重癥心衰治療指南與臨床實踐重癥心衰治療指南與臨床實踐指南與臨床實踐的關系Evidence-BasedMedicineProblem-BasedMedicine指南與臨床實踐的關系Evidence-BasedMedic心臟重癥特點1.心衰合并多器官功能衰竭，心、肺、腎2.心衰心臟受損嚴重為突出表現，大面積心梗，

心臟手術，重癥心肌炎3.心衰特殊原因，少見，特別是一些新的藥品，

器械心臟重癥特點重癥心衰治療指南與臨床實踐課件Yourheartisanamazingpowerhousethatpumpsandcirculates5or6gallonsofbloodeachminutethroughyourentirebody.YourheartisanamazingpowerUnderstandinghowtheheartworksTounderstandheartdisease,youmustfirstknowhowtheheartworks.Theheartislikeanyothermuscle,requiringbloodtosupplyoxygenandnutrientsforittofunction.Itbeatsabout100,000timesaday,pumpingbloodthroughyourcirculatorysystem.Thecycleofpumpingbloodthroughoutyourbodycarriesfreshoxygentoyourlungsandnutrientstoyourbody'stissues.Bloodalsotakeswaste,suchascarbondioxide,awayfromyourtissues,.Withoutthisprocess,wecouldnotlive.UnderstandinghowtheheartwoHeartdisease:thenumber-onekillerHeartdiseaseaffectsabout14millionmenandwomenintheUnitedStates,andithasahighmortalityrateHeartdisease:thenumber-oneOneofthemostdevastatingconsequencesofheartdiseasecanbesuddencardiacarrest.OneofthemostdevastatingcoBlockageofthecoronaryarteriesbyplaquemaycauseaheartattack(myocardialinfarction)orafatalrhythmdisturbance(suddencardiacarrest).BlockageofthecoronaryarterSuddencardiacdeath-afatalconsequenceofheartdiseaseEveryone'sexperiencewithheartdiseaseisdifferent.Somepeopleexperienceshortnessofbreathorchestpainandmakeittothehospitalintimetobetreated.Othersarenotaslucky.Forsomepeople,suddencardiacarrestcanbethefirstsymptomtheyexperience,anditisoftendeadlyunlesstreatedimmediately.Suddencardiacdeath-afatalBesideschestpain(angina)andshortnessofbreath,someothercommonsymptomsofheartdiseaseincludejawpain,backpain,andheartpalpitations.Besideschestpain(angina)anWhatarecommonsymptomsofheartdisease?Symptomsofheartdiseaseusuallyoccurduringexerciseoractivity.That'sbecausetheheartexperiencesincreaseddemandfornutrientsandoxygenthatcannotbemetbecausethecoronaryarteriesareblocked.Othersymptomsofheartdiseaseincludechestpain(angina),shortnessofbreath,jawpain,andbackpain,especiallyontheleftside.WhatarecommonsymptomsofheDoctorsuseavarietyofteststodetectheartdisease.Onecommontestistheelectrocardiogram(ECGorEKG).DoctorsuseavarietyoftestsWhatisanelectrocardiogram(EKG)?Ahealthyheartworksasan"electricalpump"andneedsastrongbloodsupplytoconductelectricity.Peoplewithheartdisease,however,haveaweakbloodsupply,sotheirheartsconductelectricitypoorly.Anelectrocardiogram(EKG)isanoninvasivetestthatmeasurestheelectricalactivityoftheheart.AnEKGtakesapproximatelyfiveminutesandispainless.ManyotherheartconditionscanbediagnosedwithanEKG,forexampleabnormalheartrhythms,evidenceofpriorheartattack,evidenceofanevolvingheartattack,unstableangina,congenitalheartabnormalities,evidenceofabnormalbloodelectrolytes,andevidenceofinflammationoftheheart(myocarditis,pericarditis).Whatisanelectrocardiogram(Sometimes,ifanelectrocardiogramcomesbacknormal,doctorswillusestressteststodetectheartdisease.Sometimes,ifanelectrocardioAnothertestoptionisechocardiography,whichusessoundwavestogenerateimagesoftheheart.AnothertestoptionisechocarComputerizedtomography(CT)scansareusedtoshowthatheartdiseaseisnotpresentandthatthecoronaryarteriesarenormal.Computerizedtomography(CT)sCoronaryangiographyviacardiaccatheterizationisconsideredthe"goldstandard"ofheartdiseasetests.CoronaryangiographyviacardiHeartdiseasetreatmentisdifferentforeveryone.HeartdiseasetreatmentisdifForsomepatientswithheartdisease,medicationsmaybenecessary.ForsomepatientswithheartdWhenmedicationsaren'tenough,sometimesinvasiveproceduresareusedtohelptreatheartdisease.Whenmedicationsaren'tenoughHeartdiseaseisahighlypreventableandreversibledisease.Ahealthydietisamajorfactorincontrollingheartdisease.HeartdiseaseisahighlyprevOtherlifestylechangesthatcanbemadetohelppreventheartdiseaseincludedrinkingalcoholinmoderationandquittingsmoking.OtherlifestylechangesthatcExercise,controllinghighbloodpressureanddiabetes,andtakingdailyaspirinaremorewaystoreduceyourchancesofdevelopingheartdisease.Exercise,controllinghighblo

心臟重癥病房的治療手段進展3.1

呼吸機輔助通氣

3.2

腎臟替代治療

3.3

主動脈內球囊反搏術(IABP)和左心輔助裝置(LVAD)3.4

ECMO（體外膜肺氧合）

心臟重癥病房的治療手段進展3.1

呼吸機輔助通氣

在國外，特別是歐美發達國家，心臟重癥醫學的誕生起源于心肺復蘇術的開始，要早于真正的綜合性ICU的建立。從1962年開始，MelterHe和Day分別創立冠心病監護病房，從此心臟重癥醫學在世界發達國家特別是歐美地區迅速發展，以CCU或CICU為代表的心臟重癥監護病房已經成為心臟醫療中心中不可缺少的組成部分，代表了一家中心的心臟醫療水平，救治水平和管理水平，更與醫療單位或中心的現代化水平掛鉤在國外，特別是歐美發達國家，心臟重癥醫學的誕生起源于心肺復蘇定義心力衰竭是由于任何心臟結構或功能異常導致心室充盈或射血功能受損的一組臨床綜合征，其主要臨床表現為呼吸困難和乏力（活動耐量受限），以及液體潴留（肺淤血和外周水腫）。心衰為各種心臟疾病的眼中和終末階段，發病率高，是當今最重要的心血管病之一。定義心力衰竭是由于任何心臟結構或功能異常導致心室充盈或重癥心衰治療指南與臨床實踐課件重癥心衰治療指南與臨床實踐課件心衰發展分為4個階段根據心衰發生發展的過程，從心衰的危險因素進展成結構性心臟病，出現心衰癥狀，直至難治性終末期心衰,可分成4個階段。前心衰(A)前臨床心衰(B)臨床心衰(C)難治性終末期心衰(D)這4個階段不同于紐約心臟協會(NYHA)的心功能分級。心衰階段的劃分正是體現了重在預防的概念，其中預防患者從階段A進展至階段B，即防止發生結構性心臟病，以及預防從階段B進展至階段C,以至于進展到D階段。心衰發展分為4個階段根據心衰發生發展的過程，從心衰的危險因素重癥心衰治療指南與臨床實踐課件重癥心衰治療指南與臨床實踐課件依據左室射血分數(LVEF),心衰可分為LVEF降低的心衰(heartfailurereducedleftventricularejectionfraction,HF-REF)

LVEF保留的心衰(heartfailurewithpreservedleftventricularejectionfraction,HF-PEF).LVEF是心衰患者分類的重要指標，也與預后及治療反應相關。LVEF保留或正常的情況下收縮功能仍可能是異常的。依據左室射血分數(LVEF),心衰可分為重癥心衰治療指南與臨床實踐課件CASE1女性，83歲反復活動后氣喘5年，加重1月5年來反復活動后氣喘，發作時端坐呼吸，咳白色泡沫樣痰，夜間陣發性加劇，經治療后好轉。近1月來癥狀加劇，不能平臥，雙下肢浮腫。既往有高血壓病，糖尿病病史20多年。CASE1女性，83歲入院肺部CT掃描入院肺部CT掃描重癥心衰治療指南與臨床實踐課件重癥心衰治療指南與臨床實踐課件重癥心衰治療指南與臨床實踐課件入院診斷，心功能衰竭，心功能IV級。肺部感染

冠狀動脈粥樣硬化性心臟病，急性冠脈綜合癥高血壓病糖尿病入院診斷，入院后治療方案抗感染糾正心衰（強心、利尿、擴血管）治療后癥狀改善，但反復發作入院后治療方案抗感染重癥心衰治療指南與臨床實踐課件左室內徑在正常上限，室壁未見增厚，心腔形態失常、心尖部圓鈍，前壁、室間隔中段以下及整個心尖部運動減弱或無運動，余室壁運動未見明顯異常，整體收縮不協調；二維法LVEF30％。

右心大小正常，室壁運動未見明顯異常

估計肺動脈收縮壓至少57-62mmHg；左室內徑在正常上限，室壁未見增厚，心腔形態失常、心尖部圓鈍，重癥心衰治療指南與臨床實踐課件重癥心衰治療指南與臨床實踐課件討論病人下一步治療方案病人冠心病，引起心衰，繼發肺部感染，明確。但病人83歲，年齡大，不能平臥，是否因該PCI。PCI的風險：病人不能耐受手術，手術風險大。討論病人下一步治療方案重癥心衰治療指南與臨床實踐課件重癥心衰治療指南與臨床實踐課件重癥心衰治療指南與臨床實踐課件重癥心衰治療指南與臨床實踐課件重癥心衰治療指南與臨床實踐課件

Someoftheriskfactorsforheartdiseaseincludesmoking,highbloodpressure,highcholesterol,diabetes,andobesity

SomeoftheriskfactorsforWhataretheriskfactorsforheartdisease?Someofthecommonriskfactorsforheartdiseaseincludesmoking,highbloodpressure(hypertension),highcholesterol,diabetes,familyhistoryofheartdisease,peripheralarterydisease,andobesity.

WhataretheriskfactorsforAdditionalheartdiseaseriskfactorsincludelackofexercise,anunhealthydiet,stress,anda"typeA"personalityAdditionalheartdiseaseriskWhatarelifestyleriskfactorsforheartdisease?Lifestyleriskfactorsthatcontributetoheartdiseaseincludelackofexercise,high-fatdiet,emotionalstress,andhavinga"typeA"personality(aggressive,impatient,competitive).WhatarelifestyleriskfactorCASE2男性，30歲胸悶，氣喘，浮腫1月，加劇1周既往無高血壓病，糖尿病病史個人史：煙，20-40支/天X10年，

酒，白酒6-7兩/次X4-5次/周X5-6年每天3-4餐職業：刑警大隊隊長。CASE2男性，30歲體格檢查BP192/116mmHgHR106bpmIBM40.1（Height170cm，WT116kg）急性痛苦病容，端坐呼吸，雙肺滿布濕性羅音，哮鳴音。下肢可凹水腫。體格檢查BP192/116mmHgEchocardiogramEchocardiogram重癥心衰治療指南與臨床實踐課件ComputedTomographyofChestComputedTomographyofChestElectriocardiogramElectriocardiogram入院診斷1.擴張型心肌病(原發性、酒精性、缺血性、心律失常，肥胖型）？心律失常快速性心房撲動

肺部感染胸腔積液，心包積液左心室內占位性病變（血栓、粘液瘤）2.肥胖3.高血壓病。入院診斷1.擴張型心肌病治療策略1.保守藥物治療

降壓，，利尿，抗菌素，低分子肝素鈣，呼吸機，倍他樂克，23.75mgQD2.介入，冠脈造影3.心臟移植治療策略1.保守藥物治療左心室附壁血栓左室附壁血栓的形成多是繼發于急性心梗之后，是急性心梗的常見并發癥之一。附壁血栓形成后反過來引起急性心梗的可能很小，主要是可能會出現血栓的脫落，從而出現體循環動脈栓塞的可能性加大，最常見的栓塞部位就是腦。所以目前的主要矛盾并不是并發心梗的風險，而是并發腦栓塞的風險較大.左心室附壁血栓左室附壁血栓的形成多是繼發于急性心梗之后，是急重癥心衰治療指南與臨床實踐課件重癥心衰治療指南與臨床實踐課件討論病人通過正規的心衰藥物治療，以及抗菌素，低分子肝素鈣的治療，病人癥狀改善不明顯，BP130-140/90-100mmHgWeight108kg.房撲射頻消融術？討論病人通過正規的心衰藥物治療，以及抗菌素，低分子肝素鈣的治重癥心衰治療指南與臨床實踐課件控制體重措施每日三餐，2兩/餐兩個月體重11682kg。病人呼吸困難癥狀明顯改善，UCG提示EF從18%增加到30%左心室血栓消失。下肢水腫消失。心電圖仍然房撲。病人出院，門診隨訪。控制體重措施每日三餐，2兩/餐重癥心衰治療指南與臨床實踐課件靜息心肌灌注顯像：左室心腔明顯擴大，后壁心肌血流灌注輕度減低。靜息心肌灌注顯像：左室心腔明顯擴大，后壁心肌血流灌注輕度減低重癥心衰治療指南與臨床實踐課件重癥心衰治療指南與臨床實踐課件隨訪6個月后病人一般情況穩定，無心悸胸悶，氣喘等癥狀，已經開始正常工作。隨訪6個月后病人一般情況穩定，無心悸胸悶，氣喘等癥狀，已經開思考病人的主要病因是肥胖，因此控制體重是主要的，開始階段對體重控制沒有重視，病人癥狀控制不好，癥狀反復，從控制體重開始，病情逐步好轉并趨于穩定。在之后的隨訪過程中，繼續控制體重，心臟結構與功能明顯好轉。房撲轉為竇律。說明，對于肥胖型心肌病的治療，預后要比原發性擴張型心肌病要好。思考病人的主要病因是肥胖，因此控制體重是主要的，開始階段對體重癥心衰治療指南與臨床實踐課件ShouldWeTargetObesityinAdvancedHeartFailure?Obesityisariskfactorforthedevelopmentofheartfailure(HF),buthasbeenassociatedwithimprovedsurvivalinpatientswithestablishedHF.ShouldWeTargetObesityinAdMorbidlyobeseindividuals(BMI≥40kg/m2)aged<50yearswithseverelydepressedsystolicfunctionandNYHAclassIII-IVsymptomsshouldbeconsideredformalabsorptivebariatricsurgeryatanexperiencedcenter.Morbidlyobeseindividuals(BMTranslRes.

2014Apr18.

Obesity

andheartfailure:epidemiology,pathophysiology,clinicalmanifestations,andmanagement.Obesity

isariskfactorforheartfailure(HF)inbothmenandwomen.Severe

obesityproduceshemodynamicalterationsthatpredisposetochangesincardiacmorphologyandventricularfunction,as

obesity

cardiomyopathy.Substantialweightlossinseverelyobesepersonsiscapableofreversingmost

obesity-relatedabnormalitiesofcardiacperformanceandmorphologyandimprovingtheclinicalmanifestationsof

obesitycardiomyopathy.TranslRes.

2014Apr18.

ObesiFollow-up

for7monthslaterFollow-upfor7monthslater重癥心衰治療指南與臨床實踐課件小結1.如何從復雜的病情中找出清晰的思路2.病因治療始終都是心臟重癥的根本3.多器官功能衰竭，一定不能忽視萬惡之源的尋找4.指南要靈活運用5.心衰的治療一定要考慮病人預后小結1.如何從復雜的病情中找出清晰的思路重癥心衰治療指南與臨床實踐重癥心衰治療指南與臨床實踐指南與臨床實踐的關系Evidence-BasedMedicineProblem-BasedMedicine指南與臨床實踐的關系Evidence-BasedMedic心臟重癥特點1.心衰合并多器官功能衰竭，心、肺、腎2.心衰心臟受損嚴重為突出表現，大面積心梗，

心臟手術，重癥心肌炎3.心衰特殊原因，少見，特別是一些新的藥品，

器械心臟重癥特點重癥心衰治療指南與臨床實踐課件Yourheartisanamazingpowerhousethatpumpsandcirculates5or6gallonsofbloodeachminutethroughyourentirebody.YourheartisanamazingpowerUnderstandinghowtheheartworksTounderstandheartdisease,youmustfirstknowhowtheheartworks.Theheartislikeanyothermuscle,requiringbloodtosupplyoxygenandnutrientsforittofunction.Itbeatsabout100,000timesaday,pumpingbloodthroughyourcirculatorysystem.Thecycleofpumpingbloodthroughoutyourbodycarriesfreshoxygentoyourlungsandnutrientstoyourbody'stissues.Bloodalsotakeswaste,suchascarbondioxide,awayfromyourtissues,.Withoutthisprocess,wecouldnotlive.UnderstandinghowtheheartwoHeartdisease:thenumber-onekillerHeartdiseaseaffectsabout14millionmenandwomenintheUnitedStates,andithasahighmortalityrateHeartdisease:thenumber-oneOneofthemostdevastatingconsequencesofheartdiseasecanbesuddencardiacarrest.OneofthemostdevastatingcoBlockageofthecoronaryarteriesbyplaquemaycauseaheartattack(myocardialinfarction)orafatalrhythmdisturbance(suddencardiacarrest).BlockageofthecoronaryarterSuddencardiacdeath-afatalconsequenceofheartdiseaseEveryone'sexperiencewithheartdiseaseisdifferent.Somepeopleexperienceshortnessofbreathorchestpainandmakeittothehospitalintimetobetreated.Othersarenotaslucky.Forsomepeople,suddencardiacarrestcanbethefirstsymptomtheyexperience,anditisoftendeadlyunlesstreatedimmediately.Suddencardiacdeath-afatalBesideschestpain(angina)andshortnessofbreath,someothercommonsymptomsofheartdiseaseincludejawpain,backpain,andheartpalpitations.Besideschestpain(angina)anWhatarecommonsymptomsofheartdisease?Symptomsofheartdiseaseusuallyoccurduringexerciseoractivity.That'sbecausetheheartexperiencesincreaseddemandfornutrientsandoxygenthatcannotbemetbecausethecoronaryarteriesareblocked.Othersymptomsofheartdiseaseincludechestpain(angina),shortnessofbreath,jawpain,andbackpain,especiallyontheleftside.WhatarecommonsymptomsofheDoctorsuseavarietyofteststodetectheartdisease.Onecommontestistheelectrocardiogram(ECGorEKG).DoctorsuseavarietyoftestsWhatisanelectrocardiogram(EKG)?Ahealthyheartworksasan"electricalpump"andneedsastrongbloodsupplytoconductelectricity.Peoplewithheartdisease,however,haveaweakbloodsupply,sotheirheartsconductelectricitypoorly.Anelectrocardiogram(EKG)isanoninvasivetestthatmeasurestheelectricalactivityoftheheart.AnEKGtakesapproximatelyfiveminutesandispainless.ManyotherheartconditionscanbediagnosedwithanEKG,forexampleabnormalheartrhythms,evidenceofpriorheartattack,evidenceofanevolvingheartattack,unstableangina,congenitalheartabnormalities,evidenceofabnormalbloodelectrolytes,andevidenceofinflammationoftheheart(myocarditis,pericarditis).Whatisanelectrocardiogram(Sometimes,ifanelectrocardiogramcomesbacknormal,doctorswillusestressteststodetectheartdisease.Sometimes,ifanelectrocardioAnothertestoptionisechocardiography,whichusessoundwavestogenerateimagesoftheheart.AnothertestoptionisechocarComputerizedtomography(CT)scansareusedtoshowthatheartdiseaseisnotpresentandthatthecoronaryarteriesarenormal.Computerizedtomography(CT)sCoronaryangiographyviacardiaccatheterizationisconsideredthe"goldstandard"ofheartdiseasetests.CoronaryangiographyviacardiHeartdiseasetreatmentisdifferentforeveryone.HeartdiseasetreatmentisdifForsomepatientswithheartdisease,medicationsmaybenecessary.ForsomepatientswithheartdWhenmedicationsaren'tenough,sometimesinvasiveproceduresareusedtohelptreatheartdisease.Whenmedicationsaren'tenoughHeartdiseaseisahighlypreventableandreversibledisease.Ahealthydietisamajorfactorincontrollingheartdisease.HeartdiseaseisahighlyprevOtherlifestylechangesthatcanbemadetohelppreventheartdiseaseincludedrinkingalcoholinmoderationandquittingsmoking.OtherlifestylechangesthatcExercise,controllinghighbloodpressureanddiabetes,andtakingdailyaspirinaremorewaystoreduceyourchancesofdevelopingheartdisease.Exercise,controllinghighblo

心臟重癥病房的治療手段進展3.1

呼吸機輔助通氣

3.2

腎臟替代治療

3.3

主動脈內球囊反搏術(IABP)和左心輔助裝置(LVAD)3.4

ECMO（體外膜肺氧合）

心臟重癥病房的治療手段進展3.1

呼吸機輔助通氣

在國外，特別是歐美發達國家，心臟重癥醫學的誕生起源于心肺復蘇術的開始，要早于真正的綜合性ICU的建立。從1962年開始，MelterHe和Day分別創立冠心病監護病房，從此心臟重癥醫學在世界發達國家特別是歐美地區迅速發展，以CCU或CICU為代表的心臟重癥監護病房已經成為心臟醫療中心中不可缺少的組成部分，代表了一家中心的心臟醫療水平，救治水平和管理水平，更與醫療單位或中心的現代化水平掛鉤在國外，特別是歐美發達國家，心臟重癥醫學的誕生起源于心肺復蘇定義心力衰竭是由于任何心臟結構或功能異常導致心室充盈或射血功能受損的一組臨床綜合征，其主要臨床表現為呼吸困難和乏力（活動耐量受限），以及液體潴留（肺淤血和外周水腫）。心衰為各種心臟疾病的眼中和終末階段，發病率高，是當今最重要的心血管病之一。定義心力衰竭是由于任何心臟結構或功能異常導致心室充盈或重癥心衰治療指南與臨床實踐課件重癥心衰治療指南與臨床實踐課件心衰發展分為4個階段根據心衰發生發展的過程，從心衰的危險因素進展成結構性心臟病，出現心衰癥狀，直至難治性終末期心衰,可分成4個階段。前心衰(A)前臨床心衰(B)臨床心衰(C)難治性終末期心衰(D)這4個階段不同于紐約心臟協會(NYHA)的心功能分級。心衰階段的劃分正是體現了重在預防的概念，其中預防患者從階段A進展至階段B，即防止發生結構性心臟病，以及預防從階段B進展至階段C,以至于進展到D階段。心衰發展分為4個階段根據心衰發生發展的過程，從心衰的危險因素重癥心衰治療指南與臨床實踐課件重癥心衰治療指南與臨床實踐課件依據左室射血分數(LVEF),心衰可分為LVEF降低的心衰(heartfailurereducedleftventricularejectionfraction,HF-REF)

LVEF保留的心衰(heartfailurewithpreservedleftventricularejectionfraction,HF-PEF).LVEF是心衰患者分類的重要指標，也與預后及治療反應相關。LVEF保留或正常的情況下收縮功能仍可能是異常的。依據左室射血分數(LVEF),心衰可分為重癥心衰治療指南與臨床實踐課件CASE1女性，83歲反復活動后氣喘5年，加重1月5年來反復活動后氣喘，發作時端坐呼吸，咳白色泡沫樣痰，夜間陣發性加劇，經治療后好轉。近1月來癥狀加劇，不能平臥，雙下肢浮腫。既往有高血壓病，糖尿病病史20多年。CASE1女性，83歲入院肺部CT掃描入院肺部CT掃描重癥心衰治療指南與臨床實踐課件重癥心衰治療指南與臨床實踐課件重癥心衰治療指南與臨床實踐課件入院診斷，心功能衰竭，心功能IV級。肺部感染

冠狀動脈粥樣硬化性心臟病，急性冠脈綜合癥高血壓病糖尿病入院診斷，入院后治療方案抗感染糾正心衰（強心、利尿、擴血管）治療后癥狀改善，但反復發作入院后治療方案抗感染重癥心衰治療指南與臨床實踐課件左室內徑在正常上限，室壁未見增厚，心腔形態失常、心尖部圓鈍，前壁、室間隔中段以下及整個心尖部運動減弱或無運動，余室壁運動未見明顯異常，整體收縮不協調；二維法LVEF30％。

右心大小正常，室壁運動未見明顯異常

估計肺動脈收縮壓至少57-62mmHg；左室內徑在正常上限，室壁未見增厚，心腔形態失常、心尖部圓鈍，重癥心衰治療指南與臨床實踐課件重癥心衰治療指南與臨床實踐課件討論病人下一步治療方案病人冠心病，引起心衰，繼發肺部感染，明確。但病人83歲，年齡大，不能平臥，是否因該PCI。PCI的風險：病人不能耐受手術，手術風險大。討論病人下一步治療方案重癥心衰治療指南與臨床實踐課件重癥心衰治療指南與臨床實踐課件重癥心衰治療指南與臨床實踐課件重癥心衰治療指南與臨床實踐課件重癥心衰治療指南與臨床實踐課件

Someoftheriskfactorsforheartdiseaseincludesmoking,highbloodpressure,highcholesterol,diabetes,andobesity

SomeoftheriskfactorsforWhataretheriskfactorsforheartdisease?Someofthecommonriskfactorsforheartdiseaseincludesmoking,highbloodpressure(hypertension),highcholesterol,diabetes,familyhistoryofheartdisease,peripheralarterydisease,andobesity.

WhataretheriskfactorsforAdditionalheartdiseaseriskfactorsincludelackofexercise,anunhealthydiet,stress,anda"typeA"personalityAdditionalheartdiseaseriskWhatarelifestyleriskfactorsforheartdisease?Lifestyleriskfactorsthatcontributetoheartdiseaseincludelackofexercise,high-fatdiet,emotionalstress,andhavinga"typeA"personality(aggressive,impatient,competitive).WhatarelifestyleriskfactorCASE2男性，30歲胸悶，氣喘，浮腫1月，加劇1周既往無高血壓病，糖尿病病史個人史：煙，20-40支/天X10年，

酒，白酒6-7兩/次X4-5次/周X5-6年每天3-4餐職業：刑警大隊隊長。CASE2男性，30歲體格檢查BP192/116mmHgHR106bpmIBM40.1（Height170cm，WT116kg）急性痛苦病容，端坐呼吸，雙肺滿布濕性羅音，哮鳴音。下肢可凹水腫。體格檢查BP192/116mmHgEchocardiogramEchocardiogram重癥心衰治療指南與臨床實踐課件ComputedTomographyofChestComputedTomographyofChestElectriocardiogramElectriocardiogram入院診斷1.擴張型心肌病(原發性、酒精性、缺血性、心律失常，肥胖型）？心律失常快速性心房撲動

肺部感染胸腔積液，心包積液左心室內占位性病變（血栓、粘液瘤）2.肥胖3.高血壓病。入院診斷1.擴張型心肌病治療策略1.保守藥物治療

降壓，，利尿，抗菌素，低分子肝素鈣，呼吸機，倍他樂克，23.75mgQD2.介入，冠脈造影3.心臟移植治療策略1.保守藥物治療左心室附壁血栓左室附壁血栓的形成多是繼發于急性心梗之后，是急性心梗的常見并發癥之一。附壁血栓形成后反過來引起急性心梗的