不同类型心力衰竭患者预后的比较

随着射血分数中间值心力衰竭(HFmrEF)被确立为一个新的独立识别的心力衰竭类型,其预后与另外2种类型心力衰竭-射血分数减低心力衰竭(HFrEF)和射血分数保留心力衰竭(HFpEF)比较是否存在明显差异值得关注。本文对近期发表的有关不同类型心力衰竭患者临床预后比较的相关文献进行梳理、归纳和总结,分析不同类型心力衰竭患者预后的差异。     

射血分数超常的心力衰竭研究进展

心力衰竭是各种心血管疾病的终末阶段,因病死率和致残率高成为重大公共卫生事件。左室射血分数(LVEF)大小与心力衰竭的预后相关,并将心力衰竭分为三类,即射血分数降低型心力衰竭(HFrEF)、射血分数轻度降低型心力衰竭(HFmEF)和射血分数保留型心力衰竭(HFpEF)。近期研究指出,射血分数≥65%的心力衰竭可能因药物疗效不佳和预后不良独立于上述三种分类,被认为是一种新的心力衰竭分型,即射血分数超常型心力衰竭(HFsnEF)。本文就概念及临床特征、病理生理机制及诊断与治疗的研究现状做一综述。     

心力衰竭患者心肺运动试验特征的探讨

目的:探讨不同射血分数心力衰竭患者心肺运动试验特征.方法:回顾性收集2007年3月～2019年7月在同济大学附属同济医院心脏康复中心行心肺运动试验检查的438例心力衰竭患者为研究对象,比较不同射血分数心力衰竭患者心肺运动试验特征,其中153例射血分数减少型心力衰竭(HFrEF),115例射血分数中间型心力衰竭(HFmr...     

心力衰竭患者不良预后的危险因素分析

目的 比较不同左室射血分数(LVEF)心力衰竭患者的预后,探讨心力衰竭患者不良预后的相关临床因素。方法 纳入2009年1月至2017年12月因心力衰竭住院并随访的患者,分为射血分数减低的心力衰竭组(HFr EF,LVEF 40%)、射血分数中间值心力衰竭组(HFmr EF,40%≤LVEF 50%)、射血分数保留的心力衰竭组(HFp EF,LVEF≥50%)。收集临床资料,记录终点事件。结果 共纳入患者517例,其中HFr EF组172例,HFmr EF组80例,HFp EF组265例。随访28. 7(14. 4,60. 3)月,发生全因死亡181例,心血管死亡120例,猝死18例。Kaplan-Meier生存分析显示各组心血管死亡率差异有统计学意义(P=0. 016),HFr EF组(P=0. 006)和HFmr EF组(P=0. 047)心血管死亡率高于HFp EF组。增龄、体质指数降低、反复心力衰竭住院、血红蛋白降低、肾小球滤过率降低、N末端B型利钠肽原升高、卒中或一过性脑缺血发作史、合并慢性阻塞性肺疾病、左房内径 45 mm、LVEF 35%、肺动脉高压是不良预后的独立危险因素。结论 不同LVEF患者预后存在差异,多个独立危险因素提示预后不良。     

心电图在心功能评价中的应用进展

心电图是临床最常用的检查手段之一,其不但在冠心病、心律失常、心室肥厚及电解质紊乱的诊断方面具有重要价值,而且在心功能评价中亦具有重要意义。准确的心功能评价不但有助于心力衰竭的诊断、判断患者的远期预后,而且在患者治疗方案的选择和确定方面也可提供依据。与收缩功能减低的心力衰竭不同,目前推荐的改善心力衰竭预后的治疗方法对左心室射血分数（LVEF）保存的心力衰竭患者并无显著改善预后的价值,这进一步凸显了即使在有典型心力衰竭症状的患者评价左心室收缩功能的重要性。     

射血分数保留的心力衰竭患者心肌能量消耗情况及预后不良的相关因素

  目的  分析射血分数保留的心力衰竭患者心肌能量消耗(MEE)情况及预后不良的相关因素。  方法  回顾性收集2020年1月~2021年1月我院收治的107例射血分数保留的心力衰竭患者临床资料,所有患者均进行超声心动图检查,且出院后均随访6月,根据患者随访期间是否发生不良心血管事件(MACE)将患者分为预后良好组(n=72)和预后不良组(n=35)。统计分析射血分数保留的心力衰竭患者预后不良的单因素,采用多因素Logistic回归分析射血分数保留的心力衰竭患者预后不良的危险因素,并对典型病例超声心动图图像进行分析。  结果  107例射血分数保留的心力衰竭患者中,共35例发生MACE,不良预后发生率为32.71%。单因素分析结果显示,预后不良组外周血红细胞计数、血红蛋白水平及左室射血分数(LVEF)低于预后良好组,血清脑钠肽水平及MEE高于预后良好组(P<0.05)。多因素Logistic回归分析结果显示,血清脑钠肽水平高、MEE高、LVEF低均为射血分数保留的心力衰竭患者预后不良的独立危险因素(OR=2.457、3.083、2.986,P<0.05)。  结论  射血分数保留的心力衰竭患者预后不良的独立危险因素包括血清脑钠肽水平高、MEE高、LVEF低,超声心动图MEE和LVEF可用于预测射血分数保留的心力衰竭患者MACE的发生。      

半乳糖凝集素3在射血分数保留的心力衰竭患者中的临床意义

<正>心力衰竭是一种复杂的临床综合征,是大多数心脏疾病发展的严重阶段和最终结局,在我国心衰5年死亡率达60%以上。目前心力衰竭患者中有接近50%是射血分数保留的心衰(HFpEF),也称为舒张性心衰。相对于射血分数降低的心衰(HFrEF),其预后更差,且目前无有效改善预后的治疗方法,因此,如何早期诊断射血分数保留的心衰对于心脏疾病研究具有重要意义。N末端脑钠肽前体(NT-proBNP)是心力衰竭     

血清sST2、apelin和CPP水平与心力衰竭患者预后的相关性分析

目的:分析血清可溶性生长刺激表达基因2蛋白(sST2)、apelin及和肽素(CPP)水平与不同射血分数心力衰竭患者预后的相关性。方法:选择2018年11月至2020年5月在福建省立金山医院诊断为心力衰竭的119例患者,根据左室射血分数,将其分为射血分数降低组(HFrEF组,n=31)、射血分数中间值组(HFmrEF组,n=21)和射血分数保留组(HFpEF组,n=67)。检测3组患者血清中N末端脑钠肽前体(NT-proBNP)、sST2、apelin和CPP的含量。所有患者入院后根据指南规范化治疗心力衰竭,随访2年,分析各心脏生物学标志物与心血管死亡之间的关系。结果:3组间患者性别、收缩压、脉压、体质量指数、尿素氮、糖化血红蛋白、左心室舒张末期内径、右心房横径、右心室舒张末期内径差异均有统计学意义(P0.05)。3组患者血清中NT-proBNP和sST2含量差异有统计学意义(P0.05),CPP和apelin含量差异无统计学意义。多元线性模型分析结果显示,血清NT-proBNP水平与左室射血分数相关(F=3.49,P=0.03),而血清sST2、apelin、CPP水平与左室射血分数无相关性。随访24个月时HFrEF组、HFmrEF组、HFpEF组患者累计心血管死亡率分别为29.0%、23.8%、10.4%,差异有统计学意义(P=0.04)。Kaplan-Meier生存分析显示,HFrEF、HFmrEF、HFpEF组心血管病累计生存率依次升高(χ~2=6.48,P=0.04)。Cox回归分析结果显示,NT-proBNP、尿素氮水平及使用盐皮质激素受体拮抗剂是心力衰竭患者心血管死亡的独立影响因素(P0.01)。结论:左室射血分数、NT-proBNP、尿素氮水平及使用盐皮质激素受体拮抗剂对心力衰竭患者心血管死亡有预测作用,而血清sST2、apelin和CPP水平预测价值有限。     

老年心衰的预后判断

心力衰竭在发达国家中是心血管中发病率唯一呈上升趋势的疾病,是65岁以上老年患者住院的最常见原因,虽然近年来治疗上有较大进展,但其预后仍然不佳,判断预后的量化指标临床就显重要,本文就此加以概述。 1 左心射血分数与心衰预后的关系 在急性心肌梗塞后,左室射血分数和心力衰竭功能分级同病死率关系密切,经近年来的临床观察研究表明,左室射血分数低于20％者有75％发生重大临床事件(死亡、心脏骤停、充血性心力衰竭),而射血分数大于50％者仅有22％发生重大临床事件(P<0.01)。因此,左心射血分数可作为发生心力衰竭及不良预后的预报     

中性粒细胞和血小板与淋巴细胞比值在不同类型心力衰竭中的差别

目的 分析在射血分数中间值心力衰竭(HFmr EF)患者的中性粒细胞与淋巴细胞比值(NLR)、血小板淋巴细胞比值(PLR)与射血分数减低心力衰竭是否存在差别。方法 连续收集安徽医科大学第一附属医院心内科自2018年1月至2019年1月射血分数50%的心力衰竭患者222例,依据左心室射血分数(LVEF),分为射血分数减低心力衰竭组(HFr EF)(LVEF 40%) 121例和射血分数中间值心力衰竭(HFmr EF)(49% LVEF 40%) 101例。采用病例对照研究分析两组间NLR、PLR的差别。结果 两组在年龄、性别比例、入院舒张压、合并心房颤动的发生率差异均无统计学意义(P 0. 05); HFmr EF组患者入院收缩压水平及合并高血压的发生率明显高于HFr EF组(P 0. 05),合并糖尿病的发生率明显偏低(P 0. 05);两组NLR、PLR水平差异均无统计学意义(P 0. 05);在HFmr EF组不同心功能分级之间NLR、PLR水平差异无统计学意义(P 0. 05)。结论NLR和PLR水平在HFmr EF患者与HFr EF患者相似,两者可能具有相同的预后及死亡率。     

不容忽视的心肌炎——来自《2021年ESC急慢性心力衰竭诊断与治疗指南》的启示

2021年9月,Eur Heart J发布了《2021年ESC急慢性心力衰竭诊断与治疗指南》,该版指南对2016年版指南作出重要更新。其中,心肌炎作为心力衰竭的一种特定临床情况应给予重点关注。本文结合我国心肌炎临床诊疗实践,对新版指南中心肌炎部分进行全面解读,以加深临床医师对此类疾病的认识和理解。     

Chronic heart failure in older adults

Assessment and management of heart failure (HF) in older adults may be simplified and structured by the mnemonic DEFEAT-HF: Diagnosis, Etiology, Fluid volume, Ejection fraction, And Treatment of Heart Failure. A clinical diagnosis and etiology of HF can often be established during history and physical examination. Fluid volume status must be assessed by estimating jugular venous pressure in centimeters of water by identifying the top of the jugular venous pulsation in the neck and estimating its vertical height from the right atrium. Left ventricular ejection fraction must be obtained to classify patients into systolic and diastolic HF and to guide evidence-based therapy.     

《心力衰竭通用定义和分类》将开启心力衰竭诊疗的标准化进程

近期，美国、欧洲和日本心力衰竭学会/协会联合发布了《心力衰竭通用定义和分类》共识。利钠肽被写入心力衰竭通用定义，成为继肌钙蛋白之后第二个被写入疾病定义的心脏标志物。共识将心力衰竭分为4类，新增了射血分数改善的心力衰竭。《心力衰竭通用定义和分类》具有广泛的适用性，有助于临床医生、科研人员和患者理解和采纳，是心力衰竭诊疗标准化向前迈出的重要一步。临床工作人员在使用该定义和分类时，应积极进行科学研究，以推动心力衰竭诊疗的标准化进程。     

Role of Echocardiography in the Diagnosis of Heart Failure with Preserved Left Ventricular Systolic Function: Update 2013

Heart failure and its complications are significant causes of mortality and morbidity in most societies. Major parts of the studies that constitute the base of modern treatment of heart failure have been limited to the study of heart failure associated with reduced left ventricular ejection fraction (HFrEF). Only during the past 10–15 years, heart failure associated with preserved left ventricular ejection fraction (HFpEF) or primarily right-sided heart failure have come more into focus as our understanding of the critical role of other etiologies for the clinical syndrome of heart failure than a reduced left ventricular (LV) ejection fraction has increased. Furthermore, whilst the powerful prognostic role of a reduced LV ejection fraction has long since been well validated, only relatively recently it was realized that patients with heart failure symptoms and preserved LV ejection fraction also have a substantially impaired prognosis. Previously, these patients had often been dismissed as not having "real heart failure". In parallel, it has become clear that diagnoses like hypertensive heart disease, diabetic cardiomyopathy and heart failure associated with atrial fibrillation, among others, can be understood as forms of HFpEF.     

Heart failure in 2010

The Heart Failure Congress 2010 in Berlin presented the latest trials and trends in the medical and mechanical therapy of heart failure in the presence of impaired or preserved left ventricular ejection fraction. It covered all aspects of heart failure from epidemiology through basic and translational science to prevention. The congress highlighted new drugs, novel biomarkers, updated trials, the role of imaging in risk stratification and the importance of telecare in the reduction of heart failure readmission.     

Sleep disordered breathing in older adults with heart failure with preserved ejection fraction

Heart failure in older adults is frequently accompanied by sleep disordered breathing (SDB). Treatment of SDB in persons with heart failure with preserved ejection fraction (HFpEF) is unclear because most data is on heart failure with reduced ejection fraction (HFrEF). The purpose of this paper was to evaluate studies that report on the effects of positive airway pressure on patient outcomes in older adults with HFpEF and comorbid SDB. A search of the literature found six data-based studies (N = 36 to 126). Treatment with positive airway pressure reduced nighttime SDB symptoms and improved daytime functional status in persons with HFPEF and SDB (New York Heart Association Functional Class: effect sizes = ?0.67 to ?1.60). Limitations (i.e. only two studies were randomized controlled trials, small sample sizes, and women were under-represented) suggest that additional evidence is needed to guide treatment of SDB in older adults with HFpEF.     

Drug and drug-device therapy in heart failure patients in the post-COMET and SCD-HeFT era

Reduced left ventricular ejection fraction and heart failure are the most important risk factors for sudden cardiac death. Recent trials have contributed to the knowledge base of critical therapies for the treatment of left ventricular systolic dysfunction and heart failure as it relates to arrhythmic and sudden cardiac death. Both pharmacologic and device therapies can reduce sudden cardiac death. The trials discussed in this paper have identified the pharmacologic and device interventions that are likely to improve the length and quality of life of the patient with left ventricular dysfunction and reduce the risk of sudden cardiac death. The mortality and anti-arrhythmic effects of angiotensin-converting enzyme inhibitors and beta-blockers have been confirmed in large-scale controlled clinical heart failure trials. Recent trials have evaluated which agents are most effective and which patients will derive the most benefit from device therapy in terms of the reduction in the risk of sudden cardiac death and in the amelioration of heart failure. The recent data from the Carvedilol or Metoprolol European Trial (COMET) and the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) are discussed as the latest in the series of landmark studies that have shaped the current approaches to treating patients with heart failure and that have altered the heart failure treatment paradigm.     

射血分数正常的老年心力衰竭患者的临床观察

目的探讨左室射血分数(LVEF)正常的老年心力衰竭患者的临床特点。方法住院老年心力衰竭患者56例,LVEF正常心力衰竭组和LVEF降低心力衰竭组各28例,22例健康体检者为对照组,比较各组在体质量指数(BMI)、收缩压、舒张压、血浆N末端B型利钠肽(BNP)浓度的差异。结果 LVEF正常心力衰竭组和LVEF降低心力衰竭组美国纽约心脏病学会(NYHA)心功能分级无明显差异(P>0.05)。而BNP水平在LVEF正常心力衰竭组与对照组及LVEF降低心力衰竭组之间差异有统计学意义(P<0.05)。结论多数有心力衰竭症状而LVEF正常者血浆BNP和血压均高。