急性心力衰尽的紧急处置（左心+右心）
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_png/qaUKmdu4nyBzmG5X6LPWkkEEULQ5cn7r04P5ojlFCwMwBBgibpZOP7DF3sXT5Vqu8qMVVpKyg8vIpVwoSfptEyA/640?wx_fmt=png&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">不想<span style="color: black;">错失</span>每条推送？</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">点击上方“</span><span style="color: black;"><span style="color: black;"><strong style="color: blue;">心内之友</strong></span></span><span style="color: black;"><span style="color: black;">”→点击右上角“…”→点选“设为星标</span><span style="color: black;">★</span><span style="color: black;">”，</span></span></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">就<span style="color: black;">能够</span>在推文发出后<span style="color: black;">第1</span>时间看到啦~~</span></p><span style="color: black;">
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">随着生活节奏和生活方式的改变，心脏病的种类<span style="color: black;">亦</span>在<span style="color: black;">持续</span>更新，今天把<span style="color: black;">平常</span>临床<span style="color: black;">平常</span>的急性左心<span style="color: black;">衰尽</span>分享给<span style="color: black;">大众</span>，如有问题，欢迎<span style="color: black;">大众</span>批评指正。</p>
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<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">概念</strong></span></p><span style="color: black;">2021年由美国心力<span style="color: black;">衰尽</span>学会（HFSA）、欧洲心脏病学会心力<span style="color: black;">衰尽</span>协会（HFA）、日本心力<span style="color: black;">衰尽</span>学会（JHFS）<span style="color: black;">一起</span>撰写的《心力<span style="color: black;">衰尽</span>的通用定义和<span style="color: black;">归类</span>》<span style="color: black;">颁布</span>，该共识得到了中国、加拿大、澳大利亚和新西兰等多个国家心力<span style="color: black;">衰尽</span>学会的认可。共识提出了心衰的通用定义以及新的分期和<span style="color: black;">归类</span>标准。</span><img src="https://mmbiz.qpic.cn/mmbiz_png/t7CLudq09QjtvnLvWEqD5LEXOWib0iahFBzsyLaV8vEMEQfrVYdaglGWx69taAVfkia6wGgyTLTAiaLOY1bCIQeHUQ/640?wx_fmt=png&wx_lazy=1&wx_co=1&tp=webp&wxfrom=5" style="width: 50%; margin-bottom: 20px;"><span style="color: black;">心衰是一种由不同病因<span style="color: black;">引起</span>的临床<span style="color: black;">综合症</span>，其病理生理机制存在差异，而非一种特定的<span style="color: black;">疾患</span>。既往各权威学术<span style="color: black;">公司</span>对心衰的定义各不相同，有些侧重于临床<span style="color: black;">综合症</span>的诊断特征，而有些更偏重血液动力学和生理学特征。</span><span style="color: black;">共识提出了全面的心力<span style="color: black;">衰尽</span>的通用定义：心力<span style="color: black;">衰尽</span>是一种临床<span style="color: black;">综合症</span>，其症状和/或体征由心脏结构和/或功能<span style="color: black;">反常</span><span style="color: black;">导致</span>，并由利钠肽（BNP）水平<span style="color: black;">上升</span>和/或肺部或全身充血的客观证据所证实。</span><span style="color: black;">定义中的心脏结构和/或功能<span style="color: black;">反常</span><span style="color: black;">包含</span>：射血分数（EF）<50％，心腔<span style="color: black;">反常</span>扩大，E/E>15，中/重度心室肥厚，或中/重度瓣膜狭窄或反流。</span><span style="color: black;">利钠肽（如BNP和NT-proBNP）是诊断心衰不可或缺的<span style="color: black;">构成</span>部分，<span style="color: black;">尤其</span>是在诊断不确<span style="color: black;">按时</span>。 </span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">心力<span style="color: black;">衰尽</span>分期</strong></span></p><strong style="color: blue;"><span style="color: black;">A期（心衰<span style="color: black;">危害</span>期）</span></strong><span style="color: black;"><span style="color: black;">病人</span>有心衰<span style="color: black;">危害</span>但<span style="color: black;">日前</span>或既往<span style="color: black;">没</span>心衰症状或体征，且<span style="color: black;">无</span>心脏病的结构或生物标志物证据。</span><span style="color: black;"><span style="color: black;">身患</span>高血压、动脉粥样硬化性心血管<span style="color: black;">疾患</span>、糖尿病、<span style="color: black;">肥壮</span>、已知接触过心脏毒性物质、有心肌病或遗传性心肌病阳性家族史的<span style="color: black;">病人</span>属于这一类。这些<span style="color: black;">病人</span>并不是都会<span style="color: black;">出现</span>心衰，但可能<span style="color: black;">必须</span>进行危险<span style="color: black;">原因</span><span style="color: black;">干涉</span>。</span><strong style="color: blue;"><span style="color: black;">B期（心衰前期）</span></strong><span style="color: black;"><span style="color: black;">病人</span><span style="color: black;">日前</span>或既往<span style="color: black;">没</span>心衰症状或体征，但存在结构性心脏病或心功能<span style="color: black;">反常</span>或利钠肽水平<span style="color: black;">上升</span>的证据。</span><span style="color: black;">结构性心脏病：左心室肥厚、心腔扩大、室壁运动<span style="color: black;">反常</span>、心肌组织<span style="color: black;">反常</span>（如，心肌水肿、CMR T2或LGE<span style="color: black;">影像</span><span style="color: black;">表示</span>的瘢痕/纤维化<span style="color: black;">反常</span>）、瓣膜性心脏病。</span><span style="color: black;">心脏功能<span style="color: black;">反常</span>：左心室或右心室收缩功能降低，有创或<span style="color: black;">没</span>创<span style="color: black;">检测</span>中充盈压<span style="color: black;">增多</span>的证据，舒张功能<span style="color: black;">反常</span>。</span><span style="color: black;">利钠肽水平<span style="color: black;">上升</span>或心肌肌钙蛋白水平<span style="color: black;">上升</span>，尤其是在暴露于心脏毒性物质的情况下。</span><strong style="color: blue;"><span style="color: black;">C期（心衰期）</span></strong><span style="color: black;"><span style="color: black;">病人</span><span style="color: black;">日前</span>或既往存在由心脏结构和/或功能<span style="color: black;">反常</span><span style="color: black;">导致</span>的心衰症状和/或体征。</span><strong style="color: blue;"><span style="color: black;">D期（晚期心力<span style="color: black;">衰尽</span>）</span></strong><span style="color: black;"><span style="color: black;">病人</span>在<span style="color: black;">休憩</span>时有严重的心衰症状和/或体征，尽管接受了指南<span style="color: black;">指点</span>的管理和治疗（GDMT），但仍反复住院，为难治性或对GDMT不耐受，<span style="color: black;">必须</span>接受高级治疗，如<span style="color: black;">思虑</span>心脏移植、机械循环支持或姑息治疗。</span><img src="https://mmbiz.qpic.cn/mmbiz_png/dC8JRYvqT7VBfAjydXH8TueldRMeSgicb7Mktz5w0KYpgqHUSzSdMwmo88fxVdpyOgYiasBXYN3ibKwGVTlMWNQ0Q/640?wx_fmt=png&wx_lazy=1&wx_co=1&tp=webp&wxfrom=5" style="width: 50%; margin-bottom: 20px;">
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">心力<span style="color: black;">衰尽</span><span style="color: black;">归类</span></strong></span></p><span style="color: black;">新版共识<span style="color: black;">按照</span>左心室射血分数（LVEF）提出了新的心衰<span style="color: black;">归类</span>：</span><span style="color: black;">✓射血分数降低的心力<span style="color: black;">衰尽</span>（HFrEF）：LVEF≤40%；</span><span style="color: black;">✓射血分数轻度降低的心力<span style="color: black;">衰尽</span>（HFmrEF）：LVEF41-49%；</span><span style="color: black;">✓射血分数<span style="color: black;">保存</span>的心力<span style="color: black;">衰尽</span>（HFpEF）：LVEF≥50%；</span><span style="color: black;">✓射血分数改善的心力<span style="color: black;">衰尽</span>（HFimpEF）：基线LVEF≤40%，LVEF较基线水平<span style="color: black;">加强</span>超过10个百分点，且再次<span style="color: black;">测绘</span>时LVEF＞40%。</span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">心功能分级</strong></span></p><strong style="color: blue;"><span style="color: black;">1、NYHA心功能分级标准</span></strong><img src="https://mmbiz.qpic.cn/sz_mmbiz_jpg/VibUMkIFrLHD45m7YHYZvR7icicmwicwibZAGcl8TVSictj5xH7U7IMm7H5dwsmU5IR66b94bxdHeV3TL0kFffd6JL2w/640?wx_fmt=jpeg&wx_lazy=1&wx_co=1&tp=webp&wxfrom=5" style="width: 50%; margin-bottom: 20px;"><strong style="color: blue;"><span style="color: black;">2、Killip分级</span></strong><img src="https://mmbiz.qpic.cn/sz_mmbiz_jpg/VibUMkIFrLHD45m7YHYZvR7icicmwicwibZAGpf6tibhJYfnymkhX8CRPS8FWa741Fvl6CKC5H0yWn9ZNQm3rKkOSNZA/640?wx_fmt=jpeg&wx_lazy=1&wx_co=1&tp=webp&wxfrom=5" style="width: 50%; margin-bottom: 20px;"><strong style="color: blue;"><span style="color: black;"><span style="color: black;">3、急性左心衰Forrester法分级</span></span></strong><img src="https://mmbiz.qpic.cn/mmbiz_png/jb2WzfXAxvYPttqTEFyLQo8kLxL1bmHw9nIEHpqm5vHj68T0n9M3JYGEuoTH7zRRadptKOFuurhjoKWY2DbRicg/640?wx_fmt=png&wx_lazy=1&wx_co=1&tp=webp&wxfrom=5" style="width: 50%; margin-bottom: 20px;"><strong style="color: blue;"><span style="color: black;">4、急性左心衰临床程度分级</span></strong><img src="https://mmbiz.qpic.cn/sz_mmbiz_png/vqmH7z5oXNiatobsPibVMJAtfoc0Lm6Yv4KcVianWQxAyDBqn9ZiaiagcI0c4m7npdRmuEh73IuAfs8hcD24n55Oeyg/640?wx_fmt=png&wx_lazy=1&wx_co=1&tp=webp&wxfrom=5" style="width: 50%; margin-bottom: 20px;">
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">急性心力<span style="color: black;">衰尽</span>的<span style="color: black;">归类</span></strong></span></p><strong style="color: blue;"><span style="color: black;">急性左心<span style="color: black;">衰尽</span>：</span></strong><span style="color: black;">临床上急性左心<span style="color: black;">衰尽</span>最为<span style="color: black;">平常</span>：</span><span style="color: black;">急性<span style="color: black;">爆发</span>或加重的心肌收缩力<span style="color: black;">显著</span>降低、舒张受限或心脏负荷加重,<span style="color: black;">导致</span>急性心排血量骤降、肺循环压力<span style="color: black;">忽然</span><span style="color: black;">上升</span>、<span style="color: black;">周边</span>循环阻力<span style="color: black;">增多</span>,<span style="color: black;">显现</span>急性肺淤血、肺水肿,严重者表现为组织器官灌注不足的心源性休克。</span><strong style="color: blue;"><span style="color: black;">急性右心<span style="color: black;">衰尽</span>：</span></strong><span style="color: black;">某些<span style="color: black;">原由</span>使右室心肌收缩力急剧下降或右室的前后负荷<span style="color: black;">忽然</span>加重,从而<span style="color: black;">导致</span>右心排血量急剧减低的临床<span style="color: black;">综合症</span>。</span><span style="color: black;">全心衰是<span style="color: black;">上下</span>心<span style="color: black;">同期</span><span style="color: black;">显现</span><span style="color: black;">衰尽</span>表现。临床<span style="color: black;">都数</span><span style="color: black;">状况</span>是右心<span style="color: black;">衰尽</span>继发于左心<span style="color: black;">衰尽</span>而形成全心<span style="color: black;">衰尽</span>，当右心<span style="color: black;">衰尽</span><span style="color: black;">显现</span>之后，右心排血量减少，左心<span style="color: black;">衰尽</span>的<span style="color: black;">呼气</span>困难等肺淤血症状反而有所减轻。</span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;"><strong style="color: blue;"><span style="color: black;">急性左心衰的病因</span></strong></strong></span></p><strong style="color: blue;"><span style="color: black;">1、原发性心肌损害：</span></strong><span style="color: black;">与冠心病<span style="color: black;">相关</span>的心肌梗死，<span style="color: black;">尤其</span>是急性广泛前壁心肌梗死，乳头肌和腱索断裂，室间隔破裂穿孔、感染性心内膜炎<span style="color: black;">导致</span>的瓣膜穿孔，腱索断裂<span style="color: black;">导致</span>瓣膜性急性反流等。</span><strong style="color: blue;"><span style="color: black;">2、<span style="color: black;">心率</span>失常：</span></strong><span style="color: black;">原有心脏病<span style="color: black;">基本</span>上快速性<span style="color: black;">心率</span>失常或严重缓慢性<span style="color: black;">心率</span>失常；</span><strong style="color: blue;"><span style="color: black;">3、心脏负荷<span style="color: black;">反常</span>：</span></strong><span style="color: black;">高血压血压急剧<span style="color: black;">上升</span>，输血，输液<span style="color: black;">太多</span>，过快等。</span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;">发病机制</span></strong></span></p><span style="color: black;">心脏收缩力<span style="color: black;">忽然</span>严重减弱，或左室瓣膜急性反流，心排血量急剧减少，左室舒张末压<span style="color: black;">快速</span><span style="color: black;">上升</span>，肺静脉回流不畅。<span style="color: black;">因为</span>肺静脉压快速<span style="color: black;">上升</span>，肺毛细血管压随之<span style="color: black;">上升</span>，使血管内液体渗入到肺间质和肺泡内，形成急性肺水肿。肺水肿<span style="color: black;">初期</span>可因交感神经的激活，血压可<span style="color: black;">上升</span>，但随着病情<span style="color: black;">连续</span><span style="color: black;">发展</span>，血压将逐步下降。</span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;">临床表现</span></strong></span></p><span style="color: black;">左心<span style="color: black;">衰尽</span>：以肺瘀血及心排血量降低表现为主。</span><strong style="color: blue;"><span style="color: black;">(1)<span style="color: black;">呼气</span>困难：</span></strong><span style="color: black;">①劳力性<span style="color: black;">呼气</span>困难：劳力性<span style="color: black;">呼气</span>困难是左心<span style="color: black;">衰尽</span>最早<span style="color: black;">显现</span>的症状，运动使回心血量<span style="color: black;">增多</span>，左心房压力<span style="color: black;">升高</span>，加重肺淤血。</span><span style="color: black;">②夜间阵发性呼吸困难：<span style="color: black;">病人</span>熟睡后因憋气<span style="color: black;">忽然</span>惊醒，被迫采取坐位，可伴<span style="color: black;">呼气</span>急促，阵咳，咯<span style="color: black;">泡泡</span>样痰，可伴有哮鸣音，又<span style="color: black;">叫作</span>“心源性哮喘”。</span><span style="color: black;">③端坐<span style="color: black;">呼气</span>：肺淤血达到<span style="color: black;">必定</span>程度，平卧时回心血量<span style="color: black;">增多</span>且横膈上抬，使<span style="color: black;">呼气</span>更加困难，<span style="color: black;">病人</span><span style="color: black;">不可</span>平卧。</span><span style="color: black;">④急性肺水肿：又<span style="color: black;">叫作</span>“心源性哮喘”，是左心衰<span style="color: black;">呼气</span>困难最严重的形式。</span><strong style="color: blue;"><span style="color: black;">(2)咳嗽咳痰：</span></strong><span style="color: black;"><span style="color: black;">起始</span>常于夜间发生，坐位或立位时减轻，多为白色浆液性<span style="color: black;">泡泡</span>状痰，是肺泡和支气管黏膜瘀血<span style="color: black;">导致</span>，偶有痰中带血丝。<span style="color: black;">长时间</span>慢性瘀血肺静脉压力<span style="color: black;">上升</span>，<span style="color: black;">引起</span>肺循环和支气管血液循环之间形成侧支，一旦破裂可<span style="color: black;">导致</span>大咯血。</span><strong style="color: blue;"><span style="color: black;">(3)乏力、疲倦、<span style="color: black;">头昏</span>、心悸：</span></strong><span style="color: black;">是心排血量不足和器官、组织灌注不足及代偿性心率加快<span style="color: black;">导致</span>的<span style="color: black;">重点</span>症状。</span><strong style="color: blue;"><span style="color: black;">(4)少尿及肾功能损害症状：</span></strong><span style="color: black;">血液进行再分配时肾的血流量<span style="color: black;">显著</span>减少可<span style="color: black;">显现</span>少尿。<span style="color: black;">长时间</span>慢性的肾血流量减少可<span style="color: black;">显现</span>血尿素氮、肌酐<span style="color: black;">上升</span>并可有肾功能不全的相应症状。</span><strong style="color: blue;"><span style="color: black;">(5)肺部湿性啰音：</span></strong><span style="color: black;"><span style="color: black;">因为</span>肺毛细血管压<span style="color: black;">升高</span>，液体可渗出到肺泡而<span style="color: black;">显现</span>湿性啰音。<span style="color: black;">病人</span>如取侧卧位则下垂的<span style="color: black;">一边</span>哆音较多(移动性啰音)。随着病情由轻到重，肺部哆音可从局限于肺底部直至全肺。</span><strong style="color: blue;"><span style="color: black;">(6)心脏体征：</span></strong><span style="color: black;">除<span style="color: black;">基本</span>心脏病的固有体征外，慢性左心<span style="color: black;">衰尽</span>的<span style="color: black;">病人</span><span style="color: black;">通常</span>均有心脏扩大、肺动脉瓣区第二心音亢进及舒张期奔马律。</span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;">辅助<span style="color: black;">检测</span></span></strong></span></p><span style="color: black;">辅助<span style="color: black;">检测</span><span style="color: black;">重点</span><span style="color: black;">包含</span>以下四个辅助<span style="color: black;">检测</span>：</span><strong style="color: blue;"><span style="color: black;">特异性<span style="color: black;">检测</span></span></strong><span style="color: black;">① 心肌<span style="color: black;">损害</span>标记物</span><span style="color: black;">肌钙蛋白：是心肌<span style="color: black;">损害</span>标记物，严重心衰<span style="color: black;">病人</span>可有肌钙蛋白<span style="color: black;">上升</span>。</span><span style="color: black;">肌红蛋白、肌酸激酶、肌酸激酶同工酶：<span style="color: black;">以上</span>心肌<span style="color: black;">损害</span>标记物同时<span style="color: black;">上升</span>，结合<span style="color: black;">病人</span>症状、心电图，<span style="color: black;">首要</span><span style="color: black;">思虑</span>急性冠脉<span style="color: black;">综合症</span>，不排除其他<span style="color: black;">状况</span>如心肌炎等可能。</span><span style="color: black;">② BNP 和 NT-proBNP：有助于心衰的诊断和疗效<span style="color: black;">评定</span>，后者受年龄和肾功能影响<span style="color: black;">很强</span>。</span><span style="color: black;">慢性心衰的排除界值为 BNP ＜ 35 pg/ml，NT-proBNP ＜ 125 pg/ml；</span><span style="color: black;">急性心衰的排除界值为 BNP ＜ 100 pg/ml，NT-proBNP ＜ 300 pg/ml；</span><span style="color: black;">急性心衰的诊断界值：BNP ≥ 300 pg/ml；NT-proBNP ≥ 450 pg/ml（＜ 50 岁），≥ 900 pg/ml（50-75 岁），≥ 1800 pg/ml（＞ 75 岁）。</span><strong style="color: blue;"><span style="color: black;">心电图<span style="color: black;">检测</span></span></strong><span style="color: black;">心电图是心衰<span style="color: black;">病人</span>的<span style="color: black;">基本</span>检查，能<span style="color: black;">供给</span>以下信息：</span><span style="color: black;">① <span style="color: black;">心率</span>、心率<span style="color: black;">心率</span>失常在心电图中可直接<span style="color: black;">表现</span></span><span style="color: black;">② 心肌损害、缺血<span style="color: black;">状况</span><span style="color: black;">可否</span>存在 ST-T 改变</span><span style="color: black;">③ 左室肥大V5 或 V6 导联 R 波<span style="color: black;">升高</span> ＞ 25 mm，V5/V6 导联 R 波加 V1/V2 导联 S 波 ＞ 35mm，I、aVL、V5、V6 导联 T 波倒置</span><span style="color: black;">④ 左房肥大P 波双峰</span><span style="color: black;">⑤ 右室肥大心电轴右偏，V1 导联 R 波<span style="color: black;">升高</span>，V1 和 V2 导联 T 波倒置，V6 导联深 S 波，有时呈右束支传导阻滞</span><span style="color: black;">⑥ 右房肥大P 波高尖</span><strong style="color: blue;"><span style="color: black;">超声心动图<span style="color: black;">检测</span></span></strong><span style="color: black;">超声心动图对心衰<span style="color: black;">病人</span>的<span style="color: black;">检测</span>至关<span style="color: black;">要紧</span>。</span><span style="color: black;">① 心包超声可识别心包积液、钙化</span><span style="color: black;">② 心脏结构心腔<span style="color: black;">体积</span>、心肌肥厚、心脏几何形状</span><span style="color: black;">③ 瓣膜关闭不全、狭窄</span><span style="color: black;">④ 功能室壁运动、射血分数、区分收缩功能和舒张功能<span style="color: black;">阻碍</span></span><span style="color: black;">⑤ 估测肺动脉高压<span style="color: black;">按照</span>三尖瓣反流<span style="color: black;">状况</span>估测肺动脉收缩压</span><span style="color: black;">⑥ 识别射血分数<span style="color: black;">保存</span>的心衰（HFpEF）左房容积指数 ＞ 34 ml/㎡，左室质量指数 ≥ 115 （男）或 95（女）g/㎡</span><strong style="color: blue;"><span style="color: black;">胸部X线<span style="color: black;">检测</span></span></strong><span style="color: black;">① <span style="color: black;">显现</span>以下征象，结合症状体征，提示心衰可能</span><span style="color: black;">心脏扩大肺淤血/肺水肿：肺门血管影模糊、蝶形肺门；弥漫性肺内大片<span style="color: black;">暗影</span></span><span style="color: black;">② 胸片还可<span style="color: black;">供给</span>其他信息：胸腔积液：少量时肋膈角变钝，<span style="color: black;">海量</span>时可见弧形积液平面，严重心衰时可伴胸腔积液原有肺部<span style="color: black;">疾患</span></span><span style="color: black;">③<span style="color: black;">重视</span>X 线胸片正常并<span style="color: black;">不可</span>排除心衰</span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;">治疗<span style="color: black;">办法</span></span></strong></span></p><strong style="color: blue;"><span style="color: black;">（1）<span style="color: black;">通常</span>治疗：</span></strong><span style="color: black;">✦体位：坐位或半卧位，双腿下垂；</span><span style="color: black;">
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">✦吸氧：纯氧或高流量吸氧，SPQ2达95%以上，<span style="color: black;">呼气</span>机，<span style="color: black;">泡泡</span>消除剂；</p>
</span><strong style="color: blue;"><span style="color: black;">（2）<span style="color: black;">药品</span>治疗：</span></strong><strong style="color: blue;"><span style="color: black;">①吗啡：</span></strong><span style="color: black;">✦严重的急性左心衰尤其是伴有焦虑和<span style="color: black;">呼气</span>困难的病人，应<span style="color: black;">初期</span><span style="color: black;">运用</span>吗啡；✦吗啡<span style="color: black;">能够</span><span style="color: black;">导致</span>静脉扩张和 微弱的动脉扩张，<span style="color: black;">同期</span>减慢心率；✦3-5mg iv 15min可重复；✦5-10mg皮下或肌肉注射；✦颅内<span style="color: black;">流血</span>，神志<span style="color: black;">阻碍</span>，休克，慢性阻塞性肺<span style="color: black;">疾患</span>，支气管哮喘禁用；</span><strong style="color: blue;"><span style="color: black;">②利尿剂：</span></strong><span style="color: black;">✦首选呋塞米，托拉塞米，布美他尼等袢利尿剂；✦<span style="color: black;">经过</span>血管扩张和快速利尿<span style="color: black;">功效</span>减少循环血量，减轻心脏前负荷，降低肺毛细血管楔压；✦<span style="color: black;">重视</span>低钾低钠低氯及碱中毒；</span><strong style="color: blue;"><span style="color: black;">③扩血管药：</span></strong><span style="color: black;"><span style="color: black;">选取</span>原则：若以肺水肿、肺充血位置，<span style="color: black;">没</span><span style="color: black;">显著</span><span style="color: black;">周边</span>灌注不足，宜<span style="color: black;">选择</span>静脉扩张剂（硝酸甘油）；以心排量降低，有<span style="color: black;">显著</span>灌注不足，而肺充血不严重，宜<span style="color: black;">选择</span>动脉扩张剂（硝普钠）；两者兼有，宜<span style="color: black;">选择</span>动静脉扩张剂（硝普钠）；</span><span style="color: black;">a.硝酸甘油：✦<span style="color: black;">重点</span>扩张静脉，减轻心脏前负荷；✦大剂量时有扩张小动脉降低心脏后负荷<span style="color: black;">功效</span>；✦首选静脉给药；✦用药至肺水肿症状缓解或动脉收缩压降至90-95mmHg，原有高血压者下降不宜超过原血压20%；</span><span style="color: black;">b.硝普钠：✦直接<span style="color: black;">功效</span>于血管平滑肌，<span style="color: black;">平衡</span>扩张小动脉及静脉；✦<span style="color: black;">功效</span>强，<span style="color: black;">生效</span>快，<span style="color: black;">连续</span>时间短；✦需据血压及症状随时<span style="color: black;">调节</span>剂量，最大剂量300-400ug/min；</span><span style="color: black;">c.酚妥拉明：✦α受体阻滞剂，<span style="color: black;">重点</span>扩张小动脉，<span style="color: black;">亦</span>扩张静脉，适用于肺水肿伴外周阻力高的病人；✦需<span style="color: black;">按照</span>血压反应<span style="color: black;">调节</span>剂量；✦<span style="color: black;">重视</span>心率增快；（<span style="color: black;">日前</span><span style="color: black;">运用</span>相对少）</span><span style="color: black;">d.乌拉地尔：✦外周及中枢双重<span style="color: black;">功效</span>；✦用于高血压、急性心梗<span style="color: black;">导致</span>心力<span style="color: black;">衰尽</span>；✦<span style="color: black;">不消</span>于二尖瓣严重狭窄<span style="color: black;">导致</span>的肺水肿；</span><span style="color: black;">e.重组人脑利纳肽（rhBNP）：✦属内源性激素物质，是一种兼具多重<span style="color: black;">功效</span> 的新型抗心衰<span style="color: black;">药品</span>；✦<span style="color: black;">重点</span><span style="color: black;">功效</span>是扩张静脉和动脉（<span style="color: black;">包含</span>冠脉），从而减低前后负荷，在<span style="color: black;">没</span>直接正性肌力 <span style="color: black;">功效</span>下<span style="color: black;">加强</span>CO；✦<span style="color: black;">拥有</span>利尿、排纳、<span style="color: black;">控制</span>RAAS和交感神经系统的多重<span style="color: black;">功效</span>；</span><strong style="color: blue;"><span style="color: black;">④强心剂：</span></strong><span style="color: black;">a.洋地黄类：西地兰（<span style="color: black;">重视</span>血钾<span style="color: black;">状况</span>），地高辛；</span><span style="color: black;">b.非洋地黄类：米力农，多巴酚丁胺，左西孟旦；</span><strong style="color: blue;"><span style="color: black;">⑤氨茶碱：</span></strong><span style="color: black;">✦<span style="color: black;">显著</span>的支气管扩张<span style="color: black;">功效</span>，温和的<span style="color: black;">周边</span>血管扩张、利尿和正性肌力<span style="color: black;">功效</span>，改善<span style="color: black;">呼气</span>困难；✦在心源性哮喘与支气管哮喘难以鉴别时可用；✦安全窗较窄，可<span style="color: black;">导致</span>低血压，诱发<span style="color: black;">心率</span>失常，在急性心梗及心肌缺血时不宜<span style="color: black;">运用</span>；</span><strong style="color: blue;"><span style="color: black;">（3）其它辅助治疗：</span></strong><span style="color: black;">主动脉内球囊反博，限外滤过法，辅助循环。</span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;"><strong style="color: blue;"><span style="color: black;">急性右心衰的病因</span></strong></strong></span></p><span style="color: black;">右心<span style="color: black;">衰尽</span>的病因<span style="color: black;">包含</span>伴有右心室受累的原发性心肌病、右心室心肌缺血和梗死、<span style="color: black;">各样</span><span style="color: black;">导致</span>右心室容量负荷<span style="color: black;">增多</span>的<span style="color: black;">疾患</span>（先天性心脏病、瓣膜性心脏病）以及压力负荷<span style="color: black;">增多</span>的<span style="color: black;">疾患</span>（左心<span style="color: black;">疾患</span>在内的<span style="color: black;">各样</span><span style="color: black;">原由</span><span style="color: black;">导致</span>的肺动脉高压、肺动脉瓣狭窄）。</span><img src="https://mmbiz.qpic.cn/mmbiz_png/hfg42PFJHkeG92ZmLAGXYicd43JU1e0KAlyibxQjkicxfBLdC5NicFLOpicN9q75ibLbtLS2oiaovLQYYj7eybneT4WoA/640?wx_fmt=jpeg&wx_lazy=1&wx_co=1&tp=webp&wxfrom=5" style="width: 50%; margin-bottom: 20px;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;">发病机制</span></strong></span><span style="color: black;">心脏收缩力<span style="color: black;">忽然</span>严重减弱，或左室瓣膜急性反流，心排血量急剧减少，左室舒张末压<span style="color: black;">快速</span><span style="color: black;">上升</span>，肺静脉回流不畅。<span style="color: black;">因为</span>肺静脉压快速<span style="color: black;">上升</span>，肺毛细血管压随之<span style="color: black;">上升</span>，使血管内液体渗入到肺间质和肺泡内，形成急性肺水肿。肺水肿<span style="color: black;">初期</span>可因交感神经的激活，血压可<span style="color: black;">上升</span>，但随着病情<span style="color: black;">连续</span><span style="color: black;">发展</span>，血压将逐步下降。</span><span style="color: black;"><strong style="color: blue;"><span style="color: black;">临床表现</span></strong></span><span style="color: black;">右心衰<span style="color: black;">重点</span>表现为右心排<span style="color: black;">流血</span>量减少和体循环静脉淤血。</span><strong style="color: blue;"><span style="color: black;">1、 右心排血量减少表现</span></strong><span style="color: black;">右心排血量减少可继发左心功能下降，<span style="color: black;">导致</span>肺循环淤血，<span style="color: black;">导致</span><span style="color: black;">呼气</span>困难。而继发于左心功能不全的右心<span style="color: black;">衰尽</span>，肺循环淤血反而会减轻，<span style="color: black;">呼气</span>困难的症状<span style="color: black;">亦</span>会减轻。</span><strong style="color: blue;"><span style="color: black;">2、 体循环静脉淤血表现</span></strong><strong style="color: blue;"><span style="color: black;">2.1 消化道症状</span></strong><span style="color: black;"><span style="color: black;">针对</span>右心衰的<span style="color: black;">病人</span>而言，右心回流血液受阻<span style="color: black;">伴同</span>的体循环静脉压<span style="color: black;">上升</span>，颈静脉怒张需除外腔静脉系统<span style="color: black;">疾患</span>（如上腔静脉<span style="color: black;">综合症</span>等），但颈静脉压<span style="color: black;">上升</span>的征象又是右心<span style="color: black;">衰尽</span>与其他非心源性水肿的<span style="color: black;">重点</span>鉴别点。会<span style="color: black;">引起</span>内脏（胃肠道、肝、胆等）瘀血，从而影响消化，诱发食欲不振等症状。还有<span style="color: black;">有些</span><span style="color: black;">病人</span>可能<span style="color: black;">显现</span>腹胀、恶心呕吐、便秘、腹泻等消化系统症状。</span><strong style="color: blue;"><span style="color: black;">2.2 夜尿<span style="color: black;">增加</span></span></strong><span style="color: black;">右心衰<span style="color: black;">病人</span>，由于心排血量降低，体循环瘀血，有效循环血量减少，会让肾血流不足，从而<span style="color: black;">引起</span>24小时总尿量减少。</span><span style="color: black;">但卧床<span style="color: black;">休憩</span>时，<span style="color: black;">因为</span>回心血量相对<span style="color: black;">增多</span>，心输出量<span style="color: black;">增加</span>，从而<span style="color: black;">导致</span>夜尿<span style="color: black;">增加</span>。</span><strong style="color: blue;"><span style="color: black;">2.3 水肿</span></strong><span style="color: black;">外周水肿可能由多种<span style="color: black;">原由</span><span style="color: black;">引起</span>，如肝脏<span style="color: black;">疾患</span>、肾脏<span style="color: black;">疾患</span>、低蛋白血症、甲状腺功能<span style="color: black;">衰退</span>、腔静脉或下肢静脉<span style="color: black;">疾患</span>和<span style="color: black;">药品</span><span style="color: black;">功效</span>（ 如CCB）等。水肿多从足踝、小腿等<span style="color: black;">起始</span>，还<span style="color: black;">能够</span><span style="color: black;">显现</span>胸水和腹水等。</span><strong style="color: blue;"><span style="color: black;">2.4腹腔积液</span></strong><span style="color: black;">右心<span style="color: black;">衰尽</span><span style="color: black;">引起</span>的浆膜腔积液（ 腹水和胸腔积液等）多为漏出液，积液的性质以及积液细菌培养、脱落细胞学<span style="color: black;">检测</span>有助于鉴别感染、肿瘤、<span style="color: black;">自己</span>免疫病等其他病因。</span><span style="color: black;">辅助<span style="color: black;">检测</span></span><img src="data:image/svg+xml,%3C%3Fxml version=1.0 encoding=UTF-8%3F%3E%3Csvg width=1px height=1px viewBox=0 0 1 1 version=1.1 xmlns=http://www.w3.org/2000/svg xmlns:xlink=http://www.w3.org/1999/xlink%3E%3Ctitle%3E%3C/title%3E%3Cg stroke=none stroke-width=1 fill=none fill-rule=evenodd fill-opacity=0%3E%3Cg transform=translate(-249.000000, -126.000000) fill=%23FFFFFF%3E%3Crect x=249 y=126 width=1 height=1%3E%3C/rect%3E%3C/g%3E%3C/g%3E%3C/svg%3E" style="width: 50%; margin-bottom: 20px;"><img src="data:image/svg+xml,%3C%3Fxml version=1.0 encoding=UTF-8%3F%3E%3Csvg width=1px height=1px viewBox=0 0 1 1 version=1.1 xmlns=http://www.w3.org/2000/svg xmlns:xlink=http://www.w3.org/1999/xlink%3E%3Ctitle%3E%3C/title%3E%3Cg stroke=none stroke-width=1 fill=none fill-rule=evenodd fill-opacity=0%3E%3Cg transform=translate(-249.000000, -126.000000) fill=%23FFFFFF%3E%3Crect x=249 y=126 width=1 height=1%3E%3C/rect%3E%3C/g%3E%3C/g%3E%3C/svg%3E" style="width: 50%; margin-bottom: 20px;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;">治疗<span style="color: black;">办法</span></span></strong></span><strong style="color: blue;"><span style="color: black;">1. 治疗原则</span></strong><span style="color: black;">· 针对右心功能<span style="color: black;">衰尽</span>的不同<span style="color: black;">周期</span>，给予相应的<span style="color: black;">办法</span>积极预防和治疗；</span><span style="color: black;">· <span style="color: black;">首要</span><span style="color: black;">思虑</span>积极治疗<span style="color: black;">引起</span>右心功能<span style="color: black;">衰尽</span>的原发<span style="color: black;">疾患</span>；</span><span style="color: black;">· 优化减轻右心的前负荷、后负荷，<span style="color: black;">加强</span>心肌收缩力；</span><span style="color: black;">· 维持窦性节律、房室同步和<span style="color: black;">上下</span>心室同步。</span><strong style="color: blue;"><span style="color: black;">2. <span style="color: black;">恢复</span>治疗</span></strong><span style="color: black;">专业<span style="color: black;">恢复</span>治疗：<span style="color: black;">包含</span><span style="color: black;">呼气</span><span style="color: black;">熬炼</span>和运动治疗，<span style="color: black;">能够</span><span style="color: black;">增多</span><span style="color: black;">病人</span>的运动耐量和生活<span style="color: black;">自信心</span>，<span style="color: black;">加强</span>生活质量。</span><span style="color: black;">健康教育：心理与精神治疗。</span><strong style="color: blue;"><span style="color: black;">3. 抗凝治疗</span></strong><span style="color: black;">右心衰<span style="color: black;">病人</span>因体循环瘀血、血流缓慢、常卧床、活动量少，很容易合并静脉血栓的形成，<span style="color: black;">乃至</span><span style="color: black;">出现</span>肺血栓栓塞，<span style="color: black;">因此呢</span><span style="color: black;">必须</span>抗凝治疗，<span style="color: black;">运用</span>低分子肝素，口服华法林等。</span><span style="color: black;"><span style="color: black;">运用</span>华法林时要<span style="color: black;">定时</span>监测国际标准化比值（INR），<span style="color: black;">意见</span> INR维持在1.5~2.5。</span><strong style="color: blue;"><span style="color: black;">4. 利尿剂</span></strong><span style="color: black;">利尿剂可消除水钠潴留，有效缓解心衰<span style="color: black;">病人</span>的<span style="color: black;">呼气</span>困难及水肿，改善运动耐量。恰当使用利尿剂是心衰<span style="color: black;">药品</span>治疗取得成功的<span style="color: black;">重要</span>和<span style="color: black;">基本</span>。</span><span style="color: black;"><span style="color: black;">适应证：有液体潴留证据的心衰<span style="color: black;">病人</span>均应<span style="color: black;">运用</span>利尿剂。</span></span><span style="color: black;">禁忌证：<span style="color: black;">没</span>液体潴留的症状及体征；痛风是噻嗪类利尿剂的禁忌证；已知对某种利尿剂过敏或存在不良反应。</span><strong style="color: blue;"><span style="color: black;">5. 左西孟旦</span></strong><span style="color: black;">左西孟旦属于钙离子增敏剂，可直接与肌钙蛋白结合，使钙离子诱导心肌收缩所必需的心肌纤维蛋白的空间构型稳定；可激活ATP<span style="color: black;">敏锐</span>钾通道，扩张血管（以静脉为主）；剂量增大时，其有<span style="color: black;">必定</span>的磷酸二酯酶<span style="color: black;">控制</span>剂<span style="color: black;">功效</span>。</span><strong style="color: blue;"><span style="color: black;">6. ACEI 与β受体阻滞剂</span></strong><span style="color: black;">对全心衰的<span style="color: black;">病人</span>，ACEI 能<span style="color: black;">增多</span>右心室射血分数，减少右心室舒张末期容量，减轻右心室充盈压。β受体阻滞剂卡维地洛或比索洛尔能改善右心室功能。</span><span style="color: black;">但对<span style="color: black;">第1</span>大类肺动脉高压<span style="color: black;">引起</span>的右心衰<span style="color: black;">病人</span>，ACEI <span style="color: black;">不可</span><span style="color: black;">增多</span><span style="color: black;">病人</span>的运动耐量和改善血流动力学，反而可能<span style="color: black;">由于</span>血压下降而使病情恶化；β受体阻滞剂<span style="color: black;">也</span>会使<span style="color: black;">病人</span>的运动耐量和血流动力学恶化。</span><img src="data:image/svg+xml,%3C%3Fxml version=1.0 encoding=UTF-8%3F%3E%3Csvg width=1px height=1px viewBox=0 0 1 1 version=1.1 xmlns=http://www.w3.org/2000/svg xmlns:xlink=http://www.w3.org/1999/xlink%3E%3Ctitle%3E%3C/title%3E%3Cg stroke=none stroke-width=1 fill=none fill-rule=evenodd fill-opacity=0%3E%3Cg transform=translate(-249.000000, -126.000000) fill=%23FFFFFF%3E%3Crect x=249 y=126 width=1 height=1%3E%3C/rect%3E%3C/g%3E%3C/g%3E%3C/svg%3E" style="width: 50%; margin-bottom: 20px;"><span style="color: black;"><span style="color: black;">源自</span>：上术心内</span><span style="color: black;"><span style="color: black;">温馨提示：<span style="color: black;">因为</span><span style="color: black;">微X</span>修改了推送规则，需读者经常点</span><span style="color: black;">“在看”“点赞”</span><span style="color: black;">，否则会<span style="color: black;">逐步</span>收不到推文！请将“</span><span style="color: black;"><span style="color: black;"><strong style="color: blue;">心内之友</strong></span></span></span><span style="color: black;">”设为星标或每次看完后点击一下页面下端的“在看”“点赞”，谢谢</span>
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