,Heart failure,1,DEFINITION,HEART FAILURE A clinical syndrome in which an abnormality of cardiac structure or function is responsible for the inability of the heart to eject or fill with blood at a rate commensurate with the requirements of the metabolizing tissues. Heart failure results in a constellation of clinical manifestations, including circulatory congestion, dyspnea, fatigue, and weakness.,2,FORMS OF HEART FAILURE,Systolic vs diastolic heart failure Low-output vs high-output heart failure Acute vs chronic heart failure Right-sided vs left-sided heart failure,3,UNDERLYING CAUSES,Ischemic heart disease Cardiomyopathies Congenital, valvular and hypertensive heart disease (potential treatable ),4,PRECIPITATING FACTORS,Infection Arrhythmias Physical, dietary, fluid, environmental, and emotional excesses Myocardial infarction Pulmonary embolism Anemia Thyrotoxicosis and pregnancy Aggravation of hypertension Rheumatic, viral, and other forms of myocarditis Infective endocarditis,5,PATHOGENESIS,Chronic hemodynamic overloadeccentric ventricular hypertrophy Chronic pressure overload concentric ventricular hypertrophy Ventr. hypertrophy ventr. Dilatation Remodeling of ventricle HF Activation of endogenous neurohormonal system and cytokines,6,7,“,CLINICAL MANIFESTATION OF HF,Primary Symptoms Dyspnea Orthopnea Paroxysmal (nocturnal) dyspnea Acute pumnonary edema,8,CLINICAL MANIFESTATION OF HF,Other symptoms Fatigue and weakness Abdominal symptoms Cerebral symptoms,9,PHYSICAL FINDINGS OF HF,General findings Pulse pressure （severe HF) SBP with cool, diaphoretic extremities, and Cheyne -Stokes respiration Cyanosis, sinus tachycardia,10,PHYSICAL FINDINGS OF HF,Cardiovascular findings S3 and S4 Cardiomegaly Murmurs Pulsus alternans Distention of j v. (systemic v. p),11,PHYSICAL FINDINGS OF HF,Pulmonary rales Cardiac edema Symmetric and dependent in the legs Most prominet in evening Hydrothorax and ascites Congestive hepatomegaly.,12,LABORATORY EXAMINATION,N-terminal-pro-BNP and BNP Two-dimensioanl echocardiography with Doppler flow studies Chest roentgenogram ECG,13,Echocardiogram,2D echo with Dopler technique for systolic and diastolic function of LV LVDd and LVDs（Dd and Ds） LVEF,14,DIAGNOSIS OF HF,Combination of the clinical manifestation of HF, together with the findings characteristic of one of the underlying forms of heart disease.,15,DIFF. DIAGNOSIS OF HF,Pulmonary disease Pulmonary embolism Ankle edema Enlargement of the liver and ascites,16,TREATMENT OF HF,Correction of the underlying cause Removal of the precipitating cause Prevention of deterioration of cardiac function Control of the congestive HF state,17,GENERAL MEASURES,Treating coronary risk factors Moderate dietary Na restriction Daily measurement of weight Prevent respiratory infection Avioding excessive alcohol, temperature extremes, and tiring trips,TREATMENT OF HF,Control of excessive fluid Diet Diuretics Thiazide diuretics Metolazone Frusemide Bumetanide torsemide Potassium-sparing diuretics,19,TREATMENT OF HF,Blockade of renin-angiotensin-aldosterone and adrenergic system ACE inhibitors Angiotensin receptor blockers Beta-adrenoceptor blockers Aldosterone antagonist,20,TREATMENT OF HF,Enhancement of myocardial contractility Digitalis Sympathomimetic amines Phosphodiesterase inhibitors,21,TREATMENT OF HF,Vasodilators Nitrates Nitroglycerine Isosorbide dinitrate Mononitrates Nitroprusside nesiritide,22,TREATMENT OF HF,Ventricular resynchronization Management of arrhythmia Anticoagulants Refractory heart HF Assisted circulation/cardiac transplant.,23,STAGE A,At high risk for HF but without structural heart disease or symptoms of HF. Treat hypertension Encourage smoking cessation Treat lipid disorders Encourage regular exercise Discourage alcohol intake, illicit drug use Control metabolic syndrome ACEI or ARB in appropriate patients for vascular disease or diabetes,24,STAGE B,Structural heart disease but without signs or symptoms of HF All measures under Stage A ACEI or ARB in appropriate patients Beta-blockers in appropriate patients,25,STAGE C,Structural heart disease with prior or current symptoms of HF. All measures under Stages A and B Dietary salt restriction DRUGS FOR ROUTINE USE Diuretics for fluid retention ACEI Beta-blockers DRUGS IN SELECTED PATIENTS Aldosterone antagonist ARBs Digitalis Hydralazine/nitrates DEVICES IN SELECTED PATIENTS Biventricular pacing Implantable defibrillators,26,STAGE D,Refractory HF requiring specialized interventions. Appropriate measures under Stages A, B, C Decision re: appropriate level of care OPTIONS Compassionate end of-life care/hospice Extraordinary measures heart transplant chronic inotropes permanent mechanical support experimental surgery or drugs,27,PROGNOSIS OF HF,28,Depend on Nature of the underlying heart disease Presence of a treatable precipitating factor The response to treatment,谢 谢,