无症状性心力衰竭研究进展

充血性心力衰竭的二级预防是对无症状性心力衰竭 (silentheartfailare ,SHF)采取干预措施 ,本文就SHF的有关问题作一综述。1　关于无症状性心力衰竭的概念目前认为系指 :由于原发的心肌损害因素诱发神经激素 细胞因子系统长期、慢性激活状态 ,心室重塑进展 ,引起心脏舒缩功能障碍 ,但肺部充血症状缺乏或轻微的这一阶段[1,2 ] 。近年来随着心脏有创及无创检查技术的进步 ,尤其是心脏二维超声及多普勒检查的普遍开展 ,发现无症状左室功能障碍的患病率相当高。有统计资料证实 ,在成年人群无症状左室功能障碍患病率 1%～5 % [3] 。高血压、…     

脑钠肽结合超声多普勒评价舒张性心力衰竭患者的心功能

目的 采用血浆脑钠肽(BNP)浓度测定结合超声多普勒心动图的参数来评价舒张性心力衰竭患者的心功能,为临床提供判断舒张性心力衰竭及其严重程度的敏感和特异的客观指标.方法 选择舒张性心力衰竭患者85例(心力衰竭组),按纽约心脏病学会(NYHA)心功能分级,Ⅱ级31例、Ⅲ级36例、Ⅳ级18例,以及健康对照组30例.测定血浆BNP浓度,超声多普勒结合组织多普勒显像(TDI)测定左室结构、左室舒张功能及左室舒张末压.结果 舒张性心力衰竭患者血浆BNP浓度明显高于对照组(P<0.001),且随心力衰竭程度加重而逐渐升高(P<0.001).舒张性心力衰竭组左房内径(LA)、室间隔厚度(IVS)、左室后壁厚度(LVPW)、舒张早期流速峰值/舒张早期速度峰值(E/Em)较对照组升高,E/舒张晚期流速峰值(A)降低(P<0.01),血浆BNP浓度与E/A比值呈负相关(r=-0.634,P<0.01),与E/Em比值呈正相关(r=0.728,P<0.01).结论 血浆BNP浓度测定结合超声多普勒心动图的参数判断舒张性心力衰竭患者的心功能简便准确.     

组织多普勒评价优化的双心室顺序起搏的中期疗效

目的应用组织多普勒技术评价左心室收缩功能和同步性,比较双心室起搏房室和室间延迟优化前后的即刻变化,并随访优化的双心室顺序起搏的中期疗效。方法选择拟行心脏再同步化治疗(CRT)的慢性心力衰竭患者15例,术前进行二维超声心动图和组织多普勒检查,术后一周在超声指导下进行房室和室间延迟的优化,比较术前、术后一周,1个月、3个月和6个月各参数的变化。结果双心室同时起搏后一周,左心室射血分数由术前的0．28±0．07增加到0．36±0．10(P＜0．01),整体收缩振幅(GSCA)由(3．444±0．93)mm增加到(4．10±1．40)mm(P＜0．01),Tei指数、左心室舒张充盈时间比例、左右心室间收缩时间差(T1-12)、左心室内不同步指数(Ts-SD)、位移达峰时间的标准差(Tdis-SD)和位移达峰时间的最大差值(Tdis-MAX)也显著改善。房室和室间延迟优化后即刻,主动脉瓣血流速度时间积分和GSCA显著增加(P＜0．05),Ts-SD的变化有下降趋势,但差异无统计学意义。优化的双心室顺序起搏后6个月,GSCA和左心室射血分数进一步增加,左心室舒张末和收缩末容积下降(P＜0．05)。Tei指数、左心室舒张充盈时间比例、左右心室间和左心室内同步性随时间变化无进一步改善。结论双心室起搏房室和室间延迟优化进一步改善患者的血流动力学。术后6个月,其收缩功能进一步改善,左心室缩小,但同步性和舒张充盈无进一步改善。     

美心力治疗充血性心力衰竭的临床观察

目的：探讨美心力对充血性心力衰竭（CHF）患者的治疗效果。方法：对97例CHF患者静脉滴注美心力，并于治疗前、一疗程、二疗程以彩色超声多普勒测定心脏功能，同时测量血压、心率。结果：与治疗前相比，二疗程后左室舒张功能、收缩功能及血压、心率明显改善（P＜0．01）。临床总有效率二疗程为80．4％，明显高于一疗程（45．4％）（P＜0．01）。结论：美心力治疗CHF疗效较好;且二疗程优于一疗程。     

左室舒张性心功能障碍超声左心形态,功能及运动耐量的改…

对核素心血池扫描证实的５０例左室舒张性心功能障碍病例，２６例左室收缩性心功能障碍病例进行Ｍ型，二维，多普勒超声心动图及活动平板运动试验检测，并以２０例正常人对照组。结果表明：１．左心形态学改变：与ＬＶＳＨＦ组比较，ＬＶＤＤ组左房内径，左室内径无明显增加，室间隔厚度，左室后壁厚度增加。与ＣＧ组比较，ＬＶＤＤ组ＬＡＤ，ＩＶＳＴ，ＰＷＴ增加，但ＬＶＤ差异无显著性。     

多普勒超声心动图检测慢性心力衰竭患者心肌生物能量消耗水平的变化及临床意义

目的 分析慢性心力衰竭(心衰)患者的多普勒超声指标心肌生物能量消耗(MEE)与左心室结构指标及其收缩、舒张、整体功能指标及心衰严重程度(NYHA心功能分级)、C反应蛋白(CRP)、N末端B型利钠肽原(NT-proBNP)之间的关系,探讨MEE用于评估慢性心衰心功能状况的临床价值.方法 选择慢性心衰住院患者99例,据左室射血分数(LVEF)值分为LVEF正常的心衰(HFNEF)组37例,LVEF降低的心衰(HFREF)组62例(其中LVEF>35%、<50%及≤35%分别为30例及32例);据NYHA心功能分级分为Ⅱ级(26例)、Ⅲ级(42例)、Ⅳ级(31例);对照组30例.采用多普勒超声心动图检测并计算MEE及常规结构指标,左心室收缩(LVEF、LVFS)、舒张(E/A、EDT、IVRT)及整体功能指标(Tei指数),并测定各组血清CRP、血浆NT-proBNP水平,分析各组间各参数的差异,探讨MEE与上述指标间的相关性.结果 HFNEF组患者MEE水平与对照组差异无统计学意义(P>0.05),HFREF组患者MEE水平较对照组明显增加(P<0.01);慢性心衰组MEE随LVEF的降低及NYHA心功能分级级别的升高而显著增加(P<0.05);双变量相关分析显示,MEE与心室结构及收缩、舒张、整体功能指标、NYHA心功能分级及血清CRP、血浆NT-proBNP水平之间均具有相关性,其中关系最密切的是左心室收缩功能指标,即MEE与LVEF、LVFS均呈明显负相关[分别为r=-0.540、P<0.01,r=-0.454、P<0.01].结论 随左心室收缩功能障碍及心衰程度的加重,慢性心衰患者的MEE水平逐步升高,MEE与现有的心功能评价指标(如LVEF值、NYHA分级、NT-proBNP 等)均呈明显相关,特别与左心室收缩功能指标关系密切.MEE可从心肌生物能量学角度有效评定慢性心衰患者的心功能状况.     

卡维地洛在充血性心力衰竭中的作用

卡维地洛是一种新型的非选择性β受体阻滞剂,许多临床实验证实卡维地洛长期治疗可降低充血性心力衰竭患者死亡率。现对卡维地洛在充血性心力衰竭中的作用进行综述。     

缬沙坦治疗慢性充血性心力衰竭疗效观察

目的　观察缬沙坦治疗慢性心力衰竭的临床效果。方法　采用随机单盲空白对照法将 5 4例慢性心力衰竭患者分为治疗组和对照组。对照组给予标准治疗 ,治疗组除标准治疗外每日一次缬沙坦 80 mg,口服治疗 12周。两组治疗前后均进行心力衰竭总积分 ( HFC)、六分钟步行试验 ( 6 MT)及心功能测定。结果　治疗组总有效率为 88.9% ,优于对照组 77.2 % ,但无统计学意义 ( P>0 ,0 5 )。治疗组 HFC减少 ( P<0 .0 1) ,六分钟最大步行距离增加 ( P<0 .0 1) ,超声心动图检查示 :左心室射血分数 ( L VEF )和舒张早期和舒张晚期血流峰速度比值 ( Ep/Ap)升高 ,等容舒张时间 ( IRT)缩短 ( P值均 <0 .0 1) ,但只有 Ep/Ap和 IRT改善显著优于对照组( P<0 .0 5 )。结论　缬沙坦可用于慢性心力衰竭的临床治疗 ,能改善慢性心力衰竭患者的心脏功能、提高运动耐量 ,抑制并逆转左心室重塑     

充血性心力衰竭患者血清肌酸激酶同功酶与肌酸激酶比值的动态变化

目的　探讨充血性心力衰竭 (CHF)患者血清肌酸激酶同功酶 (CK -MB)与肌酸激酶 (CK)比值 (B/K)的变化规律及其临床意义。方法　测定 93例不同病因所致的CHF患者和 45例同期非心血管病对照组患者及 16例心功能Ⅰ级患者的血清CK -MB、CK及B/K比值。结果　所有患者的CK -MB、CK均在正常值范围 ,随心功能不全的加重B/K比值逐渐升高 ,心功能Ⅳ级与对照组比较有非常显著性差异(P <0 0 1) ,心功能Ⅳ、Ⅲ级与心功能Ⅱ、Ⅰ级比较有非常显著性差异 (P <0 0 0 1)。结论　CHF患者就诊时的B/K比值有可能作为反映心衰患者病情严重程度的一个指标     

左旋卡尼汀对冠心病慢性心力衰竭患者心功能的影响

目的　观察左旋卡尼汀治疗冠心病心力衰竭的长期临床疗效。　方法　选择冠心病并慢性心力衰竭患者 6 2例 ,随机分为两组 ,对照组 30例予洋地黄、利尿剂、血管扩张剂、ACEI或 β受体阻滞剂等常规药物 ;卡尼汀组 32例 ,在常规治疗的基础上加用国产卡尼汀 3g d治疗 1年。　结果　卡尼汀组心功能改善的临床显效率(75 % )和总有效率 (87 5 % )均较对照组 (5 3%和 6 0 % )显著提高 (P <0 0 5 ) ,总胆固醇、甘油三酯分别降低 18%和15 % ,高密度脂蛋白升高 14 % (P <0 0 1) ,E A、射血分数、左室短轴缩短率分别增加 2 1%、14 %、11% ,左室内径减小 10 % (P <0 0 5 ) ,且无不良反应。　结论　卡尼汀辅助治疗冠心病并慢性心力衰竭有较好疗效。     

The effects of enoximone (MDL-17043) on forearm venous circulation in healthy volunteers and patients with heart failure

Summary The effect of intravenous enoximone on forearm venous circulation was studied in ten healthy volunteers (group A) and in ten patients with NYHA class III–IV congestive heart failure (group B). Distensibility of the forearm capacitance vessels was assessed from pressure-volume curves by venous occlusion plethysmography using a mercury-in-rubber strain gauge. Three recordings each at 3-min intervals were obtained before the infusion and again 20 min after completion of the infusion. Venous volume changes (VV) at congesting pressures of 10, 20, and 30 mmHg before and after enoximone were compared. Forearm muscle blood flow was also measured by venous occlusion plethysmography; electrocardiogram, heart rate, and cuff blood pressure were recorded throughout. Enoximone at a dose of 1 mg/kg body weight was infused over 10 min through a peripheral vein in group A and via a central line in group B. In group A, the effect of the injection vehicle was also assessed.VV₁₀, VV₂₀, and VV₃₀ did not differ from baseline values after enoximone in both groups A and B. The vehicle caused a small but significant degree of venoconstriction in group A (VV₂₀, 2.64±0.9 to 2.48±0.83 ml/100 ml,P<0.05; VV₃₀, 3.47±1.27 to 3.33±1.20 ml/100 ml,P<0.05), which could be explained by an acute response to local pain from the infusion. This effect was not evident following enoximone, perhaps as a result of its counterbalancing vasodilating action to venoconstriction induced by acute pain. Muscle blood flow increased in both groups (group A, 3.05±0.33 to 4.62±1.32 ml/100 ml/min,P<0.01; group B, 2.33±0.93 to 3.13±0.95 ml/100 ml/min,P<0.02) after enoximone and did not change in group A after vehicle (3.08±1.50 to 2.73±0.87,P—not significant).It is concluded that enoximone at the dose studied does not exert appreciable effects on the forearm venous system in normal subjects or in patients with heart failure.     

血清CA125水平与充血性心力衰竭关系初探

目的探讨充血性心力衰竭(CHF)患者血清中CA125水平与心功能的关系。方法169例CHF患者符合纽约心脏病学会心功能分级标准,分为心功能Ⅱ~Ⅳ级组,根据超声心动图检查结果,将入选者分为左心室(左室)正常组(左室舒张末期容积≤55 mm)和左室增大组(左室舒张末期容积>55 mm)。用免疫放射分析法测定血清CA125水平。并选择20名正常人作为对照组。结果CHF患者CA125血清浓度明显高于正常对照组(P<0.01),心功能Ⅲ、Ⅳ级的血清浓度高于Ⅱ级(P<0.01)。左室增大组较左室正常组CA125血清浓度显著升高(P<0.01),CA125的血清浓度与心力衰竭患者的CHF严重程度和心脏左室增大呈正相关(P<0.01)。结论CA125可能是又一个与CHF相关的非创伤性指标。     

双心室优化程序起搏治疗充血性心力衰竭及短期随访结果

目的报道6例使用双心室优化起搏治疗充血性心力衰竭患者,探讨双心室优化起搏治疗的初步临床经验及V-V起搏间期优化方法。方法自2004年3月起对6例顽固性充血性心力衰竭且药物治疗效果不佳的患者植入了InSyncⅢ(8042型)起搏器。全部患者术前48h之内接受常规超声心动图检查、6min室内平面步行试验(6MHW)、临床心功能评估等作为基础对照。出院前行心室起搏优化确定最佳V-V起搏间期,术后1、3、6个月再次重复上述检查并动态心电图检查,其中第6个月重新优化V-V起搏间期。结果6例患者均顺利完成起搏器植入术。5例患者起搏方式为心房感知并心室起搏,其中总心室起搏数均>90%。1例患者起搏方式为心房感知并心室起搏,其中总心室起搏数为94%。全部患者临床心功能指标(NYHA分级)和6min室内平面步行试验均较术前有显著提高。从双心室优化起搏的即刻效果来看,优化V-V间期使主动脉瓣射血时间-速度积分(VTI)从术前的(20.7±6.6)cm增加至(23.5±6.6)cm。左心室射血分数从术前的0.24±0.09增加至0.29±0.08。结论双心室起搏治疗能改善顽固性充血性心力衰竭且药物治疗效果不佳患者的心功能,提高患者的生活质量,在此基础上进行V-V间期优化可以进一步提高患者的左心室功能。     

Randomized, controlled trial of integrated heart failure management: The Auckland Heart Failure Management Study.

AIMS: To determine the effect of an integrated heart failure management programme, involving patient and family, primary and secondary care, on quality of life and death or hospital readmissions in patients with chronic heart failure. METHODS AND RESULTS: This trial was a cluster randomized, controlled trial of integrated primary/secondary care compared with usual care for patients with heart failure. The intervention involved clinical review at a hospital-based heart failure clinic early after discharge, individual and group education sessions, a personal diary to record medication and body weight, information booklets and regular clinical follow-up alternating between the general practitioner and heart failure clinic. Follow-up was for 12 months. One hundred and ninety-seven patients admitted to Auckland Hospital with an episode of heart failure were enrolled in the study. There was no significant difference between the intervention and control groups for the combined end-point of death or hospital readmission. The physical dimension of quality of life showed a greater improvement in the intervention group from baseline to 12 months compared with the control group (-11.1 vs -5.8 respectively, 2 P=0.015). The main effect of the intervention was attributable to the prevention of multiple admissions (56 intervention group vs 95 control group, 2 P=0.015) and associated reduction in bed days. CONCLUSIONS: This integrated management programme for patients with chronic heart failure improved quality of life and reduced total hospital admissions and total bed days.     

充血性心力衰竭患者细胞因子(TNF-α,ET-1)的变化及静脉注射胺碘酮对其的影响

目的　探讨心力衰竭患者肿瘤坏死因子 - α( TNF- α)、内皮素 ( ET- 1)的变化及静注胺碘酮对其影响。方法　采用放免法检测 16例心力衰竭患者血浆 TNF- α、ET- 1水平 ,并与 2 0例健康对照组测值进行比较。全数病员均予胺碘酮治疗 ,按一次快速注入 15 0 m g,继后按 6 2 5 μg/ min持续静脉滴注 4 h共 15 0 m g方法给药 ,比较静注胺碘酮对其的影响。结果　心力衰竭患者 ET- 1测值与对照组间存在显著性差异 ( P<0 .0 5 ) ,TNF-α水平无显著性差异 ( P>0 .0 5 ) ;静注胺碘酮 30 0 mg后即刻 TNF-α下降显著 ( P<0 .0 1) ,ET- 1测值亦有下降 ,但统计学处理无显著性差异( P>0 .0 5 )。结论　 ET- 1、TNF-α的释放量增加对心力衰竭进程具有促进作用。心力衰竭患者静注胺碘酮为一安全的治疗方法 ,在一定范围内可作为心力衰竭患者抗心律失常的一线紧急用药。     

First-dose hypotension after angiotensin-converting enzyme (ACE) inhibitors in chronic heart failure: a comparison of enalapril and perindopril. Slovak Investigator Group

BACKGROUND: First-dose hypotension refers to an observed reduction in blood pressure after the administration of the first dose of ACE inhibitors in patients with congestive heart failure. AIM: To compare the first-dose responses of low-dose enalapril and perindopril in patients with stable symptomatic chronic heart failure. METHODS: Single blind, randomised, multicenter, parallel, prospective study. Patients (N=298) with chronic heart failure due to ischemic heart disease or dilated cardiomyopathy, NYHA II-IV, ejection fraction<40%, age>18 years, naive to ACE inhibitors or ATI-receptor blocker, were randomised to receive a single dose of 2. 5 mg enalapril or 2.0 mg perindopril. Baseline laboratory and clinical examinations were performed before entry into the study. Ambulatory blood pressure monitoring started 2 h before the study medication was given, and continued for at least 10 h after the medication. RESULTS: The maximum drop in blood pressure appeared approximately 4 h after dose administration in both groups, and was more pronounced in the enalapril group. Patients in the enalapril group had a significantly higher incidence of asymptomatic hypotension. No symptomatic hypotension requiring a change in medication or a prolongation of hospitalisation was observed. CONCLUSION: A low dose of perindopril is well-tolerated at initiation of ACE inhibitor therapy in patients with chronic heart failure and causes less first-dose hypotension than a low dose of enalapril.     

The Comparison of Medical Therapy,Pacing, and Defibrillation in Heart Failure (COMPANION) trial in perspective

The Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) trial is one of several randomized trials that has demonstrated an improvement in morbidity and mortality with biventricular pacemakers and/or implantable defibrillators. Although the results of the COMPANION trial overlap with other trials investigating cardiac resynchronization therapy (CRT) and implantable cardioverter-defibrillators (ICDs), there are several unique aspects of the trial that warrant special attention. This review focuses on COMPANION in light of other CRT trials, and includes a discussion on the patient population enrolled, design challenges of the trial, the cost-effectiveness of CRT and CRT-D, and results of subanalyses using data collected during the trial.     

Medical treatment of heart failure: The Canadian Cardiovascular Society's Consensus Conference revisited

Summary The report of the Canadian Cardiovascular Society's Consensus Conference on the diagnosis and management of heart failure was published in 1994. Focusing on the chronic medical treatment of patients with systolic left ventricular dysfunction, we summarize and update the consensus recommendations in the light of the results of several more recent studies. While the positive treatment recommendations are still fully valid or even reinforced by these new data, a somewhat more liberal use of beta-blockers, amiodarone, and newer calcium channel blockers seems justified.