refractory heart failure
Introduction
Introduction to refractory heart failure Heart failure can be quickly improved by appropriate etiological treatment and routine anti-heart failure treatment (rest, salt restriction, diuretic, digitalis, ACEI, etc.), if the symptoms and signs of heart failure remain unchanged for a long time under the treatment of conventional heart failure Or progressive progressive, called refractoryheartfailure. basic knowledge The proportion of illness: 0.0025% Susceptible people: no special people Mode of infection: non-infectious Complications: arrhythmia
Cause
Causes of refractory heart failure
(1) Causes of the disease
Due to cardiac surgery to correct congenital cardiovascular malformations, valvular heart disease and coronary heart disease progression, currently refractory heart failure is more common in the following patients:
1 Patients with coronary heart disease who are unable to undergo surgery are associated with multiple myocardial infarction, myocardial fibrosis and papillary muscle dysfunction.
2 patients with cardiomyopathy, especially patients with dilated cardiomyopathy.
3 patients with severe or malignant hypertensive heart disease, often accompanied by severe renal or cerebrovascular disease and rheumatic polyvalvular disease with severe pulmonary hypertension.
4 Loss of cardiovascular disease at the time of surgery, the course of disease gradually deteriorated.
Refractory heart failure may be the end stage of severe organic heart disease, but a considerable part of it is due to poor consideration, poor treatment or improper treatment. For these patients, efforts have been made to adjust treatment and care. After that, it is possible to recover the patient's life, recover from hospitalization, and become refractory. It must be pointed out that the concept or diagnostic criteria for refractory heart failure are different in different periods. In recent years, due to myocardial mechanics, cardiac hemodynamics And the deepening of the understanding of the pathophysiological mechanisms of heart failure, the treatment of heart failure has also made great progress, making some of the previously considered refractory heart failure become treatable, classic refractory heart failure refers to rest, limit water Sodium, after giving diuretics and cardiotonic agents, heart failure is still difficult to control, and such heart failure is currently possible to control by the application of vasodilators, ACE inhibitors, non-digitalis positive inotropic drugs and improve myocardial compliance Therefore, the current diagnostic criteria for refractory heart failure should include heart failure that is difficult to control with the above treatment measures.
(two) pathogenesis
1. Progressive vitality work myocardial loss
Myocardial ischemia, inflammation, degeneration, and poor necrosis are caused by long-term or relative ischemia of chronic coronary heart disease, chronic bio- or abiotic myocardial inflammation, and increased myocardial load, which cause cardiomyocyte swelling and degeneration, contractile protein Degeneration, the final result is often myocardial necrosis and alternative stromal hyperplasia and even myocardial fibrosis.
Cardiomyocyte withering and active: Apoptosis, also known as apoptosis, is an important mechanism for the maturation of mature sexual organs and mature cells. It is generally believed that cells that terminate differentiation, such as cardiomyocytes and neurons, do not undergo zero changes under normal conditions. Cardiomyocytes also withered under the influence of hypoxia, ischemia, high load and other injury factors. Some authors believe that fading is an important cause of loss of cardiomyocytes in advanced heart failure and progressive deterioration of cardiac function. Myocardial necrosis is characterized by myocardial ATP depletion. Organelle destruction, cell swelling, membrane rupture, intracellular component overflow and secondary inflammatory response, myocardial cell dying follows the principle of programmed signaling, characterized by loss of contact with adjacent cells, DNA chromatin fragmentation, cell wrinkles Shrinkage, and the intracellular oligonucleosides are accumulated by DNA endonucleolytic hydrolysis, and finally the withered cells are phagocytosed by phagocytic cells or adjacent cells. This process is accompanied by a variety of gene abnormalities in heart failure, including Inhibition of withered Bcl2 protein and promotion of withering BAX protein, especially with increased BAX protein Active is an important way of advanced heart failure and chronic loss of viable myocardium.
2. Ventricular dysfunction
Common in ventricular aneurysm, due to regional myocardial necrosis, ischemia, injury, diseased myocardial and healthy myocardium in the excitatory conduction, mainly in the mechanical relaxation and contraction activities are not synchronized, and even contradictory movement, ventricular ejection force decline, poor Development causes structural and functional abnormalities in healthy myocardial end-effects, which exacerbate cardiac function deterioration, which is a common cause of refractory heart failure such as coronary heart disease.
3. The cause of ventricular load abnormality has not been corrected
Such as severe combined valvular disease, coronary heart disease or intracardiac infection leading to abnormal or rupture of papillary muscles and / or chordae, ventricular septal perforation, etc., do not correct these mechanical disorders, drug treatment of heart failure often difficult to receive long-lasting effect.
4. There are other adverse factors that increase heart failure
The main infections are pulmonary infection and subacute infective endocarditis. Severe heart failure and elderly patients with heart failure are common with pulmonary infection, and most of them are atypical. The body temperature is not elevated, and the total number of white blood cells is normal. As a sputum culture, it is possible to find pathogenic microorganisms, repeated blood routine examinations, and also found that the neutral classification is elevated, and timely supplemented with systemic anti-infective treatment, heart failure can often be improved, if the heart failure is caused by reflux or diversion Vascular lesions, long-term heart failure refractory, anemia, systemic failure and heart failure degree should be closely observed blood culture, blood routine, urine routine, rash and spleen embolism signs, timely exclusion of subacute infective endocarditis If necessary, try anti-infective treatment.
Anemia and malnutrition: Chronic heart failure often causes red blood cell destruction due to factors such as circulatory stasis. In addition, there may be nutritional deficiencies and renal hematopoietic factors, etc. Anemia is not uncommon. Lower blood oxygen carrying capacity can increase cardiac load and aggravate sympathetic Adrenal nerve activity hyperthyroidism, digestive tract congestion, loss of appetite and digestion and absorption disorders can cause malnutrition. Increased edema, reduce the body's resistance, prone to infection and affect the treatment of heart failure.
Improper sodium intake: Chronic heart failure is prone to hyponatremia. It is well known. Some people think that blood sodium level is an independent predictor of heart failure and prognosis. Continuous blood sodium <130mmol/L is heart failure. Poor prognosis, on the other hand. Patients with chronic heart failure have limited salt restriction and are often the cause of refractory heart failure. Improper salt intake is caused by salty foods and drugs. Severe chronic heart failure includes use. Solvent sodium chloride solution should also be strictly limited for intravenous application.
Arrhythmia: rapid arrhythmia, increased ventricular rate, increased cardiac load, can increase heart failure, especially atrial fibrillation and incomplete atrial flutter, heart failure, atrial systolic ventricular filling effect is particularly significant Important, if the heart rhythm is not converted or the ventricular rate is not properly controlled, the heart function is often worsened. Although various pre-systolic contractions do not significantly affect hemodynamics, if the patient is psychologically very concerned about pre-contraction, then The resulting negative emotions such as anxiety can also affect the treatment of heart failure.
Rheumatic activities: young and middle-aged patients with heart disease should be careful to exclude atypical rheumatism when heart failure is difficult. When heart failure is severe, it is easy to ignore the low fever of rheumatism, and the increase of erythrocyte sedimentation rate. Therefore, for a long period of persistent low fever, tachycardia , sweating, atrioventricular block, fatigue, joint acid difficulties, repeated examination of C-reactive protein, etc., should be suspected of rheumatic activity, if necessary, try anti-rheumatic treatment.
Improper combination of drugs: treatment of heart failure itself and treatment with comorbidities, improper medication is often the iatrogenic cause of poor heart failure treatment, combined with antiarrhythmic drugs such as quinidine, propafenone, and even mexiletine Amiodarone, etc., anti-rheumatic treatment using non-steroidal anti-inflammatory drugs, etc., the heart and non-cardiac effects of these drugs and their interaction with anti-heart failure drugs often adversely affect heart failure treatment, in addition to Receptor blockers, calcium antagonists, and digitalis preparations have poor drug selection, and large doses or rapid drug delivery rates can often directly worsen heart failure or invalidate heart failure treatment.
Thyroid dysfunction: heart failure patients with thyroid disease and elderly patients with heart failure, when heart failure treatment is ineffective or progressive deterioration of cardiac function should exclude the effects of thyroid dysfunction (often hypothyroidism), hypothyroidism ( Hypothyroidism can occur myocardial interstitial mucous edema, myocardial degeneration, pericardial effusion, hyperthyroidism (hyperthyroidism) triggers high dynamic circulation-like changes, thereby worsening heart failure or failure of heart failure treatment, long-term chronic heart failure causes functionality It is not uncommon to have hypothyroidism. Improper thyroid hormone supplementation for hypothyroidism is also likely to interfere with heart failure treatment.
Liver and kidney dysfunction: chronic heart failure, long-term liver and kidney congestion and or lack of perfusion, coupled with the adverse effects of long-term medication, liver and kidney function is vulnerable to injury, renal clearance ability decreased, liver detoxification ability and hormone inactivation ability decreased, will affect Water-electrolyte balance, volume balance, and neuroendocrine activity in heart failure stabilize the heart failure or heart failure treatment.
Embolism and thrombosis: enlarged heart, contraction weakness and chronic atrial fibrillation, transmural myocardial infarction, etc., the formation of thrombus in the heart cavity is easy to form, severe wall thrombus interferes with cardiac blood flow, embolism causes peripheral embolism, especially lung , kidney, even heart, cerebral embolism is often an important factor in the deterioration of heart failure, slow blood flow during chronic heart failure, impaired vascular endothelial function, unstable blood coagulation and fibrinolysis, resulting in peripheral thrombosis, direct and indirect The consequences can affect the treatment of heart failure.
Behavioral and habitual factors: patients with chronic heart failure can often be forced to stop bad habits such as alcoholism, smoking, etc. If the control of tobacco and alcohol is not effective, it can become a cause of dysfunction of heart failure. Patients with heart failure are overactive in the treatment of heart failure. Conducive to heart failure correction, on the contrary, long-term bed rest, muscles, especially respiratory muscle atrophy, is also the cause of deteriorating heart failure.
Prevention
Refractory heart failure prevention
1. To comprehensively analyze the possible causes of refractory heart failure (including the exclusion of diseases requiring special treatment of internal medicine, the extracardiac causes of refractory heart failure and related factors of improper treatment), and give corresponding treatment.
2. Carefully analyze the type of hemodynamic load abnormality, give appropriate measures to reduce the load before and after the heart, and correctly use anti-heart failure drugs.
3. Pay attention to correct hypokalemia, hypomagnesemia, hyponatremia and hypoproteinemia.
4. Closely observe changes in the condition and response to treatment, and adjust the treatment plan in time.
Complication
Refractory heart failure complications Complications arrhythmia
Often complicated by arrhythmia, pulmonary infection, liver dysfunction, renal insufficiency, water and electrolyte disorders.
1. cardiac arrhythmia (cardiac arrhythmia): is due to sinus node dysfunction or activation caused by sinus node, stimulating conduction slow, block or conduction through abnormal channels, that is, the origin of cardiac activity and / or conduction disorders Abnormal frequency and/or rhythm of heart beats, an arrhythmia is an important group of diseases in cardiovascular disease. It can be associated with cardiovascular disease alone or in combination with cardiovascular disease. Sudden onset and sudden death, can also continue to affect the heart and fail.
2. Pulmonary infection: pneumonia, refers to the inflammation of the lung parenchyma including the terminal airway, alveolar cavity and interstitial lung. The cause of infection is most common, and it can also be caused by physicochemical, immune and drug. Among them, the infection is collectively referred to as a pulmonary infection. Among them, pneumonia is more typical and representative.
3. Hepatic insufficiency: refers to the serious damage to liver cells caused by certain causes, which can cause damage to the liver's morphological structure and cause serious disorders such as secretion, synthesis, metabolism, detoxification, immune function, etc., jaundice, bleeding tendency, serious infection, liver Pathological processes or clinical syndromes of clinical manifestations such as renal syndrome and hepatic encephalopathy.
4. Renal insufficiency: It is caused by a variety of causes, the glomerular destruction, the body of the clinical syndrome after the excretion of metabolic waste and regulation of water and electrolytes, acid-base balance and other disorders.
5. Water and electrolyte metabolism disorders are very common in the clinic. Many organ system diseases, some systemic pathological processes, can cause or be accompanied by water and electrolyte metabolism disorders. The metabolic disorder of water and sodium caused by different reasons may be different in the degree of water shortage and sodium loss, that is, the water and sodium may be lost in proportion, or the water shortage may be less than sodium deficiency or more than sodium deficiency.
Symptom
Symptoms of refractory heart failure Common symptoms Diastolic galloping systolic murmur fatigue Third heart sounds Comrades dyspnea
Refractory heart failure is a clinical diagnosis.
Symptom
Patients with rest or minor activities are irritated, sitting, breathing, extreme fatigue, cyanosis, burnout, cold limbs, decreased exercise tolerance with difficulty breathing, skeletal muscle atrophy, cardiogenic cachexia, refractory edema, progressive liver enlargement with upper right Abdominal pain.
2. Signs
The apex beats to the left to enlarge, can smell the third heart sound, the second sound of the pulmonary valve, the early contraction of the mitral regurgitation or the full systolic murmur; the right ventricle third heart sounds gallop; three When the cusp is reversed, early and full systolic murmurs can be heard along the lower left edge of the sternum, and increased during forced inhalation; peripheral edema, ascites; rapid weight gain; end-stage refractory heart failure patients can lick and liver pulsation Some patients continue to have tachycardia and/or diastolic galloping, and the blood pressure is low. On this basis, the pulse pressure often lasts 25mmHg (3.32kPa), and there may be pleural effusion, ascites or pericardial effusion. There are persistent bilateral wetness of the lungs and so on.
Examine
Refractory heart failure examination
The characteristic manifestations of primary heart disease and the characteristic changes of complications have resulted in a continuous increase in blood norepinephrine levels.
X-ray inspection
The heart enlarges significantly, and the cardiothoracic ratio (CTR) is often >0.55 to 0.60.
2. Echocardiography
The ventricular end-systolic diameter was measured to determine the size of the heart, and within a certain range, the significance of heart size on the assessment of disease and prognosis.
3. Heart index continued <2.0L / (min · m2); IVEF continued <0.10 ~ 0.20; maximum oxygen consumption continued <14ml / (kg · min), serum sodium continued <130mmol / L, blood norepinephrine content Continue to increase.
Diagnosis
Diagnosis and diagnosis of refractory heart failure
diagnosis
There is no uniform standard for the diagnosis of refractory heart failure. Establishing such a standard may be beneficial for guiding heart failure treatment and promoting the development of heart transplantation. The following items are generally considered to be the basis for diagnosis of refractory heart failure.
1. There are irreversible primary disease damage, such as multi-site myocardial infarction, abnormal valvular dysfunction, papillary muscle and/or chordae rupture, ventricular septal perforation, ventricular aneurysm, diffuse myocardial damage such as cardiomyopathy (primary and secondary, etc.).
2. Chronic symptomatic heart failure for more than half a year. Symptoms and signs of heart failure continue to improve or progressive deterioration under regular anti-heart failure medication for more than 4 weeks.
Differential diagnosis
Often with simple pericardial effusion or constrictive pericarditis, renal edema, portal cirrhosis, vena cava syndrome.
1. Pericardial effusion: is a more common clinical manifestation, especially after the echocardiography becomes the routine examination of cardiovascular disease, the detection rate of pericardial effusion in patients is significantly increased, which can be as high as 8.4%, large Part of the pericardial effusion does not show clinical signs due to the small amount. A small number of patients have a prominent clinical manifestation with pericardial effusion due to a large amount of fluid. When the pericardial effusion lasts for more than a few months, it constitutes a chronic pericardial effusion. There are many causes of chronic pericardial effusion, most of which are related to diseases that can affect the pericardium.
2. Constrictive pericarditis: Chronic inflammatory lesions in the parietal and visceral layers of the pericardium, causing pericardial thickening, adhesions, and even calcification, which limits the diastolic filling of the heart, thereby reducing cardiac function. A disease that causes systemic blood circulation disorders. It is the ultimate result of a variety of pericarditis.
3. Edema: It is the most common symptom in the clinic and one of the common symptoms of kidney disease. Edema can be caused by many causes, and different edema has different characteristics. Edema caused by heart disease is called cardiogenic edema or cardiac edema; edema caused by liver disease is called hepatic edema or hepatic edema; similarly, edema caused by kidney disease is called nephrogenic edema. Nephrogenic edema is a kind of systemic edema. It is a common symptom of glomerular disease. It is caused by kidney disease, which causes water and sodium retention in the body, causing edema in different degrees of tissue loosening.
4. Portal cirrhosis: the most common type of cirrhosis. Chronic alcoholism, nutritional adjustment, intestinal infection, drug or industrial poisoning and chronic heart failure, but this disease is more common in Europe and America due to long-term alcohol abuse (alcoholic cirrhosis), in China and Japan, the virus Sexual hepatitis may be the main cause (hepatic cirrhosis after hepatitis).
5. Vena cava obstruction syndrome: All causes cause complete or incomplete upper vena cava obstruction, resulting in blocked blood flow, resulting in upper limbs, neck, facial edema and superficial varicose veins of the upper body. The mediastinal tumor, inflammation, and blood vessel thrombosis can be the cause of the disease. Among them, bronchial lung cancer is the most common. The thrombosis of the inferior vena cava, inflammation or visceral tumor compression can cause the inferior vena cava obstruction syndrome. Causes changes in organ function or varicose veins in the abdominal wall and below the umbilicus, and may have edema, ulcers, etc. in the lower extremities.
