青年与中老年心力衰竭患者的临床特点及预后研究

目的 观察青年与中老年心力衰竭（心衰）患者的临床特点、心脏超声指标、实验室化验、临床用药及预后,并分析影响预后的因素。方法 回顾性分析2019年1月至2020年7月于首都医科大学附属北京朝阳医院心脏中心住院的心功能Ⅱ～Ⅳ级心力衰竭患者348例,按照年龄分为青年组62例（≤50岁）和中老年组286例（>50岁）,收集一般临床资料、实验室化验、心脏超声指标、临床治疗情况。观察两组患者主要心血管不良事件的发生率,包括心源性死亡及心衰再入院。应用Kaplan-Meier(K-M)法绘制生存曲线,应用多因素logistic回归分析影响心血管不良事件的危险因素。结果 青年组男性、高血压性心脏病、扩张性心肌病、肥胖性心肌病及心肌炎后心衰、射血分数减低性心衰、合并睡眠呼吸暂停综合征比例高于中老年组,体重指数、心率、舒张压高于中老年组（P<0.05）。青年组射血分数更低,左心室舒张末期及收缩末期内径更大,应用β受体阻滞剂、螺内酯及血管紧张素受体脑啡肽酶抑制剂比例高于中老年组（P<0.05）。K-M曲线显示,青年组24个月时主要心血管不良事件发生率及心衰再入院率更低（P<0.05）...     

急性心肌梗死合并非甲状腺病态综合征的相关研究

目的探讨急性心肌梗死(AMI)患者合并非甲状腺病态综合征(NTIS)时FT_3水平对患者远期死亡率的影响。方法共纳入1 809例AMI患者,按甲状腺功能检查分为NTIS组和甲功正常组,随访1~8.5年,采用多因素COX回归分析方法,研究FT_3水平对AMI患者远期全因死亡、心血管死亡的影响。结果 AMI患者中NTIS的发生率为21.7%。与甲功正常组相比,NTIS组住院死亡率、远期全因死亡率和远期心血管死亡率均升高(14.3%vs.1.8%,23.1%vs.14.5%,14.0%vs.7.6%,P0.05)。FT_3水平(HR=0.304,95%CI:0.134~0.693,P=0.005)与AMI患者远期全因死亡的独立相关,FT_3水平(HR=0.241,95%CI:0.093~0.622,P=0.003)也是AMI患者远期心血管死亡的独立危险因素。结论 AMI患者中常见NTIS,FT_3水平是AMI患者远期全因死亡和心血管死亡的独立危险因素。     

不同治疗方法干预冠心病预后的多因素分析

目的：对冠心病患者进行远期预后相关因素分析，研究PTCA和药物治疗干预的作用。方法：对人选冠心病患者进行信访，采用COX回归模型对主要临床终点（包括心源性死亡、再梗死、再次血运重建和以上事件复合终点）进行多因素分析，治疗干预作为其中一个因素加以研究。结果：入选295例患者，药物组165例，介入组130例，平均随访2．9年。其中死亡11例，再发心梗18例，再次血运重建36例，复合终点出现共51例。PTCA和药物治疗对主要临床终点发生的影响统计意义检验P值大于0．05。心绞痛分级与心源性死亡相关（P＝0．034）；病变血管支数、侧支情况与再次心梗发生相关（P＝0．031和P＝0．007），也与复合终点发生相关（P＝0．022和P＝0．022）；余变量P值均大于0．05。结论：在冠心病稳定型心绞痛患者中，药物和PTCA治疗干预对心血管事件（心源性死亡、再梗死、再次血运重建和以上事件复合终点）发生影响无统计意义上的差别。病变血管支数、侧支循环情况与心血管事件发生相关。     

冠心病吸烟患者戒烟干预方法的研究进展

吸烟是威胁冠心病患者预后的主要危险因素之一,戒烟是有效预防患者发生心血管不良事件、成本低且获益大的措施。医务人员有必要通过有效手段,加强对冠心病吸烟患者的临床戒烟干预,提高患者戒烟成功率,促进患者康复。本文综述了冠心病吸烟患者相关的戒烟干预方法和措施,旨在了解目前戒烟干预实施的现状和效果,为医务人员帮助患者戒烟提供方法和思路。     

血肌酐水平增高对急性冠脉综合征患者预后的影响研究

目的：探讨血肌酐水平升高对急性冠脉综合征患者预后的影响。方法以2000年6月至2013年6月住院治疗且病历资料完整的急性冠脉综合征患者645例为研究对象,将住院期间血清肌酐水平较入院时增加25％的患者纳入肌酐增高组,其他患者纳入肌酐未升高组。采用Logistic回归模型分析肌酐水平与患者预后的关系。结果645例患者中,33例纳入肌酐水平增高组,612例纳入肌酐水平未增高组。肌酐水平增高组患者院内全因病死率,以及心力衰竭、心源性休克发生率均高于肌酐水平未增高组（P＜0．05）。Logistic回归分析显示,肌酐水平增高是急性冠脉综合征患者预后不良的预测因素（比值比为15．02,95％置信区间为10．64～40．05,P＜0．05）。结论血清肌酐水平增高是急性冠脉综合征患者院内死亡及心血管不良事件的预测因素之一。     

心力衰竭患者出院后90天内不良事件预测模型构建

目的 构建心力衰竭患者出院后90天内发生不良事件的预测模型。方法 回顾性分析发布于PhysioNet的自贡市第四人民医院2016年12月至2019年6月的2 008例心力衰竭患者资料，根据出院后90天是否发生不良事件(心源性非计划性再入院或全因死亡)分为事件组和非事件组。采用Lasso-Cox回归分析法筛选影响90天内不良事件的影响因素，以此构建预测模型。结果 纳入的1 959例患者中524例(26.75%)出现不良事件，全因死亡35例(1.79%),再入院489例(24.96%);基于Lasso-Cox回归筛选出收缩压、纽约心脏病协会(NYHA)分级、查尔森共病指数(CCI)、红细胞分布宽度、肌酐、血清钾和氯化物等7个预测变量构建预测模型，模型验证结果显示，受试者工作特征(ROC)曲线下面积(AUC)为0.653,校准曲线趋于理想，模型一致性良好。Kaplan-Meier风险分层结果显示，高风险组不良事件发生风险高于其他组。结论 收缩压、NYHA分级、CCI指数、肌酐、红细胞分布宽度、血清钾和氯化物是心力衰竭患者出院后90天发生不良事件的影响因素，基于此构建的预测模型可有效评估不良事...     

老年急性心肌梗死伴心力衰竭患者心血管不良事件发生的影响因素分析与对策

目的探讨老年急性心肌梗死伴心力衰竭患者心血管不良事件发生的影响因素及干预对策。方法回顾分析2016年12月至2017年12月在我院心内科接受治疗的老年心肌梗死合并心力衰竭患者138例作为研究对象,根据是否发生心血管不良事件分为对照组83例(未发生心血管不良事件)与观察组55例(发生心血管不良事件)。两组入院后查阅病例资料,记录并统计两组患者性别、年龄、高血压、糖尿病、高脂血症、吸烟、CK、Hb、UA、BNP、SBP、DBP、Scr、TC、TG及LDL-C水平,对上述影响因素进行单因素及多因素logistic分析;针对心血管不良事件发生影响因素提出相应的干预对策。结果单因素结果表明,老年心肌梗死合并心力衰竭患者心血管不良事件发生因素与性别、糖尿病、吸烟、TC、TG、LDL-C水平无关,差异无统计学意义(P0.05);老年心肌梗死合并心力衰竭患者心血管事件发生因素与年龄、高血压、高脂血症、CK、Hb、UA、BNP、SBP、DBP、Scr水平有关,差异具有统计学意义(P0.05);多因素logistic分析结果表明,老年心肌梗死合并心力衰竭患者心血管事件发生因素与年龄、高血压、高血脂症、CK、Hb、UA、BNP及Scr水平有关。结论老年急性心肌梗死伴心力衰竭患者心血管患者不良事件发生率较高且影响因素较多,应根据危险因素制定有效的措施进行干预,降低其心血管不良事件发生率。     

抑郁对冠状动脉非阻塞性心肌梗死患者临床预后的影响

目的探讨抑郁情绪对冠状动脉非阻塞性心肌梗死(MINOCA)患者远期预后的影响。方法选取456例MINOCA患者,利用医院焦虑抑郁量表(HADS-D)对MINOCA患者抑郁情况进行评估,将患者分为抑郁组和非抑郁组,并随访3年。主要终点事件为全因死亡和主要心脏不良事件。结果在随访期间,共发生38例死亡和101起主要心脏不良事件,Kaplan-Meier生存曲线显示,抑郁情绪对全因死亡率和主要心脏不良事件发生率具有统计学意义(χ2分别=6.37、7.46,P均<0.05)。多因素Cox回归分析显示,抑郁情绪是MINOCA患者全因死亡率和主要心脏不良事件发生率的危险因素(HR分别=1.70、2.08,P均<0.05)。结论抑郁症状是MINOCA患者全因死亡率和主要心脏不良事件发生率的危险因素,影响远期预后。     

N末端B型利钠肽前体对老年心力衰竭的诊断及预后价值的研究

目的探讨氨基末端B型利钠肽前体（ NT-proBNP ）测定对老年收缩性心力衰竭诊断及预后的应用价值。方法510例患者,根据年龄、临床资料及心脏超声心动图分为老年收缩性心力衰竭组（老年心力衰竭组）、老年非心力衰竭组及对照组,测定并比较3组患者NT-proBNP水平,评价NT-proBNP对老年收缩性心力衰竭诊断的价值;同时对老年心力衰竭组患者随访,观察心力衰竭患者心源性再住院及死亡等事件,评价NT-proBNP对预后判定的价值。结果老年心力衰竭组患者为172例,老年非心力衰竭组患者为168例,对照组为170例,三组患者 NT-proBNP 水平有显著差异[（6986.6±104.6） pg/ml vs．（824.2±6.2）pg/ml vs．（266.4±9.4）pg/ml,P＜0.01]。其中老年心力衰竭组中158例患者平均随访（166.0±38.6）d,心源性再住院组及心源性死亡组的NT-proBNP水平显著高于无再发事件组,分别为（5281.6±70.2） pg/ml、（7886.2±146.3）pg/ml及（2646.8±58.4）pg/ml（P＜0.01）,差异有非常显著统计学意义。 COX多元回归分析显示logNT-proBNP（回归系数：0.992;P ＝0.005）、治疗后 NT-proBNP 下降速率（回归系数：0.966;P ＝0.002）和心房颤动（回归系数：0.884;P＝0.005）、室性心动过速（回归系数：0.924;P＝0.005）是心源性死亡、再住院患者独立相关因素。结论 NT-proBNP检测对老年收缩性心力衰竭的诊断和鉴别诊断有显著的临床价值,NT-proBNP对老年收缩性心力衰竭的预后预测价值好。 log NT-proBNP、治疗后NT-proBNP下降速率、心房颤动、室性心动过速是老年心力衰竭患者心源性死亡、再住院事件的独立相关因素。     

心肌梗死溶栓疗法危险评分对急性心肌梗死患者预后的评估价值研究

目的:探讨心肌梗死溶栓疗法(TIMI)危险评分在预测急性心肌梗死(AMI)患者远期预后中的临床价值。方法:选取我院心血管内科收治的500例AMI患者进行研究,根据患者入院时的TIMI危险评分分为A组(TIMI危险评分≤3分)、B组(TIMI危险评分4~6分)、C组(TIMI危险评分≥7分),对患者进行电话随访、患者门诊随诊等方式,统计分析3组患者5年内再发心血管不良事件及心源性死亡发生率。结果:C组患者的心肌梗死再发率、顽固性心绞痛发生率、恶性心律失常发生率、心力衰竭发生率、心源性死亡发生率、靶血管血运重建率均显著高于A、B组患者(P0.05);当TIMI危险评分为9.4分时,灵敏度为0.831,特异度为0.864,诊断指数为1.695,ROC曲线下面积(AUC)为0.892。结论:TIMI危险评分在预测AMI患者再发心血管不良事件及患者远期心源性死亡方面具有一定的临床价值。     

血清BNP、D-D水平及24 h室性期前收缩负荷对心力衰竭患者心源性不良事件发生的预测价值研究

目的探讨血清脑钠肽(BNP)、D-二聚体(D-D)水平及24 h室性期前收缩(PVC)负荷对心力衰竭患者心源性不良事件发生的预测价值。方法将该院2017年7月至2020年12月收治的82例心力衰竭患者作为观察组,同期50例入院排除心力衰竭的患者作为对照组。检测患者血清BNP和D-D水平,行24 h心电图检查,记录24 h PVC负荷。比较观察组与对照组、发生心源性不良事件与未发生心源性不良事件心力衰竭患者的BNP、D-D水平及24 h PVC负荷,分析血清BNP、D-D水平及24 h PVC负荷与心源性不良事件发生的关系及其预测心源性不良事件发生的价值。结果观察组血清BNP、D-D水平及24 h PVC负荷均明显高于对照组(P<0.05);发生心源性不良事件心力衰竭患者血清BNP、D-D水平及24 h PVC负荷均明显高于未发生心源性不良事件者(P<0.05);心力衰竭患者血清BNP、D-D水平及24 h PVC负荷与心源性不良事件发生均呈正相关(r=0.743、0.611、0.658,P<0.05);BNP、D-D及24 h PVC负荷联合检测预测心源性不良事件发生的灵敏度、特异度及曲线下面积均明显高于各项指标单独检测(P<0.05)。结论联合分析BNP、D-D水平及24 h PVC负荷变化可有效预测心力衰竭患者心源性不良事件的发生,具有较高的临床应用价值。     

Serum thiocyanate, smoking habits and smoking cessation trial in patients with peripheral atherosclerosis

The smoking habits in patients with atherosclerosis in the lower limbs and the effect of advising them to stop smoking was studied by means of self-declaration of the number of cigarettes smoked per day and determination of serum thiocyanate. Ninety-six per cent of males and 70 per cent of the females were smokers or ex-smokers. The number of years of smoking was about 40 for the smokers of both sexes and the male ex-smokers and 23 for the female ex-smokers. The number of cigarettes smoked per day reported by the patients was less than that reported by the smokers in a reference population. The serum thiocyanate levels confirmed the smoking status of the non-smokers and showed that about one-sixth of the ex-smokers had smoked in the last month prior to the study, and that the smokers on the average were heavy smokers smoking much more than the self-reported number of cigarettes. The effect of advising the patients to quit smoking was very disappointing. A maximum of 15 per cent of the smokers stopped smoking while some of the ex-smokers resumed smoking.     

ExHALED Study: Prevalence of smoking and harm levels in an emergency department cohort

Objective: To determine the prevalence of smoking among ED patients compared with the general New Zealand (NZ) smoking prevalence. Secondary outcomes were to determine smokers' level of nicotine dependence, readiness to quit and engagement with primary health care. Methods: This was a prospective, cross‐sectional prevalence study of ED patients seen consecutively over 6 days in Wellington Hospital, Wellington South, NZ. Medically stable patients ≥18 years were asked about their smoking habits by a closed‐question survey. Results: Five hundred and twenty‐eight patients comprised the study group. The ED smoking prevalence was 33.1% and higher than the general NZ smoking prevalence of 20.7%. Of those who smoked, 26.3% were ‘moderately’ to ‘very highly’ dependent on nicotine (Fagerstrom Test for Nicotine Dependence, FTND score ≥5). Of those who smoked, 74.9% stated they wanted to quit, 42.9% wanted to quit within the next month and 60.6% wanted an ED quit smoking pack. There were 13.6% of ED patients not registered with a general practitioner; of this, 61.1% were current smokers and 70.5% wanted to quit smoking. Conclusions: The prevalence rates of smoking are higher among patients attending Wellington Hospital ED than the general NZ population and the majority would like to quit smoking. One in four ED smokers have a high FTND score and are considered nicotine‐dependent. Many patients who were not registered with a general practitioner smoked, and the majority wanted to quit. Finally, there is significant interest from ED patients in receiving quit smoking packs from the ED.     

Smoking behavior and desire to quit among low-income female caregivers.

The purpose of this study was to examine smoking behavior and the desire to quit among low-income women. Two hundred and eight women caregivers were surveyed about their smoking status, exposure to environmental tobacco smoke in the home, and desire to quit smoking. Most of the smokers (74%) wanted to quit smoking. With a logistic regression model, the number of years smoked was the only significant predictor variable for the dependent variable of thoughts about quitting when age, years of smoking, number of children, marital status, number of smokers in the home, cigarettes smoked per day, and money spent per week on cigarettes were entered as independent variables. The fewer years smoked the more likely the women wanted to quit.     

Smoking Habits of Emergency Department Patients: An Opportunity for Disease Prevention

Objective: To determine smoking habits, levels of addiction, readiness to quit, and access to primary care among ED patients.
Methods: A questionnaire was administered prospectively to all non-critical adult patients who presented to one university hospital ED during 23 randomly selected four-hour time blocks; 336 (89%) of 376 eligible patients responded. Self-reported smoking was validated by carbon monoxide breath testing in a pilot sample of 49 patients.
Results: The study patients were mostly young (mean age = 35 ± 15 years), female (59%), white (62%), and high school-educated (73%). Of the 336 ED patients, 41% were current smokers (95% CI = 0.36–0.46); 42% of these were "moderately" to "very highly" dependent on nicotine (Fagerstrom Test for Nicotine Dependence > 4). Of those who smoked, 68% stated they wanted to quit, and 49% wanted to quit within the month. Fifty-six percent of all those who smoked stated that they had never been told to quit smoking by any physician. Thirty-five percent of the ED sample (118 patients) relied upon EDs for most or all of their routine, primary health care; 55% (95% CI = 0.46–0.64) of these patients were current smokers.
Conclusions: The prevalence rates of smoking and nicotine addiction among ED patients are high. Almost half of ED smokers are ready to quit, but most state they have never been told by a physician to do so. Finally, a large proportion of ED smokers receive their primary care in EDs. Therefore, the ED may be an underused setting for smoking cessation intervention.     

GPs have key role in helping patients to stop smoking

Eighteen per cent of all deaths in adults aged 35 or over in England are still attributable to smoking. Almost all these premature deaths could be avoided if smokers stopped before their mid-thirties but only a quarter of people who have ever smoked regularly manage to quit by this age. Advice from the patient's GP is one of the most important triggers to a smoker making an attempt to quit. All patients attending a surgery for any reason who have smoked within the past three years should be offered advice on stopping smoking. Smokers without smoking-related diseases are just as likely to respond to advice as those with them. It is also important to re-assess the status of former smokers who were recorded as having stopped within the past three years. Half of those who stopped six months ago will relapse at some point as will 40% of those who stopped a year ago. Offer help with stopping to all smokers. The National Centre for Smoking Cessation and Training has launched a new online training module on how GPs can best deliver smoking cessation support to their patients. Optimum treatment involves behavioural support plus one of the smoking cessation medications. Behavioural support includes a number of specific behaviour change techniques that enhance the smoker's chances of remaining abstinent. These include: measurement of carbon monoxide in expired air; advice on best use of medication and helping smokers to put in place a clear 'not a puff' rule.     

Trial design: blood pressure control and weight gain prevention in prehypertensive and hypertensive smokers: the treatment and prevention study

BACKGROUND: Cigarette smokers with elevated blood pressure (BP) are at substantially higher risk for cardiovascular events compared to normotensive smokers. Although smoking cessation should be a primary treatment goal for these patients, increases in body weight accompanying smoking abstinence may further increase BP. Intervention strategies that facilitate smoking cessation and modify adverse changes in body weight and BP are needed. METHODS: We describe an ongoing multi-site, two-phase, five-year randomized clinical trial. Participants are cigarette smokers with Prehypertension or Stage I Hypertension. In the first phase, participants receive a smoking cessation intervention combining behavioral counseling and nicotine replacement in an open-label fashion. In the second phase, participants who successfully quit smoking are randomly assigned to one of three lifestyle interventions: 1) weight gain prevention, 2) blood pressure control, or 3) usual lifestyle. Participants are followed for one year to assess changes in blood pressure, body weight, dietary intake, and physical activity. CONCLUSIONS: Results from the proposed study will provide important insights into the efficacy of various approaches to lifestyle modification in smokers at increased risk for cardiovascular events.     

Use of Nitrates and Risk of Cardiovascular Events in Patients With Heart Failure With Preserved Ejection Fraction

ObjectiveTo assess the association of nitrate use with cardiovascular events in patients with heart failure with preserved ejection fraction (HFpEF).Patients and MethodsPatient data were collected from the Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist trial, which had been conducted at 233 sites in 6 countries from August 10, 2006, through January 31, 2012. The primary outcome was the occurrence of a major adverse cardiovascular event (cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke) or heart failure hospitalization. The association between nitrate use and cardiovascular risk was evaluated using Cox proportional hazards analysis. In addition, we verified the results using propensity score–matched patients.ResultsA total of 3417 patients with HFpEF were evaluated over a mean follow-up of 3.1 years, and 778 experienced a primary outcome event. The risk of primary outcome events was significantly higher in patients taking nitrates than in those not taking nitrates (hazard ratio [HR], 1.21; 95% CI, 1.01-1.46, P=.04). The risk of major adverse cardiovascular events was significantly higher in patients taking nitrates than in those not taking nitrates (HR, 1.32; 95% CI, 1.05-1.66, P=.01). Furthermore, the risk of hospitalization for heart failure was higher in patients taking nitrates (HR, 1.25; 95% CI, 0.99-1.60, P=.06), with propensity score–matched analyses revealing similar findings. In addition, a similar association was observed in various subgroups.ConclusionThis study reported that nitrate use in patients with HFpEF was associated with a significantly increased risk of cardiovascular events.     

An analysis of smoking patterns among older adults.

BACKGROUND, SUBJECTS, AND METHODS: The 1990 Health Promotion and Disease Prevention Supplement to The National Health Interview Survey was used to develop point-prevalence data about smoking for four age groups, 55 to 64, 65 to 74, 75 to 84, and over 84 and to assess the association of sociodemographics, health status, and health beliefs with a respondent's smoking profile. RESEARCH DESIGN: Chi-square and Cohran-Mantel-Haenszel tests were used to investigate prevalence patterns. Odds ratios generated from logistic regressions were used to indicate degree of association. RESULTS: Fifty-three percent of individuals above the age of 54 smoked in the past and 17% smoked in 1990. Among these smokers, 61% tried to quit and 36% noted that their physicians never advised them to quit. Significant age group differences were noted on the various measures of smoking prevalence. Beliefs about the adverse health effects of smoking were associated with a greater likelihood of never smoking, and among smokers, a greater likelihood of being a former smoker. CONCLUSIONS: Analyses of health behaviors among older adults must recognize the diversity within this age group, and measures of health beliefs should be included in subsequent studies of health behaviors among older adults. Physicians must also play a greater role in discussing smoking with their patients and advocating smoking cessation.