心力衰竭的临床表现及治疗办法丨临床医师必要知识
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">心力衰竭</p>1、 病因：<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">心肌收缩力减弱—冠心病、心梗。诱因：<span style="color: black;">呼气</span>道感染（最<span style="color: black;">平常</span>）。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">(1) 后（压力）负荷<span style="color: black;">增多</span>：左室—主狭、高血压；右室一肺动脉高压、狭窄。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">(2) 前（容量）负荷<span style="color: black;">增多</span>—主闭（最<span style="color: black;">平常</span>），动脉导管未闭；甲亢、慢性贫血。</p>
<div style="color: black; text-align: left; margin-bottom: 10px;"><img src="https://pic2.zhimg.com/80/v2-f212620f271295f70727d8e20809b025_720w.webp" style="width: 50%; margin-bottom: 20px;"></div>2、 临床表现：<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">① 慢性左心衰：<span style="color: black;">呼气</span>困难。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">a.左室、左房大，二尖瓣相对性关闭不全，P2 亢进，心尖区<span style="color: black;">显现</span>舒张期奔马律。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">b.咳白色浆液痰—慢性左心衰；急性左心衰-咳粉红色<span style="color: black;">泡泡</span>痰。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">c.最早（<span style="color: black;">平常</span>）-劳力性<span style="color: black;">呼气</span>困难；最典型-夜间阵发性<span style="color: black;">呼气</span>困难（夜间喘憋）；最严重- 端坐<span style="color: black;">呼气</span>（与支喘 鉴别）；最典型/最有<span style="color: black;">道理</span>体征-奔马律。交替脉。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">② 慢性右心衰：肝脾胃肠道淤血。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">a.右室、右房大，三尖瓣相对性关闭不全，胸骨左缘第 4、5 肋间收缩期杂音。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">b.三大表现：颈静脉怒张，肝颈静脉回流征阳性（最特异），下肢水肿。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">c.消化道一食欲不振（最早）；d.奇脉（还可见于心包积液-最<span style="color: black;">平常</span>）</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">③ 全心衰=左心衰+右心衰（二狭最易<span style="color: black;">导致</span>）</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">当左心衰<span style="color: black;">呼气</span>困难症状减轻提示<span style="color: black;">显现</span>右心衰。</p>
<div style="color: black; text-align: left; margin-bottom: 10px;"><img src="https://pic4.zhimg.com/80/v2-5dbdb751d6568e79adaf035de0ac8667_720w.webp" style="width: 50%; margin-bottom: 20px;"></div>3、 实验室检査：<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">①首选一 UCG (超声心动图）；</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">②X 线-Kerley B 线：提示慢性肺淤血；</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">③<span style="color: black;">血液</span>脑利钠肽 BNP <span style="color: black;">上升</span>，提示心衰，<span style="color: black;">亦</span>可用来鉴别支气管哮喘。</p>
<div style="color: black; text-align: left; margin-bottom: 10px;"><img src="https://pic3.zhimg.com/80/v2-7a77842856826d8702eb2d1357768336_720w.webp" style="width: 50%; margin-bottom: 20px;"></div>4、 治疗：<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">①消除诱因，抗感染。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">②<span style="color: black;">药品</span>治疗 ；</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">1)利尿剂：首选：双氢克尿噻+螺内酯，高糖、高脂、高尿酸、休克时<span style="color: black;">不可</span>用。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">2)β-阻滞剂：比（比索洛尔）卡（卡维地洛）美（美托洛尔）。 机制一<span style="color: black;">控制</span>心肌收缩，减弱心肌收缩力，改善心肌的顺应性。禁忌症：支气管哮喘，心动过缓，急性心衰。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">适应症：心衰伴陈旧性心梗。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">3) ACEI 类：改善预后，降低死亡率。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">适应症：心衰伴有高血压、肾脏<span style="color: black;">疾患</span>、糖尿病及心梗——首选。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">禁忌症：两髙一低一窄一孕妇（血钾>5.5mmol/L，血肌酐>265umol/L ，低血压，双肾动脉狭窄）。副<span style="color: black;">功效</span>：干咳，（换用 ARB）。</p>
<div style="color: black; text-align: left; margin-bottom: 10px;"><img src="https://pic3.zhimg.com/80/v2-5fcbc656053bba238bd8c6cd27fffd4a_720w.webp" style="width: 50%; margin-bottom: 20px;"></div>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">4)正性肌力药（<span style="color: black;">增多</span>心肌收缩力）：</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">洋地黄</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">洋地黄适应症：伴有快速心房颤动/扑动的收缩性心力衰竭—最佳指征。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">洋地黄禁忌症：</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">①急性心梗 24h 内</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">②肥厚性梗阻性心肌病</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">③预激<span style="color: black;">综合症</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">④低钾</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">⑤单纯二狭洋地黄中毒：黄视、绿视-为中毒先兆、停药指征。</p>
<div style="color: black; text-align: left; margin-bottom: 10px;"><img src="https://pic3.zhimg.com/80/v2-e63d22acff33bd8af8cb6a98c12432de_720w.webp" style="width: 50%; margin-bottom: 20px;"></div>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">洋地黃中毒最<span style="color: black;">平常</span><span style="color: black;">原由</span>：</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">低钾最早：厌食等胃肠道症状、</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">最<span style="color: black;">平常</span>：<span style="color: black;">心率</span>失常一室早二联律</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">最具特征性/最特异：快速房性<span style="color: black;">心率</span>失常和房室传导阻滯。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">心电图<span style="color: black;">显现</span>鱼钩样改变：S-T 下移呈鱼钩样，只能说明曾经用过洋地黄或<span style="color: black;">药品</span><span style="color: black;">生效</span>，不<span style="color: black;">表率</span>中毒。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">治疗：立即停药，<span style="color: black;">重视</span>补钾，快速心率失常给苯妥英钠（首选）、缓慢心率失常阿托品（首选）、若<span style="color: black;">没</span>-苯妥英钠（首选）。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">重视</span>：全书除洋地黄中毒<span style="color: black;">显现</span>室性心率失常首选苯妥英钠，其他室性心率失常都选利多卡因，<span style="color: black;">不消</span>电除颤。</p>
<div style="color: black; text-align: left; margin-bottom: 10px;"><img src="https://pic1.zhimg.com/80/v2-644926b2136ac6ddc0fe792f627bb1a8_720w.webp" style="width: 50%; margin-bottom: 20px;"></div>
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