急性心力衰竭的病因、诊断、鉴别诊断及临床评估

急性心力衰竭是一个临床综合征。常突然起病,需紧急治疗。急性心力衰竭可以是新发的、或慢性心力衰竭的恶化,急性心力衰竭有多种病因及诱发因素。B型利钠肽、氨基末端B型钠尿肽原有助于诊断及提示预后,对急性心力衰竭患者的临床评估能了解病情的严重程度及预后。     

早期HMGB1水平与AMI患者行急诊PCI院内发生心力衰竭的相关性

目的 观察和分析早期高迁移率族蛋白B1（high mobility group box 1 protein,HMGB1）水平与急诊冠状动脉介入（PCI）治疗患者术后发生力衰竭的相关性。 方法 回顾分析行急诊PCI的急性心肌梗死（AMI）患者86例,分为发生院内心力衰竭组（心衰组,n=17）和非心衰组（n=69）。所有患者均于入院即刻及发生心力衰竭时采集肘静脉测定氨基末端脑钠尿肽前体（N-terminal probrain natriuretic peptides,NT-proBNP）浓度,并同时于入院即刻采血测定HMGB1浓度。入院当时及发作心力衰竭24 h内进行心脏多普勒超声心动图检查,分别记录左心室射血分数（LVEF）、舒张早期血流峰速度（E）/舒张晚期血流峰速度（A）以及每搏排出量和每分排出量4项指标。分析血浆HMGB1水平与NT-proBNP水平和超声心动图反映心功能的每搏排出量、每分排出量、LVEF、E/A各指标之间的相关性以及血浆NT-proBNP水平与反映心功能各数值之间的相关性。 结果 与非心衰组比较,院内心衰组超声心动图4项反映心脏功能的指标均降低,而早期HMGB1水平反而升高,且两组间比较差异均具有统计学意义（均P<0.05）。早期HMGB1水平与发生心力衰竭患者的NT-proBNP水平呈正相关,而与超声心动图反映心脏功能的每搏排出量、每分排出量、LVEF、E/A 呈负相关。二元Logistic回归分析提示:早期血浆HMGB1水平与AMI行急诊PCI患者心功能具有显著的正相关性。 结论 早期HMGB1水平与急诊PCI患者术后发生心力衰竭之间具有明显的相关性。     

老年心力衰竭发展过程中N末端B型钠尿肽与左室射血分数的相关性

B 型钠尿肽(BNP)为由32个氨基酸组成的多肽,其核苷酸序列中包含了不稳定的TATTTAT序列,提示BNP mRNA周转率高,使BNP可以瞬间合成,直接反映心室容量和压力负荷过重,可用于心力衰竭的辅助诊断~([1]).     

舒张功能不全患者B型钠尿肽与超声心动图指标的相关性

目的研究舒张性心功能不全（DHF）患者血浆B型钠尿肽（BNP）水平与超声心动图所测指标的相关性。方法选择89例住院患者,分为正常组、DHF组、舒张并收缩功能异常组（DHF＋SHF组）,又将DHF组根据二尖瓣舒张期E峰与A峰流速比值（EV/AV）分为3组：DHF1级组、DHF2级组、DHF3级组。采用心力衰竭诊断仪测定血浆BNP水平,超声心动图测定左室射血分数（LVEF）、左室舒张末内径（LVEDD）、左房内径（LAD）等指标。结果随着心功能恶化,BNP水平呈逐渐上升趋势。DHF组中LAD与BNP呈正相关（P〈0.01）;DHF＋SHF组中LVEDD与BNP呈正相关、LVEF值与BNP呈负相关（P〈0.01）。结论血浆BNP水平测定结合EV/AV比值分级、超声心动图测定指标有助于DHF的诊断及对心功能进行综合评估。     

急性冠脉综合征行急诊PCI术后hs-CRP和NT-proBNP的临床意义及其预测价值

目的:观察高敏C反应蛋白(hs-CRP)和氨基末端脑钠尿肽原(NT-proBNP)在急性冠脉综合征(ACS)行急诊冠状动脉介入治疗(PCI)术前后的临床意义及其近期预后的预测价值。方法:选择从2009年2月~2011年4月入住两家医院的ACS患者101例,均已成功行急诊PCI术,术后24 h、72 h~7 d、3~6个月测定血清hs-CRP和NT-proBNP水平;并观察随访3~6个月的主要心脏不良事件(MACE)。同时观察ACS药物治疗组52例,健康对照组40例,并进行对比分析。结果:药物治疗组的近期血清NT-proBNP水平显著高于PCI组;而药物治疗组的72 h~7d的血清hs-CRP水平显著高于PCI组;近期PCI组的MACE事件低于药物治疗组。结论:急诊PCI组3~6个月内治疗效果优于药物治疗组。血清NT-proBNP能够对ACS患者进行危险分层,预测MACE的发生率;hs-CRP可作为行急诊PCI的ACS患者的近期预后的预测因子。     

冠心病患者PCI术后6个月血浆NT-proBNP水平的变化及临床意义

目的: 观察冠心病患者行经皮冠状动脉介入治疗（PCI）前和6个月以后血浆中氨基末端脑钠尿肽前体（N-terminal pro-brain natriuretic peptide, NT-proBNP）水平的变化,探讨其临床意义和近期预后价值。方法: 将经冠状动脉造影（CAG）证实的71例冠心病患者,分为PCI组（51例）和对照组（20例）,用电化学发光免疫分析法动态观察其血浆NT-proBNP浓度,分别比较PCI组术前、术后即刻、术后6 h、术后24 h和术后6个月血浆NT-proBNP水平的变化情况,以及随访期间PCI组与对照组患者血浆NT-proBNP浓度的变化。经超声心动图检测两组患者住院期间与术后6个月左心室舒张末期内径（LVEDD）和收缩末期内径（LVESD）,室间隔（IVSW）与左室后壁厚度（LVPW）,左室射血分数（LVEF）,左室短轴缩短率（FS）及E/A比值以评价心功能。结果: PCI组术后6个月血浆Log NT-proBNP浓度［(2.0±0.5)ng/L］显著低于术前［(2.4±0.5)ng/L］水平（P<0.05）。对照组患者6个月后血浆Log NT-proBNP浓度［(2.5±0.6)ng/L］明显高于PCI组［(2.0±0.5)ng/L］（P<0.05）。比较超声心动图各项指标,PCI组患者术后6个月LVEF［(62±10)%］较术前［(64±10)%］有所下降（P<0.05）。结论: 冠心病患者行PCI术后6个月血浆NT-proBNP水平显著降低,提示血运重建与药物治疗联合可能优于单纯药物治疗,并且NT-proBNP对冠心病患者可能具有近期预后价值,可以指导临床医生早期干预,尽可能降低冠心病发病率和死亡率。     

hs-CRP和血小板参数与心衰患者病情严重程度的关系

目的 探讨心衰患者高敏C反应蛋白hs-CRP和血小板参数与患者病情严重程度的相关性.方法 检测760例心衰患者的hs-CRP、血小板计数(PLT)、平均血小板体积(MPV)、血小板体积分布宽度(PDW)和大血小板比率(P-LCR),将患者按不同分组进行分析.结果 hs-CRP水平随心功能分级增加而增加(P＜0.001).PLT随心功能分级增加而降低,MPV、PDW和P-LCR随心功能分级增加而增加(P＜0.001).将患者按心衰的病因分组,hs-CRP水平在各种心衰病因中无差异(P=0.123),PLT、MPV、PDW和P-LCR在各种病因中均有差异(P＜0.01);心衰患者NT-proB-NP水平与hs-CRP呈正相关(r=0.289,P＜0.001),与PLT(r=-0.139,P=0.001)呈负相关,与MPV(r =0.246,P＜0.001)、PDW(r=0.213,P＜0.001)和P-LCR(r=0.247,P＜0.001)均呈正相关.结论 心衰患者hs-CRP和血小板参数与病情严重程度密切相关,检测这些指标有助于患者的病情评估和疗效监测.     

米力农注射液治疗慢性心力衰竭的临床疗效及其对血清氨基末端B型钠尿肽前体水平的影响

目的观察应用米力农微泵治疗慢性心力衰竭(CHF)的临床疗效及其对患者血清氨基末端B型钠尿肽前体(NT-proBNP)水平的影响。方法选择我院确诊的CHF患者141例,在采用常规治疗的基础上加用米力农治疗;并选择同期体检健康者40例作为对照组。于治疗前后检测受检者血清NT-proBNP水平,评价CHF患者的治疗结果。结果 CHF患者治疗7d后总有效率为93.62%(132/141);CHF患者治疗前血清NT-proBNP水平显著高于对照组;治疗7d后显著低于治疗前,但仍显著高于对照组,差异均有统计学意义(P<0.01)。CHF患者随访1年后,发生心脏事件组患者出院时血清NT-proBNP水平显著高于未发生心脏事件组,差异有统计学意义(P<0.01)。结论CHF患者存在着高水平的NT-proBNP,米力农治疗后其水平显著降低、心功能得到改善。     

肺部超声诊断急性前壁心肌梗死合并肺水肿的价值

目的:探讨肺部超声在急性前壁心肌梗死患者中诊断肺水肿的价值。方法:随机纳入2017-01-2017-12住院的急性前壁心肌梗死患者68例,所有患者入院当日均接受心脏超声、肺部超声、下腔静脉超声及胸片、脑钠肽(BNP)检查,以临床确诊为金标准,比较分析肺部超声与胸片诊断肺水肿的灵敏度、特异度、阳性预测值、阴性预测值及准确度的差异,计算两者诊断肺水肿的Kappa值。同时对肺部B线数目与BNP、E/e’、左室射血分数(LVEF)、下腔静脉塌陷率、Tei指数、左室等容舒张时间(IVRT)、E波减速时间(EDT)进行相关分析。结果:①肺部超声较胸片诊断心源性肺水肿诊断灵敏度、特异度及准确度更高,差异有统计学意义(P<0.01),一致率为64.7%,Kappa值=0.294;②肺部B线数目与BNP、E/e’呈正相关,与LVEF、下腔静脉塌陷率呈负相关,与Tei指数、IVRT、EDT无明显相关性。结论:肺部超声在诊断急性前壁心肌梗死合并肺水肿方面灵敏度、特异度以及准确度更高,肺水肿程度与患者心脏收缩和舒张功能具有良好的相关性。     

Comparison of intrasplenic immunization with other types of antigen application

Mice have been immunized intrasplenic (i.l.), i.p., or i.v. with different doses of bovine gammaglobulin (RGG). The number of antigen reactive cells (ARZ) in the spleen was measured by immune rosette technique. Antibodies were detected by passive hemagglutination. The i.l. immunization induced no higher numbers of ARZ than the other ways of antigen application, but the maximum arose earlier, already at the third day. The most ARZ were B lymphocytes. Very low doses of antigen induced antibodies only with i.l. immunization. Most antibodies at the maximum of the primary immune response were of IgM class. A typical secondary response could not be elicited following i.l. priming. Our investigations don't refer to advantages of i.l. immunization for hybridoma techniques.     

Bedside lung ultrasound in the evaluation of acute decompensated heart failure

Dyspnea is a common presenting complaint in the emergency department (ED) and a leading cause of hospitalization in intensive care unit (ICU) and medical wards. Ultrasound (US) has traditionally been considered inadequate to explore the aerated lung. However, in the past 15 years LUS gained broader application, at least in part thanks to the interpretation of the artefacts generated by the interaction of US and lung structures/content. The total reflection of US beam occurring at the pleural level determines the artefactual image of the aerated lung: an homogenous ‘foggy-like’ picture under the pleural line. As the air content of the lungs decreases due to interstitial imbibition, deposition of collagen or presence of blood, vertical artefacts -arising from the pleural line and moving synchronously with the respiration- called B-lines appear. Multiple and bilateral B-lines identify the alveolar-interstitial syndrome (AIS). The most common cause of AIS is the wet lung: the more the congestion burden, the more the extent of the B-lines, which become confluent until the so-called white lung in case of pulmonary edema. Many studies showed a higher accuracy of LUS in diagnosing acute decompensated heart failure (ADHF) as compared to chest X-ray As recently shown, the integration of LUS to clinical assessment allow to differentiate cardiogenic dyspnea with sensitivity and specificity greater than 95 %. Moreover, LUS can easily detect pleural effusion -frequently present in ADHF-appearing as an anechoic area in the recumbent area of the thorax, delimited inferiorly by the diaphragmatic dome and superiorly by the aerated lung.     

Comparison of lung ultrasound and other volumetric methods in peritoneal dialysis patients

Although many alternative methods are present, maintaining ideal volume status in peritoneal dialysis (PD) patients still rely on clinical evaluation due to lack of an evidence-based method. Lung ultrasound (LUS) is a new method for evaluation of hidden congestion in this group.LUS findings and its relationship with other volumetric methods are investigated in this observational cross-sectional study.In this observational cross sectional study, LUS was performed to all PD patients and compared with symptoms of hypervolemia, physical examination, vascular endothelial growth factor-C (VEGF-C), and N-terminal pro-brain natriuretic peptide levels, chest radiography, echocardiography, bioelectrical impedance analysis.Data of 21 PD patients were evaluated. There was correlation between number of B lines and VEGF-C levels (r = 0.447, P = .042), daily urine output (r = 0.582, P = .007) and left ventricle mass index (r = –0.456, P = .038). Correlations with all other parameters were not significant. Daily urine output and VEGF-C levels were significantly different when B lines were grouped into 2 according to the median level (P < .05 for all).This is the widest spectrum study looking for LUS findings and other volumetric parameters in a small PD cohort. LUS might be useful to evaluate hidden hypervolemia. Its correlation with VEGF-C level is a novel finding.     

Clinical value of pulmonary congestion detection by lung ultrasound in patients with chronic heart failure

Chronic heart failure is one of the common causes of hospitalization and death. Pulmonary congestion is the common disease feature of patients with chronic heart failure, which could be correctly diagnosed by lung ultrasound. Efficacy of lung ultrasound‐guided pulmonary congestion management for patients with acute heart failure is well documented, however, more evidence is needed to establish the clinical value of pulmonary congestion detection by lung ultrasound examination in patients with chronic heart failure. This review summarized current evidence related to the use and clinical value of pulmonary congestion assessment by lung ultrasound in patients with chronic heart failure, aiming to provide new suggestions on promoting the widespread use of lung ultrasound in patients with chronic heart failure to improve the quality of life and outcome of patients with chronic heart failure.     

Comparison of different methods of functional evaluation in patients with chronic heart failure

BACKGROUND: Stratification of the severity of heart failure has major prognostic and therapeutic implications. AIMS: To prospectively compare different methods of assessment of functional capacity in patients with chronic heart failure (CHF). METHODS AND RESULTS: We studied 143 patients (78 male and 65 female) with CHF aged less than 70 years (mean 57.3 years). Functional assessment was made clinically according to NYHA classification and according to the Goldman Activity Scale Classification (GASC). Cardiovascular performance was measured by peak O(2) consumption (pVO(2)) and anaerobic threshold (AT) at cardiopulmonary exercise test and by the distance walked during a 6-min walk test (6-MWT). Clinical scales resulted significantly related. Peak VO(2) and AT showed a mild relation with distance covered at 6-MWT (r=0.56 and r=0.46, respectively). Concordance between NYHA classification and levels of performance at cardiopulmonary exercise test or at 6-MWT was less than 50%. CONCLUSION: Our results suggest that none of the usually employed methods give a definitive assessment of functional capacity of cardiovascular system and a high degree of discordance exists among the results of different tests in the same patient. Although NYHA classification maintains its value in clinical evaluation of patients with CHF, the 6-min walk test is recommended in patients with mild-to-moderate CHF (II-III NYHA classes) as a simple and useful screening test to select patients for further diagnostic evaluation.