CHF,Etiology/precipitating factors 之鑑別及處置原則 張念中,病史及理學檢查(History taking and Physical examination): History taking: symptom(症狀) and sign (徵候) Physical examination: inspection(视診), palpation(觸診), percussion(敲診), and auscultation(聽診) 左心衰竭 右心衰竭 實驗室檢查 (Laboratory examination),左心室,右 心 室,肝,IVC,SVC,JV,SVC: superior vena cava IVC: inferior vend cava JV: jugular vein PV:pulmonary vein,PV,病史及理學檢查(I),左心衰竭,病史（症狀=symptom及徵候=sign）,dyspnea（呼吸困難）： exertional dyspnea（活動時呼吸困難）：活動時身體O2需求增加，但心拍出量不跟著增加而造成，有時因伴有前胸壓迫感，需與活動型心絞痛做DD。 rest dyspnea（安靜時呼吸困難）：重度的肺積水時，安靜時也有呼吸困難。 orthopnea（起坐呼吸）：躺著時有呼吸困難，但坐時減輕。可減少下肢靜脈回流，而使肺積水減少。,Symptom,Paroxysmal 念成proksizml;重音在s nocturnal 念成noktnl ;重音在t dyspnea念成dispnia（夜間發作性呼吸困難）：半夜睡覺中，因突發喘而醒來坐起。輕度時往往坐起來後就會較好。 Cheyne 念成chein Stokes呼吸：週期性的呼吸交替變淺變深，合併無呼吸相，多見於老年人的左心衰竭。 cough（咳）：因肺積水造成氣管支黏膜有慢性積水時。 bloody sputum（血痰）：肺水腫時有泡沫狀血痰。,Cyanosis（發紺念成 ）：重症心衰竭時，因動脈血氧濃度低下或急性肺水腫時會 有末稍發紺。長久發紺形成clubbing finger(杵狀指)：肥厚性骨關節症。 Clammy念成 klemmi skin（濕冷皮膚）：休克時。,Sign,理學檢查 心臟及肺,心臟所見： Cardic dilatation（心擴大）：心尖搏動往左下方移位，或心濁音界線往左方擴大。 Gallop rhythm（奔馬調律）：左心舒張期壓上昇時，可聽到S3及S4。 Tachycardia（頻脈）每分心跳超過100跳：因左心衰竭的代償性反應造成。發生心房顫動時真正心跳數須用聽診計測，不可用摸脈搏。心房顫動可使左心衰竭惡化。,bradycardia（徐脈）每分心跳50下：心衰竭時常有竇性徐脈、徐脈性心房顫動、房室傳導阻斷，常為長期毛地黃使用及重度瀰漫性心機障礙例。這些徐脈會加重心衰竭。 pulsus alternans（交互脈）：有兩種：mechanical pulsus alternans（機械性交互脈）：血壓/脈拍強度交互變化，及electrical pulsus alternans（電氣交互脈）：QRS及STT波之振幅交互變化。左心衰竭之早期變化。 Louderp：肺壓上昇時。,apical systolic murmur（心尖部收縮期逆流性雜音）：左室擴大或乳頭肌機能不全時產生的機能性僧帽瓣逆流。 blood pressure change：心衰竭時血壓變化：早期往往因血氧過低造成反射性血壓上昇（收縮及舒張壓），後期或急性肺水腫時往往下降。,肺所見 Rales念成ra:l（囉音）crackle：多在肺下部及背部可聽到。尤其當有肺水腫時全肺野可聽到粗大的濕性囉音。 pleural effusion（胸水）。,CHF,病史及理學檢查（）,右心衰竭,病史（症狀及徵候）,常是due to 左心衰竭的續發現象 Gastro-intestinal disturbance（胃腸障礙）：胃及腸管積血造成，食慾不振、腹部澎滿感、噁心、嘔吐。 renal disturbance（腎障礙）：oliguria（少尿）、nocturia（夜尿） fatigability（倦怠感）：進行性右心衰竭常合併明顯的倦怠感，體重減少，最後產生心因性惡體質（cardiac cachexia）。 Symptom of nernous system（神經症狀）：低心搏出量造成頭重、頭痛、失眠等腦缺氧症狀。,Symptom,Sign=physical examination,edema（浮腫）：兩下肢為主，重症例，臉、全身。壓了有凹陷過數分鐘才回復。 ascites（腹水）：因portal vein壓力上昇。 jugular venous engorgement；JVE（頸靜脈擴張或怒張）：定義為看右側外頸靜脈在身體45度半坐斜躺時呈怒張狀況。躺下來看不到頸靜脈表示脫水。,JVE,Hepatomegaly（肝腫大）：因肝積血造成，三尖瓣逆流時會更嚴重。常壓迫肝臟（右上腹部）時會造成頸靜脈擴大變顯著，所謂hepato-jugular reflux。肝腫大會伴右上腹痛。- liver span Jaundice（黃疸）：常合併AST/ALT上昇。 cyanosis（發紺）：肺疾病造成右心衰竭。,實驗室檢查 (Laboratory examination),Vital signs(BP/TPR), CXR, EKG, BUSR, Cr, BUN Electrolytes: Na,K, ABG, SpO2, Echocardiography, and thyroid profile.,CHF,原因(Etiology) 誘因(precipitating factors) 處置 (management),Etiology of HF,Etiologies：etiologies as in younger pts but more multifactorial1) CAD,2) hypertensive heart disease,3) valvular heart disease,4) cardiomyopathy,5) infective endocarditis,6) myocarditis,7) pericardial disease,8) high output failure：anemia, hyperthyroid9) age related diastolic dysfunction,Precipitating Factors of HF(),Myocardial ischemia or MI Dietary Na excess Excess fluid intake Medication noncompliance Iatrogenic volume overload Arrhythmias,Precipitating Factors of HF(),Associated medical conditions：fever, infection, hyper or hypothyroidism, anemia, renal insufficiency, pulmonary embolism, hypoxemia, uncontrolled hypertension Drugs and medications ：alcohol, beta blocker, CCB, antiarrhythmics, NSAID, corticosteroids, estrogen preparations,Epidemiology of HF (I),In elderly, HF is the lading diagnosis of hospitalization, the 2nd most common cause of OPD visits and most costly DRG. In US, HF patients count to 5,000,000 (2.0% of population), 70% 60 yr, 40,000 new cases diagnosed each year. HF hospitalization: 65 yr of age: M 80%, F 85%. Incidence increases with age.,Epidemiology of HF (II),Incidence and prevalence are increasing Factors for increasing HF patients population aging; improved Rx for CAD and HT; Improved Rx for other diseases Mortality increase with advancing ages Chronic disability and impaired quality of life.,Pathophysiology of HF(I),Systolic or/and diastolic dysfunction 4 principal changes in CV system contribute to HF: Reduced responsiveness to beta-adrenergic stimulation Increased vascular stiffness: increased afterload, isolated systolic hypertension Stiffer heart: diastolic filling defect Altered myocardial energy metabolism,Pathophysiology of HF (II),Diastolic dysfunction is frequently the cause of HF particularly in the elderly. Atrial contraction is important in diastolic dysfunction. Therefore, Af would precipitate or aggravate HF in elderly. Other organ changes: GFR, respiratory function.,Clinical Features of HF in the Elderly,Symptoms: more atypical symptoms: Non-specific complaints: malaise, lassitude困乏 Neurological: confusion, irritability, sleep disturbance GI symptoms: nausea, abdominal discomfort, diarrhea Signs: may be nonspecific and atypical,Management of HF,Primary goal ：1) Improve quality of life2) Reduce frequency of heart failure exacerbations and hospitalization3) Extending survival Three Rx components ：1) Correction of underlying etiology2) Nonpharmacologic Rx3) Medications,Nonpharmacologic Rx of HF,Physical activity Patient education 3. Dietary consultation,