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ㄧ般內科病例聯合討論PGY洪啟偉/VS黃信凱980403 PatientProfileChartNo.:13723785,吳X進Age:56y/oGender:maleDateofadmission:2009/03/06Hxof1)CHF,FcIIIHCVDrelated2)hypertensionfor10+years3)Gangrenouscholecystitiss/pcholecystectomy4)BPH ChiefcomplaintShortofbreathfor1monthandaggregatedinrecenttwodays PresentillnessCHF,FcIIIHCVDrelatedandhypertensionfor10+yearslostregularmedicalcontrolforonemonthsufferedfromS.O.B,orthropnea,PNDWithbil.lowerlegspittingedemadenieddecreaseurineoutput,dysuria,Chesttightnesscharacter:heavycompressionpersistedalldaylongnoabd.painCoughwithsputumfor1monthwhiteaggregatedinrecenttwodaysdeniedasthmahx,nofever ShortnessofbreathL:Q:rapid,shallowbreathingQ:persistentlyO:progressionafterdiscontinueofmedicationP:E:exerciseR:restA:orthopnea、PND、chesttightness、urineoutputdecrease(-) PastMedicalHistory1.Medicalhistory:Hypertension--------(+)Diabetesmellitus---(-)ChronichepatitisB--(-)ChronichepatitisC--(-)2.Surgicalhistory:Gangrenouscholecystitiss/pcholecystectomy3.Drugallergy:Noknownallergy PersonalHistorySmoking:(+)2ppd/dailyDrinking:socialdrinkingBetelnutsuse:deniedHistoryofoverseatravel:deniedHistoryofcontactwithanimalsorsickpeople:denied PhysicalexamVitalsign:T:36.3P:75R:18BP:102/78Consciouslevel:clearHEENT:Eyes:conjunctivanotpale,scleranoticteriaNeck:Supple,Jugularvenousengorgement(-),nolymphadenopathyNothyroidenlargementChest&Lungs:Symmetricalexpansion,Breathingsound:moistralesanddiminishoverrightchestregion PhysicalexamHeart:HS:RegularheatbeatAbdomen:fullnessanddistensiontenderness(-),reboundingpain(-)Liver/spleen:palpable(-)/(-)Normalactivebowelsounds,NoabdominalbruitExtremities:Freelymovable,Pittingedema(+) ExamCBC/DC,e-,CardiacenzymeBUN/Cr,GOT/GPTCXREKG LAB CXR EKGAPC SinustachycardiaFirstdegreeAVblock Non-specificST-Tchanges ImpressionCongestiveheartfailurewithbilateralpulmonarycongestion AdmissionCoarse核醫CXRAbdominalecho3/63/73/83/93/103/113/12AdmissionCardiacEcho AtwardLaxis1ampq12h+aldactone1#qdWaterrestriction1200cc/dayCheckBW Cardiacecho1.DilatedLA,LV,RA,RV.2.SevereeccentricMR,moderateTR.3.PoorLVglobalperformance. Abdominalechoabdominaldistension-r/o1.CHFrelatedascites2.cirrhosis3.tumorgrowth*Hepaticcyst*Bil.pleuraleffusion*Ascites,smallamount CXR3/9Coughwithpinkishfrothysputum+Acertil0.5#qd,Dilatrend0.5#bid VentricleEjectionFractionandWallMotionStudyLVEF(%)-18LVpeakfillingrate(EDC/S)-1.06LVtimefromsystoletopeakfilling(msec)-100RVEF(%)-23RVpeakfillingrate(EDC/S)-0.86RVtimefromsystoletopeakfilling(msec)-600 DISCUSSION 心衰竭之定義心臟機能暫時性或永久行下降造成心輸出量不足以達到需求時，它是一種症候群；而不是ㄧ種疾病。 心臟衰竭的分類收縮性心衰竭systole或舒張性心衰竭diastole低輸出性lowcardiacoutput心衰竭或高輸出性心衰竭highcardiacoutput急性acute心衰竭或慢性心衰竭chronic右側right心衰竭或左側left心衰竭前向式forward心衰竭或後向式backward心衰竭鹽salt或水water堆積造成的心衰竭 鬱血性心臟衰竭診斷之FraminghamCriteria主要準則陣發性夜間呼吸困難paroxysmalnocturnaldyspnea頸靜脈擴張Neckveindistention肺部鑼音Rales心臟擴大cardiomegaly急性肺水腫Acutepulmonaryedema心臟奔馬音S3gallop中心靜脈壓升高Increasedvenouspressure>16cmH2OPositivehepatojugularreflux次要準則踝部浮腫Extremityedema夜間咳嗽Nightcough勞動性呼吸困難Dyspneaonexertion肝腫大hepatomegaly胸膜積水Pleuraleffusion肺活量減少三分之ㄧ心跳過速tachycardia>120/min診斷條件:二項主要準則或ㄧ項主要準則加上二項次要準則 慢性心臟衰竭機能評估-NYHA1.病人有心臟病，但未使體力活動受到限制，平常的體力活動不致引起疲乏、心悸、呼吸困難、或心絞痛。2.病人有心臟病使其體力活動受到輕微限制，休息時覺得舒適，但平常的體力活動會引起疲乏、心悸、呼吸困難或心絞痛。3.病人有心臟病使其體力活動受到明顯限制，休息時覺得舒適，但低於平常的體力活動或引起疲乏、心悸、呼吸困難或心絞痛。4.病人有心臟病使其無法從事任何體力活動而不引起症狀，就是休息時也可能出現心臟機能不足的症狀或心絞痛，從事任何活動的話，不舒服的程度就或加重。 心臟衰竭的促發或加重因素Predisposingfactor需求增加：貧血、發燒、感染、食鹽攝食增加、環境溫度升高、呼吸衰竭、腎衰竭、肝衰竭、甲狀腺機能亢進、動靜脈瘻管、情緒壓力、懷孕、肥胖心臟血管疾病心律不整高血壓控制不良藥物：NSAID、鈣離子阻斷劑、類固醇、酒精、Doxorubicin體液過量肺栓塞飲食或藥物控制不良 心衰竭之病因心室壓力負荷過重(pressureoverloading)高血壓,主動脈瓣狹窄心室容積負荷過重(volumeoverloading)二尖瓣閉鎖不全,主動脈瓣閉鎖不全心肌無力收縮(impairedcontractility)心肌缺氧,心肌梗塞,心肌病(diatedcardiomyopathy) 診斷和評估心衰竭之方法理學檢查X光攝影心電圖心超音波圖心臟核醫攝影心導管和冠狀動脈攝影 PathophysiologyofChronicHeartFailurePhaseI:theinitialresponsetomyocardialinjuryPhaseII:thedevelopmentofheartfailurePhaseIII:theprogressionofheartfailure PharmacologicAgentsforCHFDiureticsDigitalisVasodilatorsACEinhibitorsAT1receptorblockersBeta-blockers STAGESOFHFStageA—HighriskforHF,withoutstructuralheartdiseaseorsymptomsStageB—HeartdiseasewithasymptomaticleftventriculardysfunctionStageC—PriororcurrentsymptomsofHFStageD—RefractoryendstageHF ManagementofHeartFailure PatientswithclassAheartfailureControlofriskfactorsHTNDMlipidsModificationsoflifestyleModeratesodiumrestrictionWeightmonitoringAdherencetomedicationschedulesModerationofalcoholintakeScheduledexerciseprogram StageB,C,orDHFwithorwithoutSymptomsACEIForasymptomatichighriskpatientswithDMorvasculardiseaseandnohistoryofheartfailure(reductionintheratesofdeath,MI,andstroke)ForpatientswithMI,improvementsinSurvival,therateofhospitalization,symptoms,cardiacperformance,neurohomonallevels,andreverseremodeling ARB(lorsartan)ForheartfailureinpatientswithDMandneuropathy(delaythefirsthospitalization)ShouldnotbeusedasfirstlineUsedinpatientswhocan’ttolerateACEI(severecoughorangioedema)Improvementsincardiovascularmorbidityandsurvival,decreaseintheincidenceofnew-onsetDM ß-blockersTocounteracttheharmfuleffectsofsympatheticnervoussystemImprovementsinsurvival,morbidity,ejectionfraction,remodeling,qualityoflife,therateofhospitalizationandtheincidenceofsuddendeathUsedinstablecondition AdditionaltherapyforsymptomaticpatientswithstageCorDheartfailureSpironolactoneAnaldosteroneanatagonistAldosteroneStimulationbyangiotensinIIanddecreaseinthehepaticclearanceStimulatestheretentionofsalt,myocardialhypertrophy,andpotassiumexcretionDecreaseincollagensynthesis DiureticsMainstayforcontrollingsymptomsofcongestionThiazideorloopdiuretics,orbothDigoxinNodifferentinmortalityDecreasingintheratesofworseningheartfailureandhospitalizationLowserumconcentration(<0.09ng/ml) RevascularizationandsurgicaltherapyCatheter-basedorasurgicalapproachImprovesischemicsymptoms,cardiacperformance,andreducestheriskofsuddendeath TheEndThanksforyourattention AssessmentFindingsofAcutePulmonaryEdemaSeveredyspneaandorthopneaPallorTachycardiaExpectorationoflargeamountsofblood-tinged,frothysputumWheezingandcracklesonauscultationBubblingrespirationsAcuteanxiety,apprehension,restlessnessProfusesweatingCold,clammyskinCyanosisNasalflaringUseofaccessorybreathingmusclesTachypneaHypocapnia,evidencedbymusclecramps,weakness,dizzinessandparesthesias Thepatienthashypotension:whenisthesystolicbloodpressuretoolow?Asympotomaticpatientswithdilatedcardiomyopathyoftentolerateasystolicbloodpressureof90mmHg.Ifthepatienthasnolightheadednessorundueorfatigue,peripheralperfusionisadeqate,andbloodureanitrogenandcreatinineareunchanged,continuethesamedosesofmedications.Insymptomaticpatients,decreasethedoseofdiuretic.Ifsymptomspersist,adjustmentofthetimingofconcomitantmedicationsmaybehelpful.DecreasingthedosesoftheACEI,ß-blocker,ARB,orvasodilatorisindicated. 2002/04admission,donutamineinfusionanddiureticweregivenforCHFwithdilateddysfunction.Cardiacechoshowed1.fourchamberdilatation2.severemR+++,mildTR,moderatepulmonaryHTNpap=50mmhg3.poorglobalLvperformance
