스크랩 Heart Failure

[겨울사랑]

Heart Failure

1. Cardiac output 의 결정인자

· C.O=stroke volume × HR

· stroke volume 결정인자(증가시키는 경우)

①preload 의 증가(LV 에 최대로 blood가 왔을때)

②myocardial contrastility 증가

③afterload의 감소: aorta 로 blood 보내기위해 LV 가 생성해내야하는 force

즉, 심장수축에 대응하는 모든 load 합

2. 심부전 형태의 분류

1)LVF.RVF 의 원인

LVF	RVF
systemic HTN(most common cause) coronary artery disease AS MS	LVF(most common cause) pulmonary HTN PS TS

2)Hight output HF & Low output HF

Hight output HF	Low output HF
hyperthyroidism anemia AVF Beriberi Paget's disease pregnancy	ischemic heart disease HTN valvular heart disease cardiomyopathy pericardial disease

3) systolic HF & diastolic HF

systolic HF	diastolic HF
ventricular hypertrophy dilatation anomaly	ventricular flow resistance ventricular diastolic capacity constrictive pericarditis restrictive hypertensive cardiomyopathy impaired ventricular relaxation myocardial fibrosis & infiltration

3. congestive heart failure 의 predisposing factor

pulmonary embolism. anemia .thyrotoxicosis. RHD. HTN. infection. arrhythmia.

infective endocarditis. pregnancy

4. CHF 의 compensatory mechanism

1) 자율신경계의 항진

-심장: 심박동수.심근수축력 및 심근이완 속도의 증가

-말초순환: 동맥수축의 증가.정맥수축

2) 신장: renin-angiotensin-aldosterone 계의 활성화

-동맥수축의 증가

-염분 및 수분의 저류

3) 심실: end diastolic pressure / volume 증가

4)hypertrophy

-volume overload: eccentric hypertrophy

-pressure overload: concentric hypertrophy

5. CHF & sign

1)LHF

-Dyspnea. orthopnea

-paroxysmal dyspnea & cardiac asthma

:respiratory center depression at night, adrenergic stimuli decreased

-Cheyne-Strokes respiration: cyclic 하게 apnea, hyperpnea 의 반복

-Fatigue & weakness, cerebral Sx.

-basal pulmonary rales, hydrothorax

2) RHF

-congestive hepatomegaly & jaundise

-cardiac edema: dependent portion

-ascites, jugular vein distensio, cyanosis

3) cardiac cachexia: 3 rd & 4 th heart sound -> gallop rhythm

6. NYHA(new york heart association)'s criteria

1) class 1: no limitation of physical activity

2) class 2: slight limitation of physical activity

①class 2a: the patient can keep with other walking on the flat but has

limitation on more severe exercise such as climbing stairs

②class 2b: the patient has slight limitation on all forms of physical activity

3) class 3: marked limitation of physical activity

4) class 4: unable to carry on any physical activity without discomfort

7. pulmonary edema 의 원인

-increased pulmonary venous pressure: CHF, MS

-decreased plasma oncotic pressure: hypoalbuminemia

-increased negativity of interstitial pressure: rapid evacuation of pneumothorax,

acute sevsre asthma.

-lymphatic blockade

-disruption of alveolar-capillary membrane : alloxan administration

-unexplained mechanism: narcotic overdose. high altitude

8. pulmonary edema 의 치료

1)morphine IV

-anxiety

-adrenegic vasoconstrictor stimuli 감소

2)high concentration of O2

-100% O2 pressure 로 준다.

3)sitting position : semioflwer

4)IV diuretic: furosemide, ethacrynic acid, bumetanide

5)IV sodium nitroprusside: afterload 감소

6)IV rapid acting glycoside: ouabain, digoxin

7)Iv aminophylline

8)rotating tiurniquet

9. cardiac asthma(paroxysmal noctural dyspnea with wheezing)

1)기전

-respiration center dullness to sensort reflex(sleep)

-venous return 증가(supine)

-LV function 감소

2)PCWP 상승에 따른 dyspnea

10. CHF 치료

1)3 general approaches in the treatment of HF

-reduction of cardiac work

-control of excessive salt & water retention

-enhancement of myocardial contractility

2)control of CHF

-reduction of physical activity

absolute bed rest

-enhancement of myocardial contractility

①cardiac glycoside

②sympathomimetic amnines: isoproterenol, epinephrine, dopamine

3)control of excessive fluid retention

①Diet: Salt&　water restriction

②diuretic

③paracentesis

4)vasodilator treatment

11. RHF treatment

cardiomyopathy, hyperthyroidism 시에는 Digitalis 는 도움이 되지 않는다.

Dopamine: Heart rate without vasocontriction renal

12. Digitalis

1)약리

-myocardial contractility 개선, HR 감소.

-cardiac output 증가

-diuretic

-verapamil, amiodaron, quinidine 는 혈중 digoxin 의 농도를 증가 시키므로 약물의 사용시

용량을 줄여주어야 한다.

2)적응증

-Arrhythmia: AV node refractory period 연장시킴

①발작성 심실성 빈맥

②심방세동

③심방조동

④WPW에서 보이는 빈맥증

3) digitalis toxicity

-anorexia, nausea, vomiting,

-두통, 의식경련.색각이상

-부정맥(PVC)

-체중감소. cachexia, neuralgia, jaundise, delirium

13. treatment digitalis toxication

!)potassium: K 수치가 낮은 빈부정맥에서 사용

2)lidocain, phenytoin

3)propranolol