按一下以編輯母片標題樣式,按一下以編輯母片,第二層,第三層,第四層,第五層,20,10,.0,6,.,05,沈阳,#,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,#,#,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,#,射血分数正常的心力衰竭,射血分数正常的心力衰竭,第1页,20,10,.0,6,.,05,沈阳,2,概念：,文件中描述各不相同,:,左心室射血分数保持心衰,(preserved left ventricular ejection fraction,HF-PLVEF),1,射血分数正常性心衰,(Normal Ejection Fraction,HFNEF),2,收缩功效尚存心衰,(Preserved Systolic Function,HF-PSF),1,舒张性心衰,2,1.HFSA,J Card Fail,.;12:1;,2.Oh JK,et al,.,J Am Coll Card,.;47:500-506;,射血分数正常的心力衰竭,第2页,20,10,.0,6,.,05,沈阳,3,HFNEF,不完全是,DHF,；它一样可见于收缩性心衰,(SHF),。,即使左室整体收缩功效保留,但,HFNEF,病人存在心肌组织多普勒,(TD),速度降低。,TD,速度较,LVEF,更为敏感，在缺乏准确区分左室舒张,/,收缩功效不全情况下,对于心衰不伴有,LVEF,降低者最好称为,HFNEF,或,HF-PEF,而不称为,DHF,射血分数正常的心力衰竭,第3页,20,10,.0,6,.,05,沈阳,Epidemiology,射血分数正常的心力衰竭,第4页,20,10,.0,6,.,05,沈阳,5,心衰患病率,66-103,75-86,70-84,75,50,40,25,55-95,78,76,75,60,68,65,年纪段,平均年纪,美国,(CHS),芬兰,(Helsinki),英国,(Poole),丹麦,.(Copen.),西班牙,(Asturias),葡萄牙,(EPICA),荷兰,(Rotter.),瑞典,(Vasteras),左心室收缩功效降低百分比,HF-PEF,百分比,55,51,68,46,71,59,39,71,1.Petrie M,McMurray J.,Lancet,.;358:423-434.2.Hogg K,et al,.,J Am Coll Card,.;43:317-327.,CHF,患病率,(%),0,1,2,3,4,5,6,7,8,9,10,射血分数正常的心力衰竭,第5页,20,10,.0,6,.,05,沈阳,6,HF-PEF,患病率长久趋势,1.Owan TE,et al,.,N Engl J Med,.;355:251-259.,射血分数正常的心力衰竭,第6页,20,10,.0,6,.,05,沈阳,7,HF-PSF,患者生存率,Bhatia RS,et al,.,N Engl J Med,.;355:260-269.,射血分数正常的心力衰竭,第7页,20,10,.0,6,.,05,沈阳,8,心衰患者再住院率,1.Hogg K,et al,.,J Am Coll Card,.;43:317-327.,再住院率,(%),Philbin,等,Malki,等,Smith,等,Dauterman,等,HF-PEF,44,26,46,58,HF-REF,42,33,46,58,射血分数正常的心力衰竭,第8页,射血分数正常的心力衰竭,第9页,20,10,.0,6,.,05,沈阳,临床特点,射血分数正常的心力衰竭,第10页,20,10,.0,6,.,05,沈阳,症状和体征：收缩功效不全,vs,舒张功效不全,射血分数正常的心力衰竭,第11页,12,参数,HF-REF,HF-PEF,病史,冠心病,高血压,糖尿病,瓣膜性心脏病,阵发性呼吸困难,+,+,+,+,+,+,+,+,+,体格检验,心界扩充,心音低钝,S3 奔马律,S4 奔马律,高血压,瓣膜返流,啰音,水肿,颈静脉充盈,+,+,+,+,+,+,+,+,+,+,+,+,+,+,+,+,+,+,胸部X线(X-ray),心脏扩充,肺淤血,+,+,+,+,+,+,HF-RHF,与,HF-PEF:,症状和体征,Givertz MM,et al,.In:Braunwald E,Zipes DP,Libby P,eds.,Heart Disease,A Textbook of,心血管,Medicine,.7th edition.Philadelphia,Pa:WB Saunders.;534-561.,射血分数正常的心力衰竭,第12页,13,两种心衰临床特点比较,EF下降HF,EF正常HF,(收缩功效尚存),病因,心梗,;,特发性扩张型心肌病,高血压,糖尿病,;,房颤,一过性缺血,临床进展,连续性 HF,通常间断性,HF,左心室重构,(,左心室容积增加,),+,0,左心室重构,(,左心室肥厚,),+/-,+,失同时,常见,可能相对少见,二尖瓣血流图形,充盈受限或舒张图形异常,舒张图形异常,舒张早期二尖瓣环峰值,显著下降,+,轻度下降,+,左房压力,升高,升高,左房容积,升高,升高,Sanderson JE.,Heart,;93:155-158.,射血分数正常的心力衰竭,第13页,14,有高血压病史,HF-PEF,患者百分比,报道时，大多数,HF-PEF,患者有高血压,大多数既往或当前有,LVH,1.,Senni M,et al,.,Circulation,.1998;98:2282-2289,.,4.,Owan TE,et al,.,N Engl J Med,.;355:251-259,2.,Vasan RS,et al,.,J Am Coll Card,.1999;33:1948-1955.,5.Bhatia RS,et al,.,N Engl J Med,.;355:260-269,3.,Gottdiener JS,et al,.,Ann Intern Med,.;137:631-639,Framingham,2,Olmsted,1,CHS,3,Owan,4,Bhatia,5,37,36,170,60,59,78,880,1570,2167,2429,n=,患者,(%),n=CHF,患者总人数,55,63,59,75,58,49,48,57,71,50,0,20,40,60,80,100,EF,尚正常,EF,降低,射血分数正常的心力衰竭,第14页,病理生理机制,射血分数正常的心力衰竭,第15页,16,左心室舒张和收缩功效不全机制,左心室压力,左心室容积,舒张功效不全,高血压,高龄,左心室肥厚,向心性重构,收缩功效不全,心梗、心肌病、,容量负荷过重,高血压,离心性重构,调整剂,:,血管担心素,II,醛固酮,儿茶酚胺,细胞因子,Adapted from Zile MR,Brutsaert DL.,Circulation,.;105;1387-1393.,射血分数正常的心力衰竭,第16页,20,10,.0,6,.,05,沈阳,舒张功效不全压力,-,容积环,射血分数正常的心力衰竭,第17页,20,10,.0,6,.,05,沈阳,Impaired Ventricular Relaxation,（心室松弛性下降）,Increased Ventricular Stiffness,（心,室僵硬度增加）,Hypertrophy,Myocardial ischemia,Hypertension,Collagen deposition,Regional asynchrony,Tachycardia,Myocardial infiltration,射血分数正常的心力衰竭,第18页,20,10,.0,6,.,05,沈阳,收缩期和舒张期时相,射血分数正常的心力衰竭,第19页,20,10,.0,6,.,05,沈阳,诊疗标准,射血分数正常的心力衰竭,第20页,21,需满足以下三个条件,:,1),心衰体征或症状,：因为一些病人仅存在呼吸困难症状,缺乏体征和液体负荷,故症状可作为存在,HFNEF,临床证据。,2),正常或轻度异常,LV,收缩功效,：,LVEF,50%(,45%ESC),LV,不大；舒张末容积指数,LVEDVI,97 mL/m2,3),舒张性,LV,功效不全证据,射血分数正常的心力衰竭,第21页,22,有创性评价舒张性,LV,功效不全指标,是,HFNEF,确实切证据,包含,:,左室舒张末压,(LV end-diastolic pressure),16 mmHg,或,平均肺毛细血管楔压,(mean pulmonary capillary wedge pressure),12 mmHg,射血分数正常的心力衰竭,第22页,23,无创评价舒张性,LV,功效不全指标,心肌组织,Doppler(TD),评定,LV,舒张功效不全,:,测量左室基底部,(,二尖瓣环,),长轴心肌缩短速度或长轴速度,E/E”,比值,15,是,LV,舒张功效不全诊疗依据,如,E/E,8,则可除外,HFNEF,诊疗,E/E,比值介于,8-15,提醒有,LV,舒张功效不全,但不能作出必定诊疗,应结合其它无创指标,射血分数正常的心力衰竭,第23页,24,血流,Doppler,测定二尖瓣速度,E/A,比值和,TD,联合应用,射血分数正常的心力衰竭,第24页,20,10,.0,6,.,05,沈阳,舒张功效不全分期,射血分数正常的心力衰竭,第25页,26,左室肌重指数,LV mass index,122 g/m2(,女性,),149 g/m2(,男性,),对,HFNEF,含有充分诊疗价值,左房容积指数,(LA volume index),左房容积指数,40 mL/m2,则足以证实有,LV,舒张功效不全,相反,如左房容积指数,29 mL/m2,是排除,HFNEF,必须条件,心电图证实房颤,射血分数正常的心力衰竭,第26页,20,10,.0,6,.,05,沈阳,B,型脑钠肽，,BNP,Maisel A.S.,et al,from the Division of Cardiology and Department of Medicine,Veterans Affairs Medical Center and University of California,San Diego:Utility of B-natriuretic peptide as a rapid,point-of-care test for screening patients undergoing echocardiography to determine left ventricular dysfunction.August.,射血分数正常的心力衰竭,第27页,20,10,.0,6,.,05,沈阳,B,型脑钠肽，,BNP,Maisel A.S.,et al,from the Division of Cardiology and Department of Medicine,Veterans Affairs Medical Center and University of California,San Diego:Utility of B-natriuretic pept