治疗慢性心衰的药物课件

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,Pharmacotherapy of Congestive Heart Failure,充血性心力衰竭的药物治疗,Definition and Clinical Features,慢性心力衰竭,(,充血性心力衰竭,),心脏在正常充盈压时无法提供有效的前向射血，心脏收缩功能下降，同时心室舒张末压增加，心腔残余血液增加，导致肺循环和体循环淤血,Congestive heart failure(chronic heart failure,CHF)is a complex of symptoms-shortness of breath,tachycardia,fatigue,and congestion-that are related to,the inadequate perfusion of tissue,during exertion and to,the retention of fluid,.,慢性心衰的呼吸困难、心率增加、乏力、淤血等缘于组织灌注不足及体液潴留,Definition and Clinical Features,慢性心力衰竭,(,充血性心力衰竭,),Congestive heart failure,(,chronic heart failure,CHF,)is the pathophysiologic state in which the heart is unable to pump blood at a rate commensurate with,相称,the tissue requirements,or can do so only from an elevated filling pressure.,心输出量不能满足组织代谢需求,或需通过升高充盈压代偿,Its primary cause is that the heart,fails to provide adequate output at normal filling pressures,which is associated with a syndrome of reduced contraction capacity as well as pulmonary and systemic venous congestion.,主要原因是,心脏在正常充盈压时无法提供有效的前向射血，导致心脏收缩功能功能下降以及肺循环和体循环淤血,Systemic and Pulmonary Circulation,When left ventricle fails,Left ventricular end-diastolic pressure,左室舒张末压,LAP,左房压,Pulmonary cap wedge pressure,肺毛细血管锲压,Left ventricle,contraction,左室射血,Thickening of the respiratory membrane reduces O,2,exchange,Enlarged heart,(,Contraction,LVEDP,),and pulmonary congestion,(,O,2,Exchange,),Clinical FeaturesOrthopnea,特征与鉴别,Exertional dyspnea,nocturnal paroxysmal dyspnea and orthopneapulmonary congestion,早期,运动性呼吸困难、夜间阵发性呼吸困难，,急性加重呈,端坐呼吸,-,肺淤血 为左心衰特征,Hypertension,Myocardial Hypertrophy and Diastole Dysfunction,心肌肥厚与舒张功能障碍,Normal,Hypertension,Diastolic and Systolic Heart Failure,舒张性心衰与收缩性心衰均表现为呼吸困难,(,肺淤血,),78 yo Woman Recurrent Pul Edema,50 yo Man HCM,颈静脉怒张,肝脾肿大,下肢浮肿,肺淤血,运动性及,夜间阵发性,呼吸困难,肺水肿,端坐呼吸,心源性哮喘,心肌收缩力下降 心腔残余血增加 左室舒张末压增高,肾灌注下降,尿量减少,水钠潴留,头昏、乏力、运动耐力下降,反射性,SNS,及,RAAS,兴奋，血管痉挛、心率加快、回心血量,When the heart fails,arterial pressure reduces which causes the baroreceptor response and excitation of sympathetic nervous system(SNS)and renin-angiotensin-aldosterone system(RAAS).,心输出量下降导致反射性交感神经系统及肾素血管紧张素醛固酮系统兴奋,Compensation mechanisms during chronic heart failure,心衰代偿机制及其作用,AT1,Renin-Angiotensin-,Aldosterone System,Compensation mechanisms during chronic heart failure,心衰代偿机制的不利影响,The epinephrine/norepinephrine(SNS)and angiotensin/aldosterone(RAAS)enhance heart performance and contract peripheral vessel with water/sodium retention to compensate for reduced cardiac output and redistribution of blood to important organs such as the CNS.,肾上腺素、去甲肾上腺素、血管紧张素使心肌收缩增强、心率加快、外周血管收缩、水钠潴留，血流重新分配以保证重要脏器血流,In addition,the vasoconstrictive effectors of the SNS and RAAS lead to an increase in systemic vascular resistance,which contributes to an increased impedance,阻抗,to left ventricular ejection(increased afterload)and therefore myocardial oxygen consumption.,交感神经及肾素血管紧张素醛固酮系统兴奋增加外周阻力，进而导致心脏后负荷增加，心肌耗氧增加,颈静脉怒张,肝脾肿大,下肢浮肿,肺淤血,运动性及,夜间阵发性,呼吸困难,肺水肿,端坐呼吸,心源性哮喘,心肌收缩力下降,左室舒张末压增高,肾灌注下降,尿量减少,水钠潴留,头昏、乏力、运动耐力下降,反射性,SNS,及,RAAS,兴奋,，血管痉挛、心率加快、回心血量,强心,Digitalis,洋地黄类,降低心脏负荷与氧耗,-blocker ACEI,降低前后负荷,Vasodilator,扩血管药,利尿,Diuretics,减轻水钠潴留,Diuretics,利尿剂,减轻肺淤血,利用哪些途径和药物治疗慢性心力衰竭？,Pharmacotherapy of CHF,治疗慢性心衰的药物,Positive inotropic agents,正性肌力药,Digitalis,洋地黄,Diuretics,利尿药,氢氯噻嗪 呋塞米,Vasodilators,扩血管药,酚妥拉明,-adrenergic receptor blockers,肾上腺素能受体阻断药,Inhibitors of Renin-Angiotensin System,肾素血管紧张素系统抑制药,Therapeutic Aims of CHF,CHF is a major contributor to morbidity and mortality worldwide.Mortality in patients with advanced heart failure exceeds 50%at 1 year.,现代社会中慢性心衰高发病率和高死亡率,While,palliation of symptoms,缓解症状,and,improvement in the quality of life,改善生活质量,remain important goals,it is possible to approach therapy with the expectation that,disease progression,can,be attenuated,减缓病情进展,and,in many instances,survival prolonged,.,延长生存期,治疗目标：缓解症状、降低死亡率，缓解病情进展、改善生存质量,Clinical conditions that precipitate deterioration of CHF,Elevated blood pressure,血压升高,Arrhythmia,心律失常,Myocardial ischemia,心肌缺血,Mental and physical stress,心理与躯体应激,Valve lesion and regurgitation,先心或瓣膜病变所致的分流与反流,Infection,esp.lung infection,各类感染尤其是肺部感染,High salt intake,高盐饮食,慢性心衰治疗同时纠正诱因同样重要,Pharmacotherapy of CHF,治疗慢性心衰的药物,Positive inotropic agents,正性肌力药,Diuretics,利尿药,Vasodilators,扩血管药,-adrenergic receptor blockers,肾上腺素能受体阻断药,Inhibitors of Renin-Angiotensin System,肾素血管紧张素系统抑制药,化学结构,基本骨架,William Withering,1741,1799,Positive inotropic agents,正性肌力药,Cardiac glycosides,强心苷,Digitalis,洋地黄类,abstracts from plant digitalis,Digoxin,地高辛,cidellannid,西地兰,Positive inotropic agents,正性肌力药,Cardiac glycosides,强心苷,Digoxin,地高辛,po,cidellannid,西地兰,iv,Actions and usages,The cardiac effects are,:,increasing force of contraction,增强心肌收缩力,positive inotropic action,正性肌力作用,cardiac slowing(negative chronotropic action),负性频率作用,and reduced rate of conduction through the AV node,负性传导作用,disturbances of rhythm,对心肌电生理的影响,especially,-block of AV conduction,抑制房室传导,-increased ectopic pacemaker activity,尤其是蒲氏纤维,Used in,chronic heart failure and for controlling ventricular rate in atri