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心功能不全. (Cardiac insufficiency ). 华中科技大学同济医学院病理生理系. Clinical example. 病史: 患风湿性心脏病 10 余年。近 3 月来出现心慌、闷气 , 伴浮肿、腹胀,不能平卧。

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Cardiac insufficiency

(Cardiac insufficiency)


Cardiac insufficiency

Clinical example

103,

, ,, 36/, , 130/, (110/80mmHg)IV6cm


Cardiac insufficiency

heart failure

()


Cardiac insufficiency

  • (Cardiac insufficiency )

  • heart failure)


Cardiac insufficiency

(Causes and predisposing

factors of heart failure)


Cardiac insufficiency

(Causes)


Cardiac insufficiency

()

(Impaired myocardium)


Cardiac insufficiency

()

(Overload for myocardium)


Cardiac insufficiency

(Predisposing factors)


Cardiac insufficiency

(Classification of heart failure)


Cardiac insufficiency

  • (left-sided heart failure)

  • (right-sided heart failure)

  • (whole heart failure)


Cardiac insufficiency

  • (systolic heart failure)

  • (diastolic heart failure)


Cardiac insufficiency

(low-output heart failure)

(high-output heart failure)


Cardiac insufficiency


Cardiac insufficiency

  • :

(acute heart failure)

(chronic heart failure)


Cardiac insufficiency

  • :

(mild heart failure)

(moderate heart failure)

(severe heart failure)


Cardiac insufficiency

(Mechanisms of heart failure)


Cardiac insufficiency


Cardiac insufficiency

Ca2+

Ca2+

ATP


Cardiac insufficiency


Cardiac insufficiency

1.

(Injuries of myocardial contractile protein)


Cardiac insufficiency


Cardiac insufficiency

TNF

IL-1

IL-6

IFN

OFR

NO

ATP

[H+]


Cardiac insufficiency

2.

(Disorder of myocardial energy metabolism)


Cardiac insufficiency

O2

VitB1

ATP

(1)

(impaired energy production)

:


Cardiac insufficiency

ATP:

Ca2+

Ca2+

Ca2+

Ca2+


Cardiac insufficiency

(2)

(impaired energy utilization)

ATP:

V1 ():

V2 ():

V3 ():

ATPV1 V3


Cardiac insufficiency

ATP

(3)

(reduced energy reserve)

(CP)

CP


Cardiac insufficiency

3.

(Impaired excitation-contraction coupling)

Ca2+

Ca2+

Ca2+


Cardiac insufficiency

(1)Ca2+

  • Ca2+

  • ATP Ca2+

P-PLA

PLA

Ca2+


Cardiac insufficiency

Ry-

H +

Ca2+

  • Ca2+

    Ca2+

  • Ca2+

Ry-

Ca2+

H +


Cardiac insufficiency

(2) Ca2+

H+

+

K+

Ca2+

cAMP

ATP

Ca2+


Cardiac insufficiency

  • 1-

  • K+Ca2+


Cardiac insufficiency

(3) Ca2+

H+Ca2+,troponinCa2+


Cardiac insufficiency

4.

(Imbalance growth of myocardial hypertrophy)

  • ,

  • ATP

  • Ca2+


Cardiac insufficiency

Ca2+

Ca2+

(Impaired myocardial diastolic properties)


Cardiac insufficiency

Ca2+

Ca2+ATP

Na+ - Ca2+

Ca2+

Ca2+

Ca2+


Cardiac insufficiency

  • -

ATP

, ,

--p-V


Cardiac insufficiency

dv/dp

dv/dp

V

dv/dp


Cardiac insufficiency


Cardiac insufficiency

(Compensatory mechanisms to cardiac insufficiency)


Cardiac insufficiency

-


Cardiac insufficiency

-

  • --


Cardiac insufficiency

Ag II

ET


Cardiac insufficiency


Cardiac insufficiency


Cardiac insufficiency

1.


Cardiac insufficiency

(>150/):


Cardiac insufficiency

0

1.7

2.1

2.2

3.65 m

Lmax

Normal

Frank-Starling

2 .


Cardiac insufficiency

  • 2.2m

  • 2.2m


Cardiac insufficiency

3.


Cardiac insufficiency


Cardiac insufficiency

,CO

,,


Cardiac insufficiency

*

*

*

*


Cardiac insufficiency

ADH

  • ,

()


Cardiac insufficiency

()

()

()


Cardiac insufficiency

(Consequences of

the pumping dysfunction)


Cardiac insufficiency

(syndrome of low output)

:

  • (cardiac output,CO)

  • (ejection fraction)

  • (ventricular filling)

  • (heart rate)


Cardiac insufficiency

:


Cardiac insufficiency

  • (syndrome of venous congestion)

  • :

  • (systemic congestion)

  • (pulmonary congestion)


Cardiac insufficiency

()

(Systemic congestion)

CVP>16 cmH2O


Cardiac insufficiency


Cardiac insufficiency

() (Pulmonary congestion)

PCWP>18 mmHg


Cardiac insufficiency

: (dyspnea)

:


Cardiac insufficiency

:

  • (dyspnea on exertion)

  • (orthopnea)

  • (paroxysmal nocturnal dyspnea)


Cardiac insufficiency

:


Cardiac insufficiency

:

  • ,


Cardiac insufficiency

:


Cardiac insufficiency

(Pathophysiological basis of

prevention and treatment

for heart failure )


Cardiac insufficiency


Cardiac insufficiency

Clinical example

103,

, ,, 36/, , 130/, (110/80mmHg)IV6cm


Cardiac insufficiency


Cardiac insufficiency

1.

2.

3.

4.ATP

5.

6.


Cardiac insufficiency

Respiratory Failure


Cardiac insufficiency

PiO2 150mmHg

ventilation

PAO2 100

PACO2 40

gas exchange

PvO2 40mmHg

PvCO2 46mmHg

PaO2 100mmHg

PaCO2 40mmHg


Cardiac insufficiency

Process of external respiration


Cardiac insufficiency

PaO2

60mmHg

Hypoxemic PaCO2 I

Hypercapnic 50mmHgII


Cardiac insufficiency

3000mPaO2 60mmHg

PiO2

PaO2

Everest


Cardiac insufficiency

ventilatory disorder

1restrictive

1

2

3 RDS

4


Cardiac insufficiency

2obstructive

dyspnea


Cardiac insufficiency


Cardiac insufficiency


Cardiac insufficiency


Cardiac insufficiency


Cardiac insufficiency


Cardiac insufficiency

0

0

+5

+10

+10

+20

+20

+20

+30

+20

+20

+20

+35

+25

+20

+20

+20

+20

Unit: cmH2O


Cardiac insufficiency

PaCO2

PaO2

PaCO2

0.863VCO2

VA

PACO2 =


Cardiac insufficiency

diffusion disorder

1

2

+

PaO2

PaCO2


Cardiac insufficiency

PCO2( kPa )

PO2

13.33

PaO2

PvCO2

10.67

6.13

8.00

PvO2

5.33

PaCO2

2.67

0.75 s

0

0.50

0.25


Ventilation perfusion imbalance

10cmH2O

4L

VA

VA/Q

0.8

=

=

Q

5L

3

0.6

- 2.5cm H2O

Ventilation-perfusion imbalance


Ventilation perfusion imbalance1

4L

VA

0.8

=

=

Q

5L

Ventilation-perfusion imbalance

VA Q VA/Q

1

10

3

0.6

3

6


Cardiac insufficiency

VA/Q 0.8 0.8 =0.8

PaCO2 N

CaCO2 N

1functional shunt

PaO2 ?

CaO2


Cardiac insufficiency

2

dead space like

?


Cardiac insufficiency

2

dead space like


Cardiac insufficiency

1PaCO2

2 ,


Cardiac insufficiency

anatomic shunt


Cardiac insufficiency

ARDS


Cardiac insufficiency

PaO2 60mmHg

30mmHg

PaCO2 50mmHg

80mmHg

COPDPaO2 pH

PaCO275-110mmHg

III


Cardiac insufficiency

Hepatic insufficiency


Cardiac insufficiency


Cardiac insufficiency


Cardiac insufficiency


Cardiac insufficiency


Cardiac insufficiency


Cardiac insufficiency


Cardiac insufficiency

  • -6-


Cardiac insufficiency


Cardiac insufficiency

Ald


Cardiac insufficiency

ADH

ADH


Cardiac insufficiency


Cardiac insufficiency


Cardiac insufficiency


Cardiac insufficiency

  • intestinal endotoxenia

1

1

2,

2


Cardiac insufficiency

1.

2.

3.ECICAM-1

4.

,EC


Cardiac insufficiency


Cardiac insufficiency


Cardiac insufficiency

Hepatic encepholopathy

:


Cardiac insufficiency

=


Cardiac insufficiency


Ammonia intoxication hepothesis

ammonia intoxication hepothesis


Cardiac insufficiency

  • 80%


Cardiac insufficiency


Cardiac insufficiency


Cardiac insufficiency

ATP


Cardiac insufficiency

6-

6-

NAD

NAD

NADH

NADH

A

A

-

+

+

ATP

NAD

NADH

-

-

-

NADH

+NH3

NAD

+NH3

ATP

1.

2.


Cardiac insufficiency

  • 1. 20%

  • 3.


Cardiac insufficiency

False neurotransmitter hepothesis


Cardiac insufficiency


Cardiac insufficiency


Cardiac insufficiency


Cardiac insufficiency

CHOHCH2NH2

CHOHCH2NH2

HO

HO

CHOHCH2NH2

CH2CH2NH2

HO

HO

HO


Cardiac insufficiency

Hepatic failure

Nomal


Cardiac insufficiency

Plasma amino acid imblance hepothesis


Cardiac insufficiency

  • BCAA/AAA (decrease from 33.5 to 0.6 1.2)

  • BCAA/AAA


Cardiac insufficiency

BCAA

BCAA/AAA

AAA

/

AAA


Cardiac insufficiency

FNT

FNT

5-

5-

-

-

FNT

5-


Cardiac insufficiency


Cardiac insufficiency

  • 1. +

  • BCAA/AAA

  • 3. + BCAA


Cardiac insufficiency

GABA

GABA hepothesis


Cardiac insufficiency

  • GABA

  • GABA


Cardiac insufficiency

Cl-

Cl-

Cl-

GABA

Cl-


Cardiac insufficiency

GABAGABA


Cardiac insufficiency


Cardiac insufficiency

BCAA/AAA

(+)

GABA

(+)

GABA

GABA

-


Cardiac insufficiency


Cardiac insufficiency


Chronic renal failure

Chronic Renal Failure


Chronic renal failure1

Chronic Renal Failure


Cardiac insufficiency


Cardiac insufficiency

Causes of CRF: Obstruction/reflux


Cardiac insufficiency


Cardiac insufficiency

,

1.

2.

3.

4.

CRI


Cardiac insufficiency

30%

25% 30%

20%25%

20%


Cardiac insufficiency

?

  • ,

  • : , , NPN


Cardiac insufficiency

GFR


Cardiac insufficiency

CRI,,,,?


Cardiac insufficiency

1.

Intact nephron Hypothesis

GFR

GFR


Cardiac insufficiency

GFR

2. Trade-off Hypothesis

PTH


Cardiac insufficiency

3. Glomerular HyperfiltrationHypothesis


Cardiac insufficiency

4.-

CRI

--


Cardiac insufficiency

CRI


Cardiac insufficiency

()

1.:

Normal: 1500ml/

1000ml/ 500ml/

nocturia),

polyuria) >2000ml/d,

<400ml/d


2 1 008 1 012 n 1 002 1 035

2. , 1.008-1.012N1.002-1.035

3.

,

,


Cardiac insufficiency

()

1.: azotemia)

GFR

NPN>40mg/dl


Cardiac insufficiency

GFR BUN

40% Normal

20% 200mg/dl

=Cr*/Cr

:BUNCr


Cardiac insufficiency

2.

AG

CRI:

(,)

AG

CRI:


Cardiac insufficiency

3.

:

,

,


Cardiac insufficiency

CRI

,

,,


Cardiac insufficiency

GFR

VitD3


Cardiac insufficiency

GFR

PTH


Cardiac insufficiency

CRI


Renal hypertension

GFR

renal hypertension

-

PGA2 E2

-


Cardiac insufficiency

1.25-(OH)2VitD3

GFR

PTH


Uremia

Uremia


Uremia1

Uremia


Cardiac insufficiency

1

2


Cardiac insufficiency

PTH


Cardiac insufficiency

-

CRF


Cardiac insufficiency

PaCO2

PaCO2


Cardiac insufficiency

1 ()

(1)

(2)

(3)


Cardiac insufficiency

2.

( )

PTH


Cardiac insufficiency

PTH


Cardiac insufficiency

1.

.


Cardiac insufficiency

2.

ATP

-

-


Cardiac insufficiency

3.

1

2

3


Cardiac insufficiency

4.500-5000

1

2

3

4


Cardiac insufficiency

5.PTH

1

2

3

4


Cardiac insufficiency


Cardiac insufficiency

XX 68 80118

:,3,,10.:3,,,,.,,.

..,,,,,,,,,,150ml.:13,. :,,T37,R 130/min,,P 90/min,

Bp 160/90mmHg,,,,,,.:RBC 200/cmm,Hb 6g%,12.8/cmm,

92.2mg%,11.2mg%,

K+ 5.9%mEq/L,Na+ 123mEq/L,Ca2+ 7mg/L,7mg/dL,

1.010,(++)


Cardiac insufficiency

  • ARF

  • ?

  • ,?

  • ?

  • 7.

  • 8. ,,,

  • 9. ?

  • 10.,

  • 11.

  • 12.,


Cardiac insufficiency


Cardiac insufficiency

Renal Insufficiency(RI)

Renal failure(RF)


Cardiac insufficiency


Cardiac insufficiency


Cardiac insufficiency


Cardiac insufficiency

  • H+ K + NH3


Cardiac insufficiency

  • 125OH)2VitD3

  • PTH


Cardiac insufficiency

:


Cardiac insufficiency

Acute renal insufficiency ARI


Cardiac insufficiency

GFR


Cardiac insufficiency

  • (prerenal ARI)

  • (postrenal ARI )

  • (intrarenal ARI )


Cardiac insufficiency

GFR

RAA&ADH

1. Prerenal ARI :vascular


Cardiac insufficiency


Cardiac insufficiency

GFR

2. Postrenal ARI :obstructive


Cardiac insufficiency

3.Intrarenal ARI : parenchymal

GFR

()


Acute tubular necrosis atn

Acute Tubular Necrosis : ATN

  • S3mTAL

ATNARF75%


Etiology of atn

Etiology of ATN

1. renal ischemia:

110-8mmHg

2S3,mTAL

31mmol NaCl30umol


Cardiac insufficiency

2.Nephrointoxincation :

:

:


Cardiac insufficiency

GFR

1.

2.

3.

4.


Cardiac insufficiency

ATN


Cardiac insufficiency


Cardiac insufficiency


Cardiac insufficiency

ATN

GFR

GFR


Cardiac insufficiency

133Xe,RBF

?


Cardiac insufficiency

(1)

(2)

(3)


Cardiac insufficiency

  • 80mmHg<BP<160mmHg:RBF.GFR

  • 50mmHg<BP<70mmHg:RBF,GFR1/2-2/3

  • BP<=40mmHg:RBF,GFR


Cardiac insufficiency

  • -()

  • PGs


Cardiac insufficiency

GFR

AT


Cardiac insufficiency

A1R

A2R

AT

GFR


Cardiac insufficiency


Cardiac insufficiency

GFR


Cardiac insufficiency

1


Cardiac insufficiency

2

  • ATP

GFR


Cardiac insufficiency

GFR

ARI


Cardiac insufficiency

ARI

(oliguria stage)

(diuresis stage)

(recovery stage)


Cardiac insufficiency

816

1.

2.

3.

4.

5.


Cardiac insufficiency

1.

2.

1GFR

2

3

4


Cardiac insufficiency

ARI


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