平常的慢性心力衰竭的临床表现和治疗
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">近三十年来，人们对心力衰竭的认识有了很大的<span style="color: black;">加强</span>，对心力衰竭的诊断和治疗取得了很大的进步。<span style="color: black;">那样</span>今天来重点学习下<span style="color: black;">平常</span>的慢性心力衰竭的临床表现和治疗，让<span style="color: black;">咱们</span><span style="color: black;">一块</span>来<span style="color: black;">瞧瞧</span>。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">【临床表现】</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">(一)慢性左心衰竭 以肺淤血及心排血量减少表现为主。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">症状</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">1.<span style="color: black;">呼气</span>困难:①劳力性<span style="color: black;">呼气</span>困难，是最早<span style="color: black;">显现</span>的症状;②夜间阵发性<span style="color: black;">呼气</span>困难;③端坐<span style="color: black;">呼气</span>;④急性肺水肿，为急性左心衰最严重的临床表现。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">2.咳嗽、咳痰、咯血。白色浆液性<span style="color: black;">泡泡</span>状痰为其特点。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">3.乏力、疲倦、头昏、心慌。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">4.少尿及肾功能损害症状。少尿，血尿素氮、肌酐<span style="color: black;">上升</span>等。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">体征</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">肺部湿性啰音，可从局限于肺底直至全肺;心脏扩大，肺动脉瓣区第二心音亢进及舒张期奔马律。脉搏表现为交替脉。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">(二)慢性右心衰竭 以体循环淤血的表现为主。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">症状</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">1.消化道症状，胃肠道及肝淤血<span style="color: black;">导致</span>腹胀、食欲不振、恶心、呕吐等是右心衰最<span style="color: black;">平常</span>的症状。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">2.<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;">体征</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">1.水肿:其特征为<span style="color: black;">首要</span><span style="color: black;">显现</span>于身体最低垂的部位，为对<span style="color: black;">叫作</span>性可压陷性。胸腔积液<span style="color: black;">更加多</span>见于全心衰时。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">2.颈静脉征:颈静脉搏动<span style="color: black;">加强</span>、充盈、怒张，是右心衰时的<span style="color: black;">重点</span>体征，肝颈静脉反流征阳性是特征性体征。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">3.肝大:肝因淤血肿大常伴压痛，<span style="color: black;">连续</span>慢性右心衰可致心源性肝硬化，晚期可<span style="color: black;">显现</span>黄疸及<span style="color: black;">海量</span>腹水。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">4.心脏体征:可因右心室<span style="color: black;">明显</span>扩大而<span style="color: black;">显现</span>三尖瓣关闭不全的反流性杂音。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">(三)全心衰竭</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">既有左心衰的表现又有右心衰的表现。继发左心衰的右心衰<span style="color: black;">出现</span>后，<span style="color: black;">因为</span>右心排血量减少，<span style="color: black;">因此呢</span>阵发性<span style="color: black;">呼气</span>困难等肺淤血症状反而有所减轻。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">【治疗】</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">心衰的治疗<span style="color: black;">目的</span>为防止和延缓心力衰竭的<span style="color: black;">出现</span>发展，缓解临床症状，<span style="color: black;">加强</span>生活质量，改善<span style="color: black;">长时间</span>预后，降低病死率和住院率。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">(一)<span style="color: black;">通常</span>治疗</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">1.生活方式管理:<span style="color: black;">包含</span><span style="color: black;">病人</span>教育，体重管理和<span style="color: black;">膳食</span>管理;</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">2.<span style="color: black;">休憩</span>与活动:鼓励病情稳定的心衰<span style="color: black;">病人</span>主动运动;</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">3.病因治疗:<span style="color: black;">包含</span>病因治疗和消除诱因。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">(二)<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:改善症状的基石，是<span style="color: black;">独一</span>能够<span style="color: black;">掌控</span>体液潴留的<span style="color: black;">药品</span>，有袢利尿剂，噻嗪类利尿剂和保钾利尿剂三种。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">2.肾素-血管紧张素醛固酮系统(RAAS)<span style="color: black;">控制</span>剂;①血管紧张素转换酶<span style="color: black;">控制</span>剂(ACEI):常用<span style="color: black;">药品</span>有卡托普利、贝那普利等。②血管紧张素受体阻滞剂(ARB):常用坎地沙坦、氯沙坦、缬沙坦等。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">3.β受体拮抗剂:美托洛尔、比索洛尔等。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">4.正性肌力药:洋地黄类<span style="color: black;">药品</span>。常用制剂为地高辛、毛花苷C、毒毛花苷K等。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">5.洋地黄</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">(1)药理<span style="color: black;">功效</span>:①正性肌力<span style="color: black;">功效</span>;②负性传导<span style="color: black;">功效</span>;③迷走神经兴奋<span style="color: black;">功效</span>。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">(2)洋地黄制剂的<span style="color: black;">选取</span>:常用制剂为地高辛(口服片剂)、毛花苷C(静脉注射用制剂，适用于急性心力衰竭或慢性心衰加重时)、毒毛花苷K等。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">(3)应用洋地黄的适应证:<span style="color: black;">针对</span>心腔扩大舒张期容积<span style="color: black;">显著</span><span style="color: black;">增多</span>的慢性充血性心力衰竭效果较好。这类<span style="color: black;">病人</span>如<span style="color: black;">同期</span>伴有心房颤动则<span style="color: black;">更加是</span>应用洋地黄的最好指征。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">(4)不宜应用的<span style="color: black;">状况</span>:a.预激<span style="color: black;">综合症</span>合并心房颤动;b.二度或高度房室传导阻滞;c.病态窦房结<span style="color: black;">综合症</span>，<span style="color: black;">尤其</span>是老年人;d.单纯性舒张性心力衰竭如肥厚型心肌病;e.单纯性重度二尖瓣狭窄伴窦性<span style="color: black;">心率</span>而<span style="color: black;">没</span>右心衰竭的<span style="color: black;">病人</span>;f急性心肌梗死，尤其在最初24小时内，除非合并心房颤动或(和)心腔扩大。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">(5)洋地黄中毒及其处理</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">①影响洋地黄中毒的<span style="color: black;">原因</span>:心肌在缺血、缺氧;低血钾;肾功能不全;胺碘酮、维拉帕米(异搏定)及奎尼丁等。②洋地黄中毒表现:洋地黄中毒最<span style="color: black;">要紧</span>的反应是各类<span style="color: black;">心率</span>失常，最<span style="color: black;">平常</span>者为室性期前收缩，多表现为二联律，非阵发性交界区心动过速，房性期前收缩。洋地黄类<span style="color: black;">药品</span>的胃肠道反应如恶心、呕吐，以及中枢神经的症状，如视力模糊、黄视、倦怠等。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">(三)非<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.心脏再同步化治疗。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">2.左室辅助<span style="color: black;">安装</span>。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">3.心脏移植。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">最后<span style="color: black;">咱们</span><span style="color: black;">经过</span>一道例题，回顾今天的知识点。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">【例题】慢性右心衰<span style="color: black;">病人</span>水肿<span style="color: black;">首要</span><span style="color: black;">显现</span>于身体哪一部位：</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">A.四肢</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">B.双下肢</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">C.颜面部</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">D.身体低垂部位</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">E.眼睑部</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">【答案】D。解析：慢性右心衰<span style="color: black;">病人</span>水肿<span style="color: black;">首要</span><span style="color: black;">显现</span>于身体最低垂的部位，为对<span style="color: black;">叫作</span>性可压陷性。</p>
太棒了、厉害、为你打call、点赞、非常精彩等。 一看到楼主的气势，我就觉得楼主同在社区里灌水。 哈哈、笑死我了、太搞笑了吧等。 “板凳”（第三个回帖的人）
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