心瓣膜病,老年性心瓣膜病,老年心衰

不容忽视的老年心衰

老年心脏病人,由于心脏功能减退,容易发生心力衰竭(老年心衰)。老年心衰症状常不典型;又容易与其他老年病相混淆,造成误诊误治;而晚期心衰的病死率可高达50%,是老年心脏病人死亡的主要原因之一。因此,不容忽视,值得警惕。

一. 如何识别老年心衰?

  1. 几乎都有心脏病:老年心衰几乎都有心脏病。最常见的是冠心病,其次是高血压性心脏病,两者相加约占老年心衰的50%;再次,见于老年心脏瓣膜病(包括心脏瓣膜钙化)、肺源性心脏病、甲亢性心脏病等。真正由于老年退行性变化(老衰)引起的心衰不到2%。所以,遇到老年心衰,首先要追查病因,看是哪种心脏病所致。
  2. 扑捉老年心衰的蛛丝马迹:老年心衰前,常出现不典型的症状与体征,叫做隐性心衰。如果能早期扑捉到这些蛛丝马迹,并与一些相关的老年疾病相鉴别,对于改善预后,防止误诊误治,至为重要。
  3. 心衰气喘与咳嗽:老年人活动后常有气短,休息后好转,这是正常现象。但如果出现夜间阵发性呼吸困难,夜间平卧入睡时憋醒了,需要坐起来坐一阵,或垫高枕头,才能缓解,那是心衰。咳嗽时常吐泡沫痰,坐轻卧重;肺底能听到细小罗音;强心利尿药效果好。心衰的咳喘,容易与老慢支、哮喘相混淆。后者有过敏史或慢支史,长期反复发作,青少年多,无心脏病史与体征,皮质激素、氨茶碱、抗生素及止咳药,效果好。
  4. 倦怠、烦躁:心衰时由于造成脑与组织供血不足,可产生倦怠无力、嗜睡或失眠、烦躁或淡漠、常从睡梦中憋醒。易与老年精神病、脑中风等相混淆。
  5. 白天尿少、夜尿增多:心衰时,由于心脏排血量减少,肾脏供血不足,白天尿量少;夜间平卧入睡,回心血量增加,肾脏血流增加,夜尿便会增多。易与肾脏疾病相混淆。但是,肾脏病的浮肿从眼睑和面部开始,尿检有阳性发现;心衰的浮肿从下肢开始,尿检无阳性可见,有心脏病的表现。
  6. 心律失常:心衰时心率增快,活动后明显;有时有心跳间歇或交替脉,已经出现心律失常,应及时做心电图。
  7. 无痛性心肌梗塞:在老年性心肌梗塞中,无痛性心梗占36%~61%。如此大比例,可能因为:老年冠心病旷日持久,已经形成丰富的侧枝循环;老年人血管痛觉感受器感觉迟钝;老年人脑缺血、缺氧,痛域提高;心肌纤维化;合并糖尿病;语言表达功能欠佳等。病人无明显、剧烈的胸痛、胸闷,只有一般的胸部不适、气短、胸闷。但容易合并心衰,病死率高。

二.常见的诱因有哪些?

  1. 感染:呼吸道感染为多。患肺炎致死的老人,97%死于心衰。
  2. 快速心律失常:室上性心动过速、快速房颤、房扑等,增加心室率,增加心肌耗氧量,降低心脏排血量,容易诱发心衰。
  3. 输液:过快、过多的输液、输血,或盐类摄入过多,加重心脏负担,易诱发心衰,
  4. 恶劣环境或气候剧变。
  5. 治疗不当:洋地黄不足、过量或中毒;过度使用了抑制心肌收缩的药物,如:β受体阻滞剂、胺碘酮、奎尼丁、异搏定等。
  6. 严重贫血、甲亢、肺栓塞。

三.怎样预防老年心衰?

  1. 着手要早:心衰治疗的三大新理念中,第一个就是提前干预。主张心脏病人即使没有心衰表现,如果体检中心脏彩超左室射血分数小于40%,就要开始治疗。现在,国内外都沿用美国的方法,把心功能分为四级、心衰分为三度。心功能一级(无心衰),心功二级(1度心衰)、心功三级(2度心衰)、心功四级(3度心衰)。预防和最初的治疗工作,要着手在心功能二级之前进行。
  2. 抓住高危人群:凡有高血压、冠心病、糖尿病、肺心病、扩张型心肌病、心脏瓣膜病、心肌炎、贫血、突发心脏病史或心功能不全者,都属于心衰的高危人群。上海1980、1990、2000年连续20年对2178例住院心衰病人的调查表明,高血压、冠心病引起心衰的比例,已经从20年前的33.1%升至69.6%;显然,高血压、冠心病已成为心衰的主要危险因素。抓住主要危险因素进行预防,当然是至为重要。
  3. 针对常见原因和诱因:预防和控制上述引起心衰的常见原因和诱因,是预防心衰的主要环节。
  4. 饮食:清淡饮食为主。少量多餐,避免暴饮暴食。避免便秘。严格限制饮酒、尤其是酗酒,美国哈佛大学医学院的研究表明,吃全谷类早餐,有助于心衰的预防。

四.如何进行家庭治疗?

老年心衰不但表现不典型,而且易变,预后差。因此,应住院治疗或请医生指导下进行家庭治疗。住院治疗自由医生负责,无须赘述。这里重点是简单谈谈家庭药物治疗。

家庭治疗慢性心衰的目的,一是减轻症状,而是延长生命。以往,慢性心衰的治疗主要是强心、利尿、扩血管;后来,发现人体交感神经系统和肾素-血管紧张素-醛固酮系统的过度激活,心室重构,才是慢性心衰恶化的根本;故加入了保护心肌储备能力的药物。而且从单一用药过渡到联合用药;从单用西药到联用中药。

  1. 利尿减轻心脏负担:常用双氢克尿塞、速尿和螺内酯。多以双氢克尿塞与螺内酯联用,或速尿与螺内酯联用。服3天,停3天。
  2. 增强心肌收缩力:地高辛,每日1片0.25毫克,连服7天,能达到最大疗效。必要时可每天服半片。
  3. 保护心肌储备能力:可选用转换酶抑制剂(依那普利)、血管紧张素2受体拮抗剂(頡沙坦)、β受体拮抗剂(阿替洛尔)等。
  4. 联用中药:中医辨证施治,标本兼治。血瘀水阻者,血府逐瘀汤合五苓散加减;气阴不足者,生脉散合猪苓汤加减;阳虚水泛者,真武汤合冬虫夏草汤加减。有资料显示,芪苈强心胶囊(人参、黄芪、附子、葶苈子、泽泻、丹参、红花等),可强心、利尿、扩血管治标;又防治神经内分泌过度激活,减轻心室重构。既能减轻症状,又能延长生命。是不错的选择。
  5. 治疗原发基础心脏病。

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