从风湿性心脏病致心力衰竭的病例看心肌重构课件.pptVIP

从风湿性心脏病致心力衰竭的病例看心肌重构 褚祎、姜岚、王晶、夏雪、曹洁 Compensatory Mechanisms to Heart Failure 1. Neurohumoral Activation 2. Functional Adjustment 3. Structural Adaptation 4. Extracardial Compensation Neurohumoral Activation (1) Activation of Sympathetic Nervous System (2) Activation of Renin-Angiotensin System Functional Adjustment (1) Increased Heart Rate (2) Increased Preload (3) Increased Contractility Structural Adaptation (1) Myocyte Remodeling a. Myocardial Hypertrophy Concentric Hypertrophy Eccentric Hypertrophy b. Changes in Myocyte Phenotype (2) Changes in Non-Myocytes Extracardial Compensation (1) Redistribution of Blood Flow (2) Increase in Red Cells (3) Increase Ability of Cells to Use Oxygen 病例 病史：患者31年前于重体力劳动后出现心悸、喘憋，伴夜间憋醒，需坐起。诊断“风湿性心脏病”。其后间断出现喘憋，多于感冒后发生，发作时轻微活动即可发 生喘憋，伴夜间不能平卧。后来发现二尖瓣狭窄，心房颤动，心力衰竭。近2年来，患者运动明显受限，经常喘憋，夜间坐位入睡。3天来，受凉后喘憋加重，不能自行行走，夜间坐位入睡，伴咳血痰，暗红色为主，偶有鲜红色血痰。自发 病来，精神、睡眠差，食欲不佳，小便次数增多，尤其夜尿增多，6~7次/夜，大便如常。 查体：BP：160/90mmHg，P：64次/分，口唇略发绀，双肺可闻及满肺哮鸣音及少量细湿罗音。心尖搏动弥散，位于第Ⅴ肋间腋中线上。心尖部触及震颤。叩诊心界扩大。心律不齐，S1强弱不等，A2=P2，心尖部可闻及III级收缩期杂音，舒张期隆隆样杂音。腹部膨隆，腹软，无压痛，肝脾触诊不满意，双下肢轻度可凹性水肿。 Rheumatic heart disease: Mitral verrucous endocarditis ---- thickening of valves and chordae tendinea Valve Impairment and Compensation Mitral stenosis: fibrosis and thickening of valves, shortening of chordae tendinea Compensation: elevated transmitral pressure LA pressure PV pressure congestion of lung Dyspnea LV contraction Palpitation From functional compensation to constructional compensation Myocardial remodeling Balance between cardiomyocyte hypertrophy and apoptosis GPCR signaling Gp130 receptor-coupled signaling The PI3K–Akt axis Calcium-dependent signaling TNFα–NF-κB Fig. 2. G-protein-coupled receptor (GPCR) agonists (e.g. catecholamines, angiotensin II, prostaglandin F2α or endothelin-1), bind to transmembrane GPCRs which leads to