)療水平，救治水平和管理水平，更與醫(yī)療單位或中心的現(xiàn)代化水平掛鉤在國外，特別是歐美發(fā)達(dá)國家，心臟重癥醫(yī)學(xué)的誕生起源于心肺復(fù)蘇定義心力衰竭是由于任何心臟結(jié)構(gòu)或功能異常導(dǎo)致心室充盈或射血功能受損的一組臨床綜合征，其主要臨床表現(xiàn)為呼吸困難和乏力（活動(dòng)耐量受限），以及液體潴留（肺淤血和外周水腫）。心衰為各種心臟疾病的眼中和終末階段，發(fā)病率高，是當(dāng)今最重要的心血管病之一。定義心力衰竭是由于任何心臟結(jié)構(gòu)或功能異常導(dǎo)致心室充盈或重癥心衰治療指南與臨床實(shí)踐課件重癥心衰治療指南與臨床實(shí)踐課件心衰發(fā)展分為4個(gè)階段根據(jù)心衰發(fā)生發(fā)展的過程，從心衰的危險(xiǎn)因素進(jìn)展成結(jié)構(gòu)性心臟病，出現(xiàn)心衰癥狀，直至難治性終末期心衰,可分成4個(gè)階段。前心衰(A)前臨床心衰(B)臨床心衰(C)難治性終末期心衰(D)這4個(gè)階段不同于紐約心臟協(xié)會(huì)(NYHA)的心功能分級。心衰階段的劃分正是體現(xiàn)了重在預(yù)防的概念，其中預(yù)防患者從階段A進(jìn)展至階段B，即防止發(fā)生結(jié)構(gòu)性心臟病，以及預(yù)防從階段B進(jìn)展至階段C,以至于進(jìn)展到D階段。心衰發(fā)展分為4個(gè)階段根據(jù)心衰發(fā)生發(fā)展的過程，從心衰的危險(xiǎn)因素重癥心衰治療指南與臨床實(shí)踐課件重癥心衰治療指南與臨床實(shí)踐課件依據(jù)左室射血分?jǐn)?shù)(LVEF),心衰可分為LVEF降低的心衰(heartfailurereducedleftventricularejectionfraction,HF-REF)

LVEF保留的心衰(heartfailurewithpreservedleftventricularejectionfraction,HF-PEF).LVEF是心衰患者分類的重要指標(biāo)，也與預(yù)后及治療反應(yīng)相關(guān)。LVEF保留或正常的情況下收縮功能仍可能是異常的。依據(jù)左室射血分?jǐn)?shù)(LVEF),心衰可分為重癥心衰治療指南與臨床實(shí)踐課件CASE1女性，83歲反復(fù)活動(dòng)后氣喘5年，加重1月5年來反復(fù)活動(dòng)后氣喘，發(fā)作時(shí)端坐呼吸，咳白色泡沫樣痰，夜間陣發(fā)性加劇，經(jīng)治療后好轉(zhuǎn)。近1月來癥狀加劇，不能平臥，雙下肢浮腫。既往有高血壓病，糖尿病病史20多年。CASE1女性，83歲入院肺部CT掃描入院肺部CT掃描重癥心衰治療指南與臨床實(shí)踐課件重癥心衰治療指南與臨床實(shí)踐課件重癥心衰治療指南與臨床實(shí)踐課件入院診斷，心功能衰竭，心功能IV級。肺部感染

冠狀動(dòng)脈粥樣硬化性心臟病，急性冠脈綜合癥高血壓病糖尿病入院診斷，入院后治療方案抗感染糾正心衰（強(qiáng)心、利尿、擴(kuò)血管）治療后癥狀改善，但反復(fù)發(fā)作入院后治療方案抗感染重癥心衰治療指南與臨床實(shí)踐課件左室內(nèi)徑在正常上限，室壁未見增厚，心腔形態(tài)失常、心尖部圓鈍，前壁、室間隔中段以下及整個(gè)心尖部運(yùn)動(dòng)減弱或無運(yùn)動(dòng)，余室壁運(yùn)動(dòng)未見明顯異常，整體收縮不協(xié)調(diào)；二維法LVEF30％。

右心大小正常，室壁運(yùn)動(dòng)未見明顯異常

估計(jì)肺動(dòng)脈收縮壓至少57-62mmHg；左室內(nèi)徑在正常上限，室壁未見增厚，心腔形態(tài)失常、心尖部圓鈍，重癥心衰治療指南與臨床實(shí)踐課件重癥心衰治療指南與臨床實(shí)踐課件討論病人下一步治療方案病人冠心病，引起心衰，繼發(fā)肺部感染，明確。但病人83歲，年齡大，不能平臥，是否因該P(yáng)CI。PCI的風(fēng)險(xiǎn)：病人不能耐受手術(shù)，手術(shù)風(fēng)險(xiǎn)大。討論病人下一步治療方案重癥心衰治療指南與臨床實(shí)踐課件重癥心衰治療指南與臨床實(shí)踐課件重癥心衰治療指南與臨床實(shí)踐課件重癥心衰治療指南與臨床實(shí)踐課件重癥心衰治療指南與臨床實(shí)踐課件

Someoftheriskfactorsforheartdiseaseincludesmoking,highbloodpressure,highcholesterol,diabetes,andobesity

SomeoftheriskfactorsforWhataretheriskfactorsforheartdisease?Someofthecommonriskfactorsforheartdiseaseincludesmoking,highbloodpressure(hypertension),highcholesterol,diabetes,familyhistoryofheartdisease,peripheralarterydisease,andobesity.

WhataretheriskfactorsforAdditionalheartdiseaseriskfactorsincludelackofexercise,anunhealthydiet,stress,anda"typeA"personalityAdditionalheartdiseaseriskWhatarelifestyleriskfactorsforheartdisease?Lifestyleriskfactorsthatcontributetoheartdiseaseincludelackofexercise,high-fatdiet,emotionalstress,andhavinga"typeA"personality(aggressive,impatient,competitive).WhatarelifestyleriskfactorCASE2男性，30歲胸悶，氣喘，浮腫1月，加劇1周既往無高血壓病，糖尿病病史個(gè)人史：煙，20-40支/天X10年，

酒，白酒6-7兩/次X4-5次/周X5-6年每天3-4餐職業(yè)：刑警大隊(duì)隊(duì)長。CASE2男性，30歲體格檢查BP192/116mmHgHR106bpmIBM40.1（Height170cm，WT116kg）急性痛苦病容，端坐呼吸，雙肺滿布濕性羅音，哮鳴音。下肢可凹水腫。體格檢查BP192/116mmHgEchocardiogramEchocardiogram重癥心衰治療指南與臨床實(shí)踐課件ComputedTomographyofChestComputedTomographyofChestElectriocardiogramElectriocardiogram入院診斷1.擴(kuò)張型心肌病(原發(fā)性、酒精性、缺血性、心律失常，肥胖型）？心律失?？焖傩孕姆繐鋭?dòng)

肺部感染胸腔積液，心包積液左心室內(nèi)占位性病變（血栓、粘液瘤）2.肥胖3.高血壓病。入院診斷1.擴(kuò)張型心肌病治療策略1.保守藥物治療

降壓，，利尿，抗菌素，低分子肝素鈣，呼吸機(jī)，倍他樂克，23.75mgQD2.介入，冠脈造影3.心臟移植治療策略1.保守藥物治療左心室附壁血栓左室附壁血栓的形成多是繼發(fā)于急性心梗之后，是急性心梗的常見并發(fā)癥之一。附壁血栓形成后反過來引起急性心梗的