舒張性心力衰竭的超聲心動(dòng)圖評(píng)價(jià)及其診治現(xiàn)狀

舒張性心力衰竭的超聲心動(dòng)圖評(píng)價(jià)及其診治現(xiàn)狀衛(wèi)生部北京醫(yī)院心內(nèi)科汪芳MortalityinDHF

OwanTEetal.NEnglJMed.2006;355:251-259;BhatiaRSetal.NEnglJMed.2006;355:260-269.1yearmortality293222.225.5舒張性心力衰竭〔diastolicheartfailure,DHF〕有充血性心力衰竭典型的表現(xiàn)〔肺循環(huán)和體循環(huán)淤血〕非心臟瓣膜病靜息時(shí)伴異常的舒張性功能不全收縮功能正?；騼H有輕微減低診斷要點(diǎn)DHF的主要病因和誘發(fā)因素老年人，女性▲心房顫抖高血壓伴左心室肥厚▲肺部感染糖尿病▲腎功能不全冠心病心肌缺血▲貧血肥胖限制性和浸潤(rùn)性心肌病參數(shù)SHFDHF病史冠心病高血壓糖尿病瓣膜性心臟病陣發(fā)性呼吸困難+++++++++++++++++++++—+++體格檢查心界擴(kuò)大心音低鈍S3奔馬律S4奔馬律高血壓瓣膜返流啰音水腫頸靜脈充盈+++++++++++++++++++++++++++++++++++++++胸部X線(X-ray)心臟擴(kuò)大肺淤血+++++++++++++++++

++++收縮性HF(SHF)與DHF:病癥與體征GivertzMMetal.In:BraunwaldE,ZipesDP,LibbyP,eds.HeartDisease,7thedition.Philadelphia,Pa:WBSaunders.2001;534-561.

ESC

2005年建議舒張性心功能不全

需同時(shí)滿足以下的三個(gè)必要條件充血性心力衰竭的病癥和體征。左室收縮功能正?；騼H有輕度異常。左室松弛、充盈、舒張期擴(kuò)張能力異常或舒張期僵硬的證據(jù)。美國(guó)心臟病學(xué)會(huì)和美國(guó)心臟病協(xié)會(huì)〔AHA/ACC〕

建議的診斷標(biāo)準(zhǔn)：有典型的心力衰竭病癥和體征，同時(shí)超聲心動(dòng)圖顯示患者左心室射血分?jǐn)?shù)正常并且沒(méi)有瓣膜疾病〔如主動(dòng)脈狹窄或二尖瓣返流〕

AHH/ACC2005年慢性心力衰竭診治指南中國(guó)舒張性心力衰竭診斷標(biāo)準(zhǔn)

〔2007指南〕有典型心衰的病癥和體征；LVEF正?！?gt;45%〕，左心腔大小正常；UCG有左室舒張功能異常的證據(jù)；UCG檢查無(wú)瓣膜病，心包疾病及肥厚或限制型心肌病。舒張性心力衰竭的診斷標(biāo)準(zhǔn)

主要標(biāo)準(zhǔn)1.臨床心衰證據(jù)弗萊明翰標(biāo)準(zhǔn)

(2個(gè)主要或1個(gè)主要＋2個(gè)次要標(biāo)準(zhǔn))波士頓標(biāo)準(zhǔn)(5-7分:可能HF;8-12分:確診HF)血漿BNP升高(>400pg/ml3)或胸部X-線示肺淤血心肺運(yùn)動(dòng)試驗(yàn)示肺功能減弱2.LVEF及心腔大小正常3.左心室舒張、充盈異常，舒張期僵硬明確證據(jù)1.左心室肥厚或向心性重構(gòu)2.左房擴(kuò)大(無(wú)房顫)3.多普勒超聲心動(dòng)圖或?qū)Ч軝z查有舒張功能不全的證據(jù)YturraldeRFandGaaschWH.ProgCardiovascDis2005;47:314-319.

KorensteinDetal.BMCEmergMed2007;7:6超聲心動(dòng)圖診斷要點(diǎn)

systolicfunctionmyocardialrelaxationdiastolicfillingpressures

atrestandwithexertionNormalCardiacFunctionWhatisDiastolicFunctionCompliance*passiveRelaxation:#

activeenergedependentMitralinflowPulmvenousflowTDIColourM-modeflowpropagationvelocityLAsize,LAvolumeLVejectionfractionLVhypertrophy2DDoppler正常人23±6ml/m2松弛異常25±8ml/m2假性正常31±8ml/m2〔≥34ml/m2〕限制性充盈48±12ml/m2JAmCollCardiol,2005;45:87-92左心房容量指數(shù)〔LA容量/體外表積〕與舒張功能異常呈正比NormalSystolicHeartFailureDiastolicHeartFailureAurigemma,Zile,GaaschCirculation2005PhasesofcardiaccyclehighnormaldelayedrelaxationfillingpressureEfectofLAPressureonLVIVRTEEAAEAEA‘a(chǎn)’reversalSDSDnormalabnormalMitral‘A’durationPV‘a(chǎn)’durationMitralinflowPVflowDOPPLERFLOWVELOCITY彩色多普勒M型〔CMM〕NormalVpSlowVpFlowpropagationvelocityofmitralinflowbycolourM-modeNormalAbnormalrelaxationPseudo-normalizedEmAmSmAmSmEm彩色多普勒M型〔CMM〕normaldiastolicdiastolicsystolic dysfunctionheartfailureheartfailuresmsmsmEmsmEmEmEmAmAmAmAmmmmmTDIofmitralannulusvelocity,E/EmisalsousefultodetectimpairedLVrelaxationinpatientwithatrialfibrillationDae-WonSohn,etalJASE1999EstimationofLVfillingpressureusingE/EmSROmmen,RANishimuraetalCirculation2000

S.FNaguehetalCirculation1999Exception: inptswithconstrictivepericarditisE/E’isinverselyproportionaltoPCWP

Jong-WonHa,JaeOhetalCirculation2001S.FNaguehCirculation1999E/VpForestimationoffillingpressureGrade E/A DT S/D Pva A-adurVpTau (ms) (cm/s) (ms)(cm/s)Normal 1-2150-200 >1 <35<20>45NMild <1 >200 >1 <35<20<45Mild-mod<1 >200 >1 >35>20<45Moderate1-2150-200 0.5-<1>35>20<45Severe >2<150 <0.5 >35>20<45IndicesofdiastolicdysfunctionParameterstoidentifypatientswithelevatedLVfillingpressureEnlargedLADT<150msPVavelocity>35cm/sE/A>2E/Em>15E/Vp>2SfractionofPVflow<40%orS<50%DMitralAduration<PV‘a(chǎn)’reversaldurationEstimationofLVfillingpressuredecelerationtime(DT)

<120msecindicatesPCWP>20mmHg providedthatLVEFisabnormaleg.<40%E/Em>15indicatesPCWP>20mmHg

usefuleveninAF,sinustachycardia butnotaccurateinconstrictivepericarditisVentricularrelaxationDiastolicsuctionErectilecoronaryeffectViscoelasticforcesofmyocardiumPericardialrestraintVentricularinteractionAtrialcontributionFactorsinfluencingLVfillingduringdiastoleLoaddependenceChambercomplianceNon-uniformityofrelaxationHeartrateloadingconditionmitralregurgitationAginghypertrophiccardiomyopathyconstrictivepericardiatistechnicallimitationsetcLimitations舒張性心力衰竭

治療原那么建議分類證據(jù)級(jí)別*醫(yī)師應(yīng)當(dāng)根據(jù)發(fā)表的指南控制收縮期和舒張期高血壓IA*醫(yī)師應(yīng)當(dāng)控制心房顫抖患者的心室率IC*醫(yī)師應(yīng)當(dāng)使用利尿劑控制肺充血和周圍性水腫IC*冠狀動(dòng)脈疾病患者有病癥性或可證實(shí)的心肌缺血對(duì)心臟舒張功能有不利影響時(shí)，最好行冠狀動(dòng)脈重建治療IIaC*心房顫抖患者恢復(fù)并維持竇性心律可能有助于改善病癥IIbC*高血壓患者應(yīng)用β受體阻滯劑、ACEI、ARB或鈣拮抗劑，可能有助于最大程度緩解病癥IIbC*應(yīng)用洋地黃來(lái)最大程度減輕心力衰竭病癥的價(jià)值尚不清楚IIbC06年AHA/ACC對(duì)舒張性心力衰竭患者的治療建議DHF治療推薦HeartFailureSocietyofAmericaPracticeGuideline(2006)■低鈉飲食C■容量過(guò)度負(fù)荷患者使用噻嗪類或襻利尿劑C■使用ARBs或ACEIsARBs:B,ACEI:C■合并冠心病或糖尿病患者使用ACEIs或ARBsC■使用β阻滯劑心肌梗死史A高血壓B需要控制心室率的心房顫抖B■使用CCBdiltilzem或verapamil用于β阻滯劑不能耐受的心房顫抖C心絞痛病癥A高血壓CAdamsKF,etal.JCardFail2006;12:10-38總結(jié)DHF診斷步驟(ESC共識(shí),2007)

HF的病癥或體征LVEF>50%且左心室舒張末期容積指數(shù)(LVEDVI)

<97ml/m2左心室舒張、充盈、舒張期擴(kuò)脹和硬度異常肺動(dòng)脈楔壓>12mmHg或左心室舒張末壓>16mmHg組織多普勒NTproBNP>220pg/mlBNP>200pg/mlE/E’>1515>E/E’>8超聲血流多普勒:.E/ADT.肺靜脈血流.左房擴(kuò)大.左心室肥厚.房顫NTproBNP>220pg/mlorBNP>200pg/mlDHF組織多普勒E/E’>8FromPaulus.EurHeartJ.2007Treatment