新型血管扩张剂治疗急性心力衰竭研究进展

每年全球有数百万患者因急性心力衰竭发作入院,如何改善急性心力衰竭患者的临床预后是一项巨大的挑战。在急性心力衰竭患者中,血管扩张剂是继利尿剂之后第二常用的药物。当前仍缺乏足够证据证明传统药物治疗在改善急性心力衰竭患者的临床预后上有明显获益。近些年,在药物治疗急性心力衰竭的研究中研发了一些新型血管扩张剂,包括可溶性鸟苷酸环化酶调节剂、新型硝酰基前体药物、利钠肽、松弛素及血管紧张素受体偏配体,旨在改善急性心力衰竭患者住院期间及出院后的临床结局。     

左西孟旦治疗围产期心肌病心衰患者

<正>左西孟旦是一种新型的正性肌力药物,具有钙增敏,开放KATP通道和抑制磷酸二酯酶Ⅲ等多重效应,已成为急性心衰治疗指南允许应用于治疗急性失代偿性心衰的新药。目前已有相关研究证实对于扩张型心肌病、缺血性心肌病等心衰患者疗效较好,但对于围产期心肌病患者的应用尚无相关报道。笔者应用左西孟旦治疗围产期心肌病取得了较好的疗效,未出现明显的副作用,随访半年患者预后良好。     

急性心肌梗死并发心源性休克的治疗进展

心源性休克是急性心肌梗死的严重并发症,是急性心肌梗死患者早期死亡的最主要原因。再灌注治疗,结合药物及辅助装置可显著改善患者预后。现总结了近年国内外的相关研究,对急性心肌梗死并发心源性休克的诊断及治疗进展做一综述。     

老年急性冠脉综合征合并心源性休克的治疗

老年人急性冠脉综合征合并心源性休克的治疗是临床十分棘手的问题,药物治疗方面的临床研究极为有限。再灌注治疗方面,经过筛选的老年人早期进行血运重建对于预后有着积极的意义,即使不适宜介入治疗的患者接受适当的溶栓治疗方案总体结局也要优于药物保守治疗。主动脉内球囊反搏术在急性冠脉综合征合并心源性休克老年患者中的应用尚需谨慎。尽管新型循环辅助装置尽管显示了良好的前景,但在老年人中的应用还有待进一步研究和完善。     

急性缺血性卒中的溶栓治疗进展

重组组织型纤溶酶原激活剂静脉溶栓是目前惟一一种证实有效的治疗急性缺血性卒中的药物。在许多情况下,费用低廉的尿激酶不失为一种较好的选择。虽然溶栓治疗日趋成熟,但一些问题仍需进一步探讨,如新的溶栓药物用于发病3h以上的急性缺血性卒中患者、评价各种新的再灌注方法、静脉和动脉内药物溶栓联合应用、溶栓和新型抗小板药的联合应用,以及应用机械装置或经颅多普勒超声促进药物溶栓的作用等等。     

急性缺血性卒中的溶栓治疗进展

重组组织型纤溶酶原激活剂静脉溶栓是目前惟一一种证实有效的治疗急性缺血性卒中的药物。在许多情况下，费用低廉的尿激酶不失为一种较好的选择。虽然溶栓治疗日趋成熟，但一些问题仍需进一步探讨，如新的溶栓药物用于发病3h以上的急性缺血性卒中患者、评价各种新的再灌注方法、静脉和动脉内药物溶栓联合应用、溶栓和新型抗小板药的联合应用，以及应用机械装置或经颅多普勒超声促进药物溶栓的作用等等。     

新视点——急性心力衰竭

既往对心力衰竭(心衰)的关注,大多集中在慢性心衰上,而以心衰名义住院的患者,多数是急性心衰包括慢性心衰急性失代偿。这一部分人群并未得到合理的治疗,也缺少循证医学的证据。因此,调查急性心衰的现状,研究治疗急性心衰的新药物、新装置已经成为一种新趋势。近年来,相继有多个急性心衰的研究问世,并在2005年推出了急性心衰的治疗指南。1急性心衰的现状ADHERE(The Acute Decompensated HeartFailure National Registry)研究〔1〕回顾性分析了2004年1月前274家医院105388例急性失代偿性心衰患者的临床特征及治疗状况,高血压、冠心病和…     

慢性阻塞性肺疾病管理中吸入装置的选择与应用

慢性阻塞性肺疾病(慢阻肺)已成为我国第三大致死性疾病,疾病负担重。吸入疗法作为慢阻肺治疗的首选给药方式,起效快速、使用方便;但临床仍存在医患对吸入装置特性认识不足、吸入装置使用不当、吸入药物选择不同、吸入方法掌握不妥等情况,导致患者症状控制不佳、急性加重增多的情况时有发生。本文将重点介绍吸入药物的类型和作用机制、吸入装置的种类和特点、影响吸入药物疗效的因素等,以利于医护人员指导患者正确选择和使用吸入装置,从而实现慢阻肺的全程规范化管理。     

急性冠脉综合征患者抗血小板降阶治疗方案研究进展

双联抗血小板治疗已成为急性冠脉综合征患者的标准治疗。然而随着新型强效P2Y12受体拮抗剂的出现,对于抗血小板药的选择和联合用药策略以及抗血小板治疗的最佳持续时间出现争议,争议的焦点在于预防血栓事件发生和防止出血风险过度增加之间如何取得平衡。大量的临床实践证实,并不存在绝对标准的抗血小板治疗方案,但根据实际情况逐渐降低抗血小板治疗强度,可在不增加缺血事件的同时减少出血事件,并减少其他药物不良事件发生,基于此提出的降阶治疗正成为急性冠脉综合征患者抗血小板治疗研究领域的新热点。     

冠状静脉窦缩窄装置:难治性心绞痛治疗新进展

近年来,在缺血性心脏病治疗方面,尽管药物及介入治疗取得了巨大进展;但是,仍然有越来越多的患者由于不适宜行冠状动脉血运重建治疗,尽管接受了最佳的药物治疗,但心绞痛症状仍反复发作。针对难治性心绞痛的治疗,尝试了许多新型的治疗措施,但是没有一项治疗措施公认有效且被广泛应用。目前针对难治性心绞痛主要是采用药物治疗并纠正相关危险因素。研究表明,增加冠状静脉窦压力使冠状动脉血流从相对不缺血的心外膜向相对缺血的心内膜流动,从而减轻心肌缺血,改善心绞痛症状。经皮、静脉于冠状静脉窦内植入一个可经球囊扩张沙漏状不锈钢网状装置,导致冠状静脉窦固定狭窄,从而增加冠状静脉窦压力,目前针对该装置的一系列临床试验表明,其可行性、安全性及有效性均不断得到证实,可能成为难治性心绞痛新的治疗选择。这篇综述将从难治性心绞痛的临床特征、流行病学、治疗方案及冠状静脉窦缩窄装置作为难治性心绞痛新型治疗措施的可行性、安全性及有效性等方面来阐述。     

Etiopathogenesis of acute hepatic failure: Eastern versus Western countries

Etiopathogenesis of acute hepatic failure (AHF) in Eastern and Western countries is distinct. In the East hepatitis viruses cause AHF in more than 95% of such cases, while causes of AHF in the West are quite heterogenous. Hepatitis E virus is the major etiological agent of AHF in countries like India where the virus is hyperendemic. Occult HBV infection may also be causing AHF in a sizable proportion of cases in areas where chronic HBV infection frequency is high. Paracetamol causes AHF in about 70% cases in the UK and about 20% cases in USA, whereas in France and Denmark, non-steroidal anti-inflammatory drugs are more frequently associated with AHF. Hepatitis B virus causes AHF in about one-third of cases in the latter two countries.     

Contemporary management and research directions in advanced heart failure: where are we going?

Advanced heart failure (AHF) is not a uniform disorder, but is rather a heterogeneous group of patients with varying clinical presentations and definitions. It is growing in magnitude and represents a major public health problem. Herein we describe contemporary care of the patient with AHF, novel medical therapies, and mechanical circulatory assist devices. We speculate where progress has been made and where the major gaps in knowledge remain. Clearly, there is ample opportunity for research and discovery to further advance the care of these very sick patients.     

Endothelial Cell Permeability and Adherens Junction Disruption Induced by Junín Virus Infection

Junín virus (JUNV) is endemic to the fertile Pampas of Argentina, maintained in nature by the rodent host Calomys musculinus, and the causative agent of Argentine hemorrhagic fever (AHF), which is characterized by vascular dysfunction and fluid distribution abnormalities. Clinical as well as experimental studies implicate involvement of the endothelium in the pathogenesis of AHF, although little is known of its role. JUNV has been shown to result in productive infection of endothelial cells (ECs) in vitro with no visible cytopathic effects. In this study, we show that direct JUNV infection of primary human ECs results in increased vascular permeability as measured by electric cell substrate impedance sensing and transwell permeability assays. We also show that EC adherens junctions are disrupted during virus infection, which may provide insight into the role of the endothelium in the pathogenesis of AHF and possibly, other viral hemorrhagic fevers.     

The pathophysiology of acute heart failure--is it all about fluid accumulation?

Despite significant advancement in chronic heart failure (HF), no breakthroughs have occurred in the last 2 decades in our understanding of the pathophysiology, classification, and treatment of acute HF (AHF). Traditional thinking, which has been that this disorder is a result of gradual fluid accumulation on a background of chronic HF, has been called into question by recent large registries enrolling less selected patient populations. It is increasingly recognized that many patients with this syndrome are elderly, have relatively preserved ejection fraction, and have mild or no preexisting chronic HF. In this review, we propose 2 primary subtypes of AHF: (1) acute decompensated cardiac failure, characterized by deterioration of cardiac performance over days to weeks leading to decompensation; and (2) acute vascular failure, characterized by acute hypertension and increased vascular stiffness. Registry data suggest that the latter is the more common form of AHF in the general population, although the former is often overrepresented in studies focused in academic tertiary care centers. Regardless of the clinical subtype, a variety of pathophysiologic mechanisms may play a role in this disorder, many of which remain poorly understood. In this review, we describe current understanding of the pathophysiology of AHF, including a critical evaluation of the data supporting both traditional and novel mechanisms, and suggest a framework for integrating these mechanisms into an overall model of AHF.     

Medical and ventilatory treatment of acute heart failure: new insights

BACKGROUND: The traditional medical treatment of acute heart failure (AHF) has remained unchanged for many years. It has been based on oxygen supplementation and mechanical ventilatory support as well as the administration of morphine, diuretics, nitrates and inotropic agents. In 2005 the European Society of Cardiology (ESC) published new guidelines on the diagnosis and treatment of AHF. Also, new therapies have been introduced recently, giving rise to changes in therapeutic concepts. MATERIAL/METHOD: Based on these new guidelines and recent studies selected from the literature we here describe the new ESC classification of AHF including its epidemiology and pathophysiology. We further present a state-of-the-art status of the choices of medical treatment for patients with acute decompensated heart failure and pulmonary edema. RESULTS: Mechanical ventilatory support reduces the number of patients who require endotracheal intubation.Nitrates in dosages higher than employed today appear to be beneficiary to patients with pulmonary congestion, probably because of the pronounced afterload-reducing effect. Nesiritide, a synthetic brain natriuretic peptide, has shown better hemodynamic effects than common nitrate dosages in patients with congestive heart failure. Tezosentan, an endothelin antagonist, was tested in the biggest AHF trial ever, which, however, was terminated prematurely because it was futile to proceed given the endpoints dyspnea and death. The beta1-adrenergic drug dobutamine and the phosphodiestherase inhibitor milrinone are associated with increased mortality in patients with pronounced chronic and acute congestive heart failure. Levosimendan, a new inotropic drug, has shown lower mortality compared to dobutamine in patients with acute congestive heart failure. CONCLUSION: New concepts have finally emerged, including the application of old drugs such as nitrates in new (i.e., higher) dosages, as well as the novel compound levosimendan, recommended for patients with AHF and hypoperfused organs. The new ESC classification of AHF provides a valuable and long-awaited guideline to diagnose and treat this severe condition.     

Evaluating the Efficacy,Safety, and Tolerability of Serelaxin When Added to Standard Therapy in Asian Patients With Acute Heart Failure: Design and Rationale of RELAX-AHF-ASIA Trial

Background

Acute heart failure (AHF), a common and growing health concern worldwide, is associated with high risk of post-discharge rehospitalization and mortality. Existing evidence indicates potential therapeutic benefits of serelaxin in Caucasian AHF patients, but corresponding data in Asians remain scarce. RELAX-AHF-ASIA, a multinational, randomized, double-blind, placebo-controlled, phase III trial, will evaluate the effects of serelaxin on symptom relief and clinical outcomes in Asian AHF patients, with the use of novel assessments.

Acute heart failure: lessons learned so far

Acute heart failure (AHF) affects nearly every Canadian with heart failure (HF) at least once. Despite several attempts, no medical therapies have been shown to improve the natural history of AHF. In addition, the place of diagnosis of AHF is increasingly made in the outpatient setting. In this view, AHF is a moving target, and from recent registry data and from clinical trials, 5 critical lessons regarding the syndrome of AHF emerge: (1) The period of clinical instability preceding AHF may be much longer than previously thought. (2) Refinement of tools used to aid the early and accurate diagnosis of AHF will impact patient outcomes. (3) Standard supportive care of patients with AHF includes early use of diuretics with frequent reassessment in nearly all patients and supplemental vasodilators and oxygen therapy in selected cases. (4) Patients who survive presentation of AHF continue to suffer high rates of re-presentation, death, and rehospitalization following discharge from either hospital or emergency department. (5) Interventions shown to improve patient outcomes for AHF to date are related to process of care rather than new medications or devices.This report reviews the recent literature regarding the presentation, diagnosis, management, and prognosis of AHF. Areas of future research priority are indicated and guidelines for improving treatment are provided. AHF is an important clinical area that has not been as intensively studied as chronic HF; it presents both important needs and exciting opportunities for research and innovation.     

1198例急性心力衰竭患者急诊抢救的回顾性分析

目的对急性心力衰竭(心衰)患者的急诊抢救进行流行病学分析。方法选择2005年1月～2011年12月我院急诊抢救室的15 408例急诊患者中,急性心衰患者1198例的临床资料进行回顾性分析。结果急性心衰患者占所有急诊抢救患者的7.8%。≥80岁高龄患者比例29.1%。急诊病死率12月份最高。急诊抢救好转出院或自动离院212例(17.7%),急诊住院580例(48.4%),继续急诊留院227例(18.9%),转院64例(5.3%),死亡115例(9.6%);每年急性心衰病死率无明显下降趋势;13.9%在入抢救室2 h内死亡,63.5%在24 h内死亡。2010、2011年24 h内死亡比例较2008年以前明显下降(P<0.05)。患者在抢救室滞留时间逐年延长。结论急性心衰占急诊抢救患者的比例有逐年增加趋势,应重视并采取有效措施进一步降低急诊病死率,并减少急诊滞留时间。     

Acute heart failure

Acute heart failure (AHF) is one of the most common causes for hospital admission and is associated with a high risk of mortality. Compared to chronic heart failure, there is less robust evidence to guide diagnosis, risk stratification and management of AHF. This state-of-the art review aims to summarize new developments in this field. We also highlight areas of ongoing work including novel vasoactive agents, alternative models to traditional hospital admission and strategies to improve patient engagement.     

Vasodilators in the treatment of acute heart failure: what we know, what we don’t

Although we have recently witnessed substantial progress in management and outcome of patients with chronic heart failure, acute heart failure (AHF) management and outcome have not changed over almost a generation. Vasodilators are one of the cornerstones of AHF management; however, to a large extent, none of those currently used has been examined by large, placebo-controlled, non-hemodynamic monitored, prospective randomized studies powered to assess the effects on outcomes, in addition to symptoms. In this article, we will discuss the role of vasodilators in AHF trying to point out which are the potentially best indications to their administration and which are the pitfalls which may be associated with their use. Unfortunately, most of this discussion is only partially evidence based due to lack of appropriate clinical trials. In general, we believe that vasodilators should be administered early to AHF patients with normal or high blood pressure (BP) at presentation. They should not be administered to patients with low BP since they may cause hypotension and hypoperfusion of vital organs, leading to renal and/or myocardial damage which may further worsen patients’ outcome. It is not clear whether vasodilators have a role in either patients with borderline BP at presentation (i.e., low-normal) or beyond the first 1–2 days from presentation. Given the limitations of the currently available clinical trial data, we cannot recommend any specific agent as first line therapy, although nitrates in different formulations are still the most widely used in clinical practice.