左心衰尽
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/mmbiz/miaicBZBfRD4EjENoWOyOVlGmGsLUKT2nZC6fJUW8vYVxbdRibo650v0o5MACSROnvHphjXOaBN1r1ao3gHEdZOiaA/640?wx_fmt=gif&wx_lazy=1&tp=webp&wxfrom=5" 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;">一</span><span style="color: black;">概述</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">左心<span style="color: black;">衰尽</span><span style="color: black;">指的是</span>左心室代偿功能不全而<span style="color: black;">出现</span>的心力<span style="color: black;">衰尽</span>，临床上极为<span style="color: black;">平常</span>，以肺循环淤血为<span style="color: black;">重点</span>特征。左心<span style="color: black;">衰尽</span>分为急性左心<span style="color: black;">衰尽</span>和慢性左心<span style="color: black;">衰尽</span>。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">慢性左心<span style="color: black;">衰尽</span>（CHF）是大<span style="color: black;">都数</span>心血管<span style="color: black;">疾患</span>的<span style="color: black;">最后</span>归宿，<span style="color: black;">亦</span>是最<span style="color: black;">重点</span>的死亡<span style="color: black;">原由</span>。急性左心<span style="color: black;">衰尽</span>（AHF）是<span style="color: black;">因为</span><span style="color: black;">忽然</span><span style="color: black;">出现</span>心脏结构和功能的<span style="color: black;">反常</span>，<span style="color: black;">引起</span>短期内心排血量<span style="color: black;">明显</span>，急剧降低，组织器官灌注不足和急性淤血<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;"><span style="color: black;">二</span><span style="color: black;">病因</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">几乎所有类型的心脏、大血管<span style="color: black;">疾患</span>均<span style="color: black;">能够</span><span style="color: black;">导致</span>心力<span style="color: black;">衰尽</span>，心力<span style="color: black;">衰尽</span>反应心脏的泵血功能<span style="color: black;">阻碍</span>，<span style="color: black;">亦</span><span style="color: black;">便是</span>心肌的舒缩功能不全，<span style="color: black;">最后</span><span style="color: black;">引起</span>心肌功能由代偿发展为失代偿，基本病因有以下两类：</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;">1.原发性心肌损害</strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">（1）缺血性心肌损害：冠心病心肌缺血和(或)心肌梗死是<span style="color: black;">导致</span>心力<span style="color: black;">衰尽</span>的最<span style="color: black;">平常</span>的原因之一。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">(2)心肌炎和心肌病：<span style="color: black;">各样</span>类型的心肌炎及心肌病均可<span style="color: black;">引起</span>心力<span style="color: black;">衰尽</span>，以病毒性心肌炎及原发性扩张型心肌病最为<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)心肌代谢<span style="color: black;">阻碍</span>性<span style="color: black;">疾患</span>：以糖尿病心肌病最为<span style="color: black;">平常</span>，其他如继发于甲状腺功能亢进或减低的心肌病，心肌淀粉样变性等。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;">2.心脏负荷过重</strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">(1)压力负荷(后负荷)过重：见于高血压、主动脉瓣狭窄、肺动脉高压、肺动脉瓣狭窄等左、右心室收缩期射血阻力<span style="color: black;">增多</span>的<span style="color: black;">疾患</span>。为克服<span style="color: black;">升高</span>的阻力，心室肌代偿性肥厚以<span style="color: black;">保准</span>射血量。持久的负荷过重，心肌必然<span style="color: black;">出现</span>结构和功能改变而终至失代偿，心脏排血量下降。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">(2)容量负荷(前负荷)过重：见于以下两种<span style="color: black;">状况</span>：①心脏瓣膜关闭不全，血液反流，如主动脉瓣关闭不全、二尖瓣关闭不全等;②左、右心或动静脉分流性先天性心血管病如间隔<span style="color: black;">缺失</span>、动脉导管未闭等。<span style="color: black;">另外</span>，伴有全身血容量<span style="color: black;">增加</span>或循环血量<span style="color: black;">增加</span>的<span style="color: black;">疾患</span>如慢性贫血、甲状腺功能亢进症等，心脏的容量负荷<span style="color: black;">亦</span>必然<span style="color: black;">增多</span>。容量负荷<span style="color: black;">增多</span><span style="color: black;">初期</span>，心室腔代偿性扩大，心肌收缩功能尚能维持正常，但超过<span style="color: black;">必定</span>限度心肌结构和功能<span style="color: black;">出现</span>改变即<span style="color: black;">显现</span>失代偿表现。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">三</span><span style="color: black;">临床表现</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;">1.慢性左心<span style="color: black;">衰尽</span><span style="color: black;">重点</span>临床表现</strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;">（1）程度不同的<span style="color: black;">呼气</span>困难</strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">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。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">2）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。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">3）夜间阵发性<span style="color: black;">呼气</span>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，可伴呼吸急促，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”。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;">（2）急性肺水肿</strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">是“心源性哮喘”的进一步<span style="color: black;">发展</span>，是左心<span style="color: black;">衰尽</span><span style="color: black;">呼气</span>困难最严重的形式。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;">（3）咳嗽、咳痰和咯血</strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">咳痰是肺泡和支气管黏膜充血<span style="color: black;">导致</span>，<span style="color: black;">起始</span>常夜间<span style="color: black;">出现</span>，坐位或立位时减轻，白色浆液性<span style="color: black;">泡泡</span>痰为<span style="color: black;">重点</span>特点，偶可见痰中带血。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;">（4）其他</strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">心脏排出量不足，器官、组织灌注不足及代偿性心率加快<span style="color: black;">导致</span>的乏力、疲倦、头昏、心慌等症状；随着外周循环血容量的减少，肾的血流量会<span style="color: black;">显著</span>减少，<span style="color: black;">病人</span>可<span style="color: black;">显现</span>少尿<span style="color: black;">或</span>肾功能的<span style="color: black;">反常</span>。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;">2.急性左心<span style="color: black;">衰尽</span>的临床表现</strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">急性左心<span style="color: black;">衰尽</span><span style="color: black;">重点</span>表现为肺循环淤血，<span style="color: black;">忽然</span><span style="color: black;">显现</span>的严重的<span style="color: black;">呼气</span>困难，<span style="color: black;">呼气</span>频率<span style="color: black;">达到</span>30-40次/分钟，强迫体位，面色灰白，发绀、大汗、烦躁，<span style="color: black;">同期</span>频繁咳嗽、咳痰、咯粉红色<span style="color: black;">泡泡</span>样痰。严重者可因缺氧<span style="color: black;">引起</span><span style="color: black;">认识</span>模糊；发病<span style="color: black;">起始</span>血压有过一过性<span style="color: black;">上升</span>，病情如不缓解，血压可<span style="color: black;">连续</span>下降<span style="color: black;">乃至</span>休克。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">四</span><span style="color: black;"><span style="color: black;">检测</span></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">1.心电图：最为常用，除了心率外，<span style="color: black;">能够</span>诊断心衰<span style="color: black;">病人</span><span style="color: black;">可否</span>合并有<span style="color: black;">心率</span>失常，<span style="color: black;">由于</span>心衰<span style="color: black;">病人</span>常伴有期前收缩、房颤等<span style="color: black;">心率</span>失常；心电图还<span style="color: black;">能够</span>判断<span style="color: black;">病人</span><span style="color: black;">可否</span>合并有心肌梗死、心肌肥厚、心包积液等<span style="color: black;">状况</span>心电图<span style="color: black;">亦</span>会有<span style="color: black;">反常</span><span style="color: black;">发掘</span>。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">2.胸片：即胸部X线片，心影<span style="color: black;">体积</span>和形态<span style="color: black;">能够</span>为心脏病的病因诊断<span style="color: black;">供给</span>参考，心脏扩大的程度和动态改变<span style="color: black;">亦</span><span style="color: black;">能够</span>间接反映心脏的功能状态。左心<span style="color: black;">衰尽</span>时存在肺淤血，<span style="color: black;">经过</span>胸片会呈现出不同程度的改变，可<span style="color: black;">显现</span>肺门血管影<span style="color: black;">加强</span>，上肺纹理<span style="color: black;">增加</span>与下肺纹理密度相仿。<span style="color: black;">另外</span>，还可见胸腔有<span style="color: black;">没</span>积液和叶间隙增厚等<span style="color: black;">状况</span>。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">3.超声心动图：是一项<span style="color: black;">没</span><span style="color: black;">损害</span>的<span style="color: black;">检测</span>，<span style="color: black;">能够</span><span style="color: black;">评估</span>心脏内腔<span style="color: black;">体积</span>、室壁厚薄及运动有<span style="color: black;">没</span><span style="color: black;">反常</span>、心瓣膜结构以及心脏泵血功能，是诊断心力<span style="color: black;">衰尽</span>最<span style="color: black;">重点</span>的<span style="color: black;">检测</span>。估计心脏功能，如收缩功能，左心室射血分数反应心脏收缩功能，虽不精确，<span style="color: black;">然则</span>很方便，正常<span style="color: black;">状况</span>下左室射血分数>50%,左室射血分数<或=40%为收缩期心力<span style="color: black;">衰尽</span>的诊断标准。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">4.血脑钠肽：临床上常用BNP及NT-proBNP，其水平有助于心力<span style="color: black;">衰尽</span>的诊断，当未经治疗者BNP水平正常时，可基本排除心衰的诊断。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">5.其他：心肌核素扫描、冠状动脉造影、运动<span style="color: black;">实验</span>等<span style="color: black;">检测</span><span style="color: black;">能够</span><span style="color: black;">认识</span>心脏血流供应<span style="color: black;">状况</span>。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">五</span><span style="color: black;">治疗</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;">（一）慢性左心<span style="color: black;">衰尽</span></strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">治疗目的是减缓或阻止心衰的<span style="color: black;">出现</span>，缓解临床心衰<span style="color: black;">病人</span>的症状，延缓其<span style="color: black;">长时间</span>预后及降低死亡率。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;">1.病因治疗</strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">（1）基本病因的治疗：对所有可能<span style="color: black;">引起</span>心脏受损的<span style="color: black;">平常</span>病因进行治疗，如高血压、冠心病、糖尿病、代谢<span style="color: black;">综合症</span>等。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">（2）诱因治疗：如感染、<span style="color: black;">各样</span><span style="color: black;">心率</span>失常、避免过度<span style="color: black;">疲劳</span>及<span style="color: black;">心情</span>紧张激动等</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;">2.<span style="color: black;">通常</span>治疗</strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">（1）<span style="color: black;">休憩</span>：<span style="color: black;">掌控</span>体力活动，避免精神紧张，降低心脏负荷，有利于心功能的恢复。<span style="color: black;">同期</span>，<span style="color: black;">警觉</span><span style="color: black;">长时间</span>卧床<span style="color: black;">引起</span>静脉血栓形成、肌肉萎缩等</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">（2）<span style="color: black;">掌控</span>钠盐摄入：心衰<span style="color: black;">病人</span>血容量<span style="color: black;">增多</span>，且<span style="color: black;">身体</span>存在水钠储留，<span style="color: black;">因此呢</span>应减少钠盐摄入，有利于减轻水肿。<span style="color: black;">另一</span>应<span style="color: black;">重视</span>易消化、高维生素<span style="color: black;">膳食</span>，<span style="color: black;">休憩</span>、吸氧，避免<span style="color: black;">心情</span>激动，保持大便通畅。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;">3.<span style="color: black;">药品</span>治疗</strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">（1）利尿剂：可<span style="color: black;">选择</span>氢氯噻嗪、呋塞米、丁脲胺、利尿酸钠、氨苯喋啶、螺内酯等交替<span style="color: black;">运用</span>。用时<span style="color: black;">重视</span>毒性反应及副<span style="color: black;">功效</span>(如低钠血症、低氯血症、低钾血症等)。应用利尿剂应关注尿量变化。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">（2）血管扩张剂：常用硝酸异山梨醇酯、硝酸甘油、肼屈嗪(肼苯达嗪)口服。静脉常用酚妥拉明或硝普钠。用药过程中<span style="color: black;">重视</span>血压变化。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">（3）洋地黄制剂：用药过程中，应密切观察病情，<span style="color: black;">重视</span><span style="color: black;">心率</span>、心率(宜在70～80次/min)、绌脉、尿量，有<span style="color: black;">没</span>毒性反应(如呕吐、黄视、频发早搏、二联律及心动过缓等)。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">（4）血管紧张素转换酶<span style="color: black;">控制</span>剂：常用卡托普利或依拉普利。</p>（5）心衰伴心率增快或快速性<span style="color: black;">心率</span>失常者，<span style="color: black;">选择</span>抗<span style="color: black;">心率</span>失常<span style="color: black;">药品</span><span style="color: black;">掌控</span>室率，有助于改善心功能。
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;">4.手术治疗</strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">心脏移植。</p><strong style="color: blue;">（二）急性左心<span style="color: black;">衰尽</span>竭</strong>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;">1.<span style="color: black;">通常</span>治疗</strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">（1）静息时<span style="color: black;">显著</span><span style="color: black;">呼气</span>困难者应半卧位或端坐位，双腿下垂以减少回心血量，降低心脏前负荷。</p>（2）吸氧。
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;">2.<span style="color: black;">药品</span>治疗</strong>（1）镇静：<span style="color: black;">重点</span>应用吗啡，应密切观察疗效和<span style="color: black;">呼气</span><span style="color: black;">控制</span>的不良反应。伴<span style="color: black;">显著</span>和<span style="color: black;">连续</span>低血压、休克、<span style="color: black;">认识</span><span style="color: black;">阻碍</span>、COPD 等<span style="color: black;">病人</span>禁忌<span style="color: black;">运用</span>。老年<span style="color: black;">病人</span>慎用或<span style="color: black;">减少</span>。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">（2）支气管解痉剂：<span style="color: black;">通常</span>应用氨茶碱，此类<span style="color: black;">药品</span>不宜用于冠心病如急性心肌梗死或不稳定性心绞痛<span style="color: black;">导致</span>的急性心衰<span style="color: black;">病人</span>，不可用于伴心动过速或<span style="color: black;">心率</span>失常的<span style="color: black;">病人</span>。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">（3）利尿剂：适用于急性心衰伴肺循环和/或体循环<span style="color: black;">显著</span>淤血以及容量负荷过重的<span style="color: black;">病人</span>。呋塞米、托塞米、布美他尼静脉应用<span style="color: black;">能够</span>在<span style="color: black;">短期</span>里<span style="color: black;">快速</span>降低容量负荷，应列为首选。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">（4）血管扩张剂：此类药可应用于急性心衰<span style="color: black;">初期</span><span style="color: black;">周期</span>。收缩压水平是<span style="color: black;">评定</span>此类药<span style="color: black;">可否</span>适宜的<span style="color: black;">要紧</span>指标。</p>（5）正性肌力<span style="color: black;">药品</span>：此类<span style="color: black;">药品</span>适用于低心排血量<span style="color: black;">综合症</span>，如伴有症状性低血压或心排血量降低伴有循环淤血的<span style="color: black;">病人</span>，可缓解组织低灌注<span style="color: black;">导致</span>的症状，<span style="color: black;">保准</span><span style="color: black;">要紧</span>脏器的血流供应。
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;">3.非<span style="color: black;">药品</span>治疗</strong>病情严重、血压<span style="color: black;">连续</span>降低（<90mmHg）<span style="color: black;">乃至</span>心源性休克者，应监测血流动力学，并采用IABP、机械通气支持、血液净化、心室机械辅助<span style="color: black;">安装</span>以及外科手术等<span style="color: black;">各样</span>非<span style="color: black;">药品</span>治疗<span style="color: black;">办法</span>。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/mmbiz_jpg/u3Zib0ssfF0RhOfNnVV6QIdGHkvIeqoj6tYFyHjoWZCo47YC451lEibw7ibEYv0Riaq1tib0S5cC5nVkK2bnJb3kucQ/640?wx_fmt=jpeg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"></p>
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