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Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,左室射血分数正常的心力衰竭,心力衰竭病理生理机制的研究历程:,1669年Lower提出,1913年Mackenzie完善,前向性心衰,1832年Hope提出,,1896年Starling完善,后向性心衰,1929年Forssman发明,,1945年Cournand临床应用,心导管,强调心脏收缩功能障碍,2008 ESC,由于多谱勒超声心动图发展和普及,发现临床上有一种心力衰竭的特殊类型,表现为单纯心室的舒张功能障碍但心室收缩功能尚正常而引发的临床综合征。,Dougherty AH,Naccarelli,GV,Gray EL,Hicks CH,Goldstein RA.Congestive heart failure with normal systolic function.,Am J,Cardiol,1984;54:778-82,.,Kessler KM.Heart failure with normal systolic function:update of prevalence,differential diagnosis,prognosis,and therapy.,Arch Intern Med 1988;148:2109-11.,Grossman W.Diastolic dysfunction in congestive heart failure.,N,Engl,J Med 1991;325:15571564,.,Davie AP,Francis CM,Caruana,L,Sutherland GR,McMurray JJ.The prevalence of left ventricular diastolic filling abnormalities in patients with suspected heart failure.,Eur,Heart J 1997;18:981-4.,收缩,性心力衰竭,(Systolic Heart Failure),左室射血分数减低的心力衰竭,HF with reduced ejection fraction(HFREF),舒张性心力衰竭,(Diastolic Heart Failure),收缩功能保留(保存)的心力衰竭,HF with preserved systolic function(HFPSF),左室射血分数保留(保存)的心力衰竭,HF with preserved ejection fraction(HFPEF),左室射血分数正常的心力衰竭,HF with normal ejection fraction(HFNEF),Zile MR and Brutsaert DL.,New Concepts in Diastolic Dysfunction and Diastolic Heart Failure:Part I:Diagnosis,Prognosis,and Measurements of Diastolic Function.,Circulation 2002,105:1387-1393,Zile MR.Circulation 2002,105:1387,舒张性心力衰竭的发生率、死亡率和发病率,患者特征,死亡率,p=0.01,p=0.005,p=0.003,P0.0001,P0.0001,P 40%,舒张性心衰是由于左心室舒张期主动松弛能力受损和心肌顺应性降低,亦即僵硬度增加(心肌细胞肥大伴间质纤维化),导致左心室在舒张期的充盈受损,心搏量(即每搏量)减少,左室舒张末期压增高而发生的心衰。,多见于老年女性、高血压、糖尿病、左室肥厚者。常有冠脉疾病或AF。,可与收缩功能障碍同时出现,亦可单独存在。单纯性舒张性心衰约占心衰患者的2060,其预后优于收缩性心衰。,中国慢性心力衰竭诊治指南 (2007年),中国慢性心力衰竭诊治指南(2007年),左室射血分数正常心力衰竭,的发病机制(1),左室射血分数正常心力衰竭,的发病机制(2),(1),心肌能量缺乏或缺血:心肌舒张是一个 Ca,2+,被摄入肌浆网,消耗ATP和受磷蛋白被磷酸化过程;,(2),原发性心肌硬度增加或心肌病变:心肌固有的粘弹性特征颇为重要;,(,3),左室重量增加,室壁肥厚;,(4),左室腔的几何学图形改变;,(5),收缩与舒缓的非均一性。,左室射血分数正常心力衰竭,的发病机制(3),左室射血分数正常心力衰竭,的临床表现,与传统上认为的由收缩功能障碍所致的“充血性心力衰竭”基本相同。,In its most severe form,HFNEF results in overt symptoms of CHF.,In modest,HFNEF,symptoms of,dyspnea,and fatigue occur only during stress or activity such as exercise when heart rate and/or end-diastolic volume increase.,In its mildest form,HFNEF,may be manifested as a slow or delayed pattern of relaxation and filling with little or no elevation of diastolic pressure and little or no cardiac symptoms.,左室射血分数正常心力衰竭,的实验室检查,心导管检查可以准确检测心脏舒张功能,组织多谱勒和多谱勒超声心动图也是临床判断心脏舒张功能简便和准确的方法,Ghali,JK,Kadakia,S,Cooper RS,Liao,YL.Bedside diagnosis of preserved versus impaired left ventricular systolic function in heart failure.,Am J,Cardiol,1991;67:1002-6.,Vasan,RS,Benjamin EJ,Levy D.Congestive heart failure with normal left ventricular systolic function:clinical approaches to the diagnosis and treatment of diastolic heart failure.,Arch Intern Med 1996;156:146-57,.,Garcia MJ,Thomas JD,Klein AL.New Doppler,echocardiographic,applications for the study of diastolic function.,J Am,Coll,Cardiol,1998;32:865-75,.,舒张性心衰诊断,符合下列条件者可作出诊断:,典型心衰症状和体征;,LVEF正常(45%),左心腔大小正常;,有左室舒张功能异常的证据;,超声心动图检查无心瓣膜疾病,并排除心包疾病、肥厚性心肌病、浸润性心肌病、限制性心肌病等。,中国慢性心力衰竭诊治指南 (2007年),有心力衰竭的症状和体征,左室收缩功能正常或者轻度降低,LVEF50%和LVEDVI12mmHg或,LVEDP16mmHg或,48ms或b0.27,组织多普勒,E/E15 15 E/E8,生物学指标,NT-proBNP220pg/ml,或BNP200 pg/ml,生物学指标,NT-proBNP,220pg/ml,或BNP,200 pg/ml,彩色多普勒,E/A,50yr,50yr,280ms,或Ard-Ad30ms,或LAVI40ml/m,2,或,LVMI122g/m,2,(),LVMI149g/m,2,(),或心房颤动,组织多普勒,E/E8,HFNEF,左室射血分数正常心力衰竭的诊断,2007 ESC,左室射血分数正常心力衰竭的鉴别诊断,2007 ESC,L,左室射血分数正常心力衰竭的治疗,目前尚缺乏循证医学的资料。,治疗要点,1,积极控制血压:,舒张性心衰患者的达标血压宜低于单纯高血压患者的标准,即收缩压130mmHg,舒张压80 mmHg(类,A级)。,2,控制AF心率和心律:,慢性AF应控制心室率(类,C级);AF转复并维持窦性心律,可能有益(b类,C级)。,3,应用利尿剂:,可缓解肺淤血和外周水肿,但不宜过度(类,C级)。,中国慢性心力衰竭诊治指南 (2007年),4,血运重建:,心肌缺血可以损害心室舒张功能,CHD患者如有症状性或可证实的心肌缺血,应考虑冠脉血运重建(a类,C级)。,5,逆转左室肥厚,改善舒张功能:,可用ACEI、受体阻滞剂等(b类,C级)。,6,地高辛无正性松弛作用,不推荐应用于舒张性心衰,(b类,C级),。,7,如同时有收缩性心衰,则以治疗后者为主,。,治疗要点,中国慢性心力衰竭诊治指南 (2007年),谢 谢!,谢 谢!,
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