heart failure(xīn lì shuāi jié)

essential information

pathogeny

1. Basic etiology almost all cardiovascular diseases will eventually lead to heart failure. Myocardial infarction, cardiomyopathy, hemodynamic overload, inflammation and other causes of myocardial damage can cause changes in myocardial structure and function, and finally lead to low ventricular pumping and / or filling function. On the basis of basic heart disease, some factors can induce heart failure. The common causes of heart failure are as follows: (1) infection, such as respiratory tract infection, rheumatic activity, etc. (2) severe arrhythmias, especially tachyarrhythmias, such as atrial fibrillation, paroxysmal tachycardia, etc. (3) increased cardiac load caused by pregnancy, delivery, too much and too fast infusion, too much sodium salt intake, etc. (4) drug effects such as digitalis poisoning or inappropriate discontinuation of digitalis. (5) improper activities, excessive physical activities and emotional excitement. (6) other diseases such as pulmonary embolism, anemia, papillary muscle dysfunction, etc.

classification

According to the urgency of heart failure, it can be divided into acute heart failure and chronic heart failure. According to the location of heart failure can be divided into left heart failure, right heart failure and total heart failure. There are also systolic or diastolic heart failure. 1. Acute heart failure refers to the clinical syndrome of acute pulmonary congestion, pulmonary edema, tissue and organ hypoperfusion and cardiogenic shock caused by acute myocardial damage or aggravation of cardiac load, resulting in sudden drop of acute cardiac output, increase of pulmonary circulation pressure and increase of peripheral circulation resistance, resulting in pulmonary circulation congestion. Acute heart failure can be acute exacerbation on the basis of the original chronic heart failure, or sudden onset on the heart with normal or compensatory heart function. Before onset, most of the patients had organic cardiovascular disease, common in acute myocarditis, extensive myocardial infarction, ventricular outflow tract obstruction, pulmonary artery trunk or large branch infarction, etc. It can be manifested as systolic heart failure or diastolic heart failure. Acute heart failure is often life-threatening and must be treated urgently. Chronic heart failure refers to the persistent state of heart failure, which can be stable, deteriorated or decompensated. Chronic heart failure is the end stage of heart disease caused by various causes, is a complex clinical syndrome, the main characteristics are dyspnea, edema, fatigue, but the above manifestations do not appear at the same time. Generally, compensatory cardiac enlargement or hypertrophy and other compensatory mechanisms are involved, often accompanied by hyperemic pathological changes of organs caused by increased venous pressure, including atrial, ventricular mural thrombosis and venous thrombosis. The main causes of adult chronic heart failure are coronary heart disease, hypertension, valvular disease and dilated cardiomyopathy.

clinical manifestation

1. Acute heart failure (1) the early signs of decreased left ventricular function were fatigue, decreased exercise endurance, increased heart rate by 15-20 beats / min in patients with normal heart function, and then exertional dyspnea, nocturnal paroxysmal dyspnea, high pillow sleep, etc And wheezes. (2) the onset of acute pulmonary edema is acute, and the disease can rapidly develop to a critical state. Sudden severe dyspnea, sitting and breathing, wheezing, restlessness and fear, breathing frequency can reach 30~50 times / minute; frequent cough and a large amount of pink foam like sputum; heart rate is fast, apex often can hear and gallop; two lungs are full of moist rales and wheezing sounds. (3) cardiogenic shock 1) hypotension lasted more than 30 minutes, systolic blood pressure decreased below 90mmHg, or systolic blood pressure decreased more than 60mmhg in patients with original hypertension. 2) Tissue hypoperfusion state: ① skin wet, cold, pale and cyanosis with purple stripes; ② tachycardia & gt; 110 beats / min; ③ significantly reduced urine volume (& lt; 20ml / h), even no urine; ④ disturbance of consciousness, often restlessness, excitement, anxiety, fear and sense of dying; systolic blood pressure below 70mmhg, inhibition symptoms may appear, gradually develop to fuzzy consciousness or even coma. 3) Hemodynamic disturbance, PCWP ≥ 18mmhg, cardiac output index (CI) ≤ 36.7ml / s · m (≤ 2.2L / min · m). 4) Metabolic acidosis and hypoxemia 2. Chronic heart failure (1) symptoms and signs of left heart failure most patients with left heart failure seek medical treatment due to decreased exercise tolerance, dyspnea or fatigue. These symptoms may appear at rest or during exercise. The same patient may have multiple diseases. dyspnea is the main symptom of left heart failure, which can be manifested as exertional dyspnea, sitting breathing, paroxysmal nocturnal dyspnea and other forms. The decrease of exercise endurance and fatigue are the manifestations of insufficient blood supply of skeletal muscle. Chen Shi breathing may occur in patients with severe heart failure, indicating poor prognosis. In addition to the original signs of heart disease, physical examination can also find left ventricular enlargement, alternating pulse strength, auscultation and pulmonary rales. (2) the symptoms and signs of right heart failure are mainly the changes of organ function caused by chronic persistent congestion. Patients may have abdominal or leg edema, which is the first or only symptom to seek medical treatment. Exercise tolerance damage occurs gradually and may not attract the attention of patients, unless the changes of daily living ability are carefully inquired. In addition to the original signs of heart disease, physical examination can also find cardiac enlargement, jugular vein filling, hepatomegaly and tenderness, cyanosis, ptosis edema, pleural effusion and ascites. (3) symptoms and signs of diastolic heart failure diastolic heart failure is defined as the decrease of ventricular relaxation and compliance under normal ventricular systolic function (LVEF & gt; 40% ～ 50%), resulting in the decrease of ventricular filling volume and increase of filling pressure, resulting in congestion of pulmonary and systemic circulation. The initial symptoms are not obvious, with the development of the disease can appear exercise endurance decline, shortness of breath, pulmonary edema.

inspect

1. ECG can often indicate primary diseases. X-ray examination can show pulmonary congestion and edema. 3. Echocardiography can understand the structure and function of the heart, the condition of the heart valve, the presence of pericardial lesions, the mechanical complications of acute myocardial infarction, ventricular wall dyskinesia, and left ventricular ejection fraction. Arterial blood gas analysis arterial partial pressure of oxygen (PAO < sub > 2 < / sub >) and partial pressure of carbon dioxide (Paco < sub > 2 < / sub >) were monitored. 5. Laboratory examination blood routine and blood biochemical examination, such as electrolyte, renal function, blood glucose, albumin and high sensitivity C-reactive protein. 6. Heart failure markers the generally accepted objective indicators for the diagnosis of heart failure are the increased concentrations of B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT proBNP). 7. Markers of myocardial necrosis cardiac troponin T or I (cTnT or cTnI) has high specificity and sensitivity in detecting myocardial damage.

diagnosis

According to the patient's history of coronary heart disease, hypertension and other basic cardiovascular diseases, clinical symptoms of dyspnea, fatigue and lower limb edema during rest or exercise, signs of tachycardia, shortness of breath, pulmonary rales, pleural effusion, increased jugular pressure, peripheral edema, liver enlargement, enlargement of heart cavity, third heart sound, cardiac murmur, abnormal echocardiography, etc BNP / NT proBNP is the objective evidence of abnormal cardiac structure or function, which has the characteristics of systolic heart failure or diastolic heart failure.

treatment

1. Acute heart failure once diagnosed, it should be treated according to the standard. (1) the initial treatment was oxygen inhalation via mask or nasal catheter, and morphine, loop diuretic and cardiotonic were given intravenously. Make the patient take sitting or half lying position, legs droop, reduce venous reflux of lower limbs. (2) vasoactive drugs, such as positive inotropic drugs, vasodilators and vasoconstrictors, should be used according to systolic blood pressure and pulmonary congestion. (3) patients with severe condition, continuous decrease of blood pressure (& lt; 90mmHg) or even cardiogenic shock should be monitored for hemodynamics, and various non drug treatment methods such as intra aortic balloon counterpulsation, mechanical ventilation support, blood purification, ventricular mechanical assist device and surgery should be used. (4) dynamic determination of BNP / NT proBNP is helpful to guide the treatment of acute heart failure. If the level of BNP / NT proBNP remains high after treatment, it indicates that the prognosis is poor and the treatment should be strengthened; after treatment, the level of BNP / NT proBNP decreases by & gt; 30%, which indicates that the treatment is effective and the prognosis is good. (5) control and eliminate all kinds of inducements, and correct basic cardiovascular diseases in time. 2. Chronic heart failure the treatment of chronic heart failure has changed from short-term hemodynamic / pharmacological measures such as diuresis, cardiotonic and vasodilator to long-term, restorative strategies mainly based on neuroendocrine inhibitors, with the aim of changing the biological nature of heart failure. (1) etiological treatment, control of hypertension, diabetes and other risk factors, the use of antiplatelet drugs and statins lipid-lowering drugs for secondary prevention of coronary heart disease. Eliminate the inducement of heart failure, control infection, treat arrhythmia, correct anemia and electrolyte disorder. (2) improve symptoms, adjust the usage and dosage of diuretics, nitrates and cardiotonics according to the condition. (3) correct use of neuroendocrine inhibitors from small dose to target dose or the maximum dose that patients can tolerate. (4) monitoring of drug reactions (*): water and sodium retention can be reduced gradually by diuretic dosage or small dose maintenance treatment. It is difficult to stop the drug in the early stage. Daily weight change is measured by diuretics

Chinese PinYin : xīn lì shuāi jié