心源性恶液质重点.ppt

心源性恶液质（Cardiac Cachexia） 于 洪 涛 Definition of Cardiac Cachexia there is still no accepted global definition of cachexia In 1994,Freeman and Roubenoff suggested the cut-off level to define cardiac cachexia be at least 10% loss of lean tissue. suggested that a nonedematous weight loss of 6% or more over a period of at least 6 months should be used to define the presence of cachexia in patients with CHF 心脏恶液质综合征(syndrome of cardiac cachex． ia，socc)是由慢性充血性心力衰竭引起，以心功能 不全为特征，同时伴有内分泌、代谢、营养和凝血机 制等障碍的一组病态征候群 Anker identified 702 of 1929 patients (36%) with a weight loss of more than 6%. The prevalence of cachexia, ie, the cross-sectional frequency of weight loss 6%, in these patients was stable between 13% and 15%. 发生率 左心室功能障碍引起肺水肿。右心室衰竭时导致肝脏肿大，肠道充血。在生命支持时，使用血管活性药物、主动脉内气囊泵的使用、体外膜式氧合的使用以及机械通气会引起肠道缺血。心肌梗塞、心输出量减少引起肠道缺血。 病理生理机制 病理生理机制 胃肠道的血流灌注不足，会使得患者厌食、恶心、呕吐、腹泻、厌食、腹水和早饱感都会出现。 病理生理机制 充血性心力衰竭时处于一种炎症状态、高代谢状态，血中肿瘤坏死因子和促炎因子的水平增高。患者机体有高热卡、高蛋白质的需求。由于在疾病时的这种需要和供给的极度失衡，心脏疾病患者中容易发生营养不良。甚至出现所谓的心源性恶液质状态。 12 months (survival 95%) and 18 months 93% 12-month survival of 38% and 18-month 23%. 异常的压力 感受性反射 厌食 营养不良 遗传因素 氧自由基 氮氧合物 炎性细胞因子 （TNF） 激素作用 （儿茶酚胺、内皮素 1、皮质醇） 合成与分解 代谢失衡 Pathology 内皮细胞功能 心肌凋亡 心肌功能 骨骼肌凋亡 骨骼肌功能 静息能量消耗 能量储存 合成与分解 代谢失衡 CHF patients, and the failing heart itself may be the main source of TNF 静息能量消耗 能量储存 骨骼肌凋亡 骨骼肌功能 心肌凋亡 心肌功能 内皮细胞功能 合成与分解 代谢失衡 脂肪分解代谢增加 心肌分解代谢增加 骨骼肌分解代谢增加 血管功能障碍 全身耗竭综合征（恶液质） 心源性恶液质的处理 Nutritional support Physical training Drugs The ACE inhibitor enalapril can reduce the frequency of future development of body weight loss of more than 6% Drugs Angiotensin receptor blockers (ARBs), there has been no trial to prove recovery from the cachectic CHF state with their use. patients with cachexia had a significantly greater weight gain than noncachectic CHF patients (5.0 kg vs 0.8 kg, P 0.03) after therapy with the beta blockers carvedilol or metoprolol. Drugs High doses of GH, or a combination of GH and IGF-1, may be necessary to overcome GH resistance in cache