左卡尼汀治疗慢性心力衰竭的疗效观察

目的探讨左卡尼汀对慢性心力衰竭（CHF）患者心功能的影响。方法将60例CHF患者随机分为治疗组和对照组,每组30例,对照组予常规治疗,治疗组在常规治疗的基础上加用左卡尼汀治疗2w,观察两组患者治疗前后NY-HA分级、心率、血压、左心室舒张末期内径（LVEDd）、左心室射血分数（LVEF）及N末端原脑利钠肽（NT—pro—BNP）的变化。结果2w后,治疗组患者的心功能明显改善,LVEDd及NT—pro—BNP与对照组相比明显降低,LVEF与对照组相比明显增加。结论左卡尼汀可以改善CHF患者的心功能。     

Location,size, and distribution of mediastinal lymph node enlargement in chronic congestive heart failure

PURPOSE: The purpose of this study is to identify the prevalence, location, and size of enlarged mediastinal lymph nodes in patients with chronic congestive heart failure and to correlate the presence of lymph node enlargement with cardiac ejection fraction. METHODS: Sixty-six consecutive, retrospectively identified patients underwent computer tomography (CT) imaging of the thorax as part of a routine work-up prior to cardiac transplantation from 1993 to 1996. CT images of 44 of these patients were independently examined by 3 radiologists for evidence of pulmonary edema, pleural effusions, and the presence, size, and location of lymph nodes >1 cm in short axis. Multigated acquisition (MUGA) scans were available for cardiac ejection fraction assessment in 38 of the 44 patients. RESULTS: Twenty-nine (66%) patients had at least 1 mediastinal lymph node >1 cm. The mean ejection fraction was significantly less for patients with lymph node enlargement when compared with patients without lymph node enlargement (20% versus 35%; P < 0.01). Adenopathy was observed in 81% of patients with a calculated ejection fraction of <35%. No patient with an ejection fraction of >35% had lymph node enlargement. There was no correlation between pulmonary edema and the frequency of lymph node appearance. Sixty-three percent of the enlarged nodes were pretracheal, with a mean short axis diameter for all the enlarged nodes of 1.3 cm. CONCLUSIONS: Enlarged mediastinal lymph nodes were observed in 81% of patients with a calculated ejection fraction of <35%, most commonly in the pretracheal group. The presence of the lymph nodes did not correlate with CT evidence of pulmonary edema.     

曲美他嗪对慢性心力衰竭患者心功能及心率变异性的影响

目的探讨曲美他嗪对慢性心力衰竭（CHF）患者心功能及心率变异性（HRV）的影响。方法将60例CHF患者随机分为治疗组和对照组,每组30例,对照组给予常规治疗,治疗组在常规治疗的基础上加用曲美他嗪治疗6个月,观察两组患者治疗前后NYHA分级、左心室舒张末期内径（LVEDd）、左心室射血分数（LVEF）、N末端原脑利钠肽（NT-pro-BNP）及6min步行距离（6-MWD）的变化,采用12导联同步1-IOLTER检测系统检查,测定HRV时域指标（SDNN、SDANNindex MSDD、PNN50）。结果6个月后,治疗组患者的心功能明显改善,LVEDd及NT—pro—BNP与对照组相比明显降低,LVEF及6-MWD与对照组相比明显增加,HRV参数明显好转。结论曲美他嗪可以改善CHF患者的心功能及HRV。     

Spironolactone improves cardiac sympathetic nerve activity and symptoms in patients with congestive heart failure.

We evaluated whether spironolactone would improve cardiac sympathetic nerve activity and symptoms in patients with congestive heart failure (CHF). METHODS: Thirty patients with CHF (left ventricular ejection fraction [LVEF] < 40%; mean, 30% +/- 9%) were treated with an angiotensin-converting enzyme inhibitor, a loop diuretic, and, in most cases, digoxin. Fifteen patients (group A) were assigned to additionally receive spironolactone (12.5-50 mg/day), and the remaining 15 patients (group B) continued their current regimen. Patients were studied before and 6 mo after treatment. The delayed heart-to-mediastinum count ratio (H/M ratio), delayed total defect score (TDS), and washout rate (WR) were determined from (123)I-meta-iodobenzylguanidine (MIBG) images. LVEF was determined by echocardiography, and New York Heart Association (NYHA) functional class was estimated. RESULTS: Before treatment, LVEF, TDS, H/M ratio, WR, and NYHA functional class were similar in both groups. With treatment, LVEF did not significantly improve in either group. However, after treatment in group A, TDS decreased from 37 +/- 9 to 25 +/- 13 (P = 0.0001), H/M ratio increased from 1.62 +/- 0.20 to 1.83 +/- 0.27 (P < 0.0001), and WR decreased from 51 +/- 9 to 40 +/- 15 (P < 0.001). In group B, these parameters did not significantly change. NYHA functional class improved in both groups (in group A, from 3.3 +/- 0.5 to 1.7 +/- 0.5 [P < 0.0001]; in group B, from 3.3 +/- 0.5 to 2.4 +/- 0.6 [P = 0.01]); this was a significantly greater improvement in group A than in group B (P < 0.01). CONCLUSION: Spironolactone improves cardiac sympathetic nerve activity and symptoms in patients with CHF.     

Angiotensin-converting enzyme inhibition improves cardiac fatty acid metabolism in patients with congestive heart failure

This study aimed to examine whether angiotensin-converting enzyme (ACE) inhibition improved cardiac fatty acid metabolism in patients with congestive heart failure (CHF). Myocardial 123I-beta-methyl-iodophenylpentadecanoic acid (123I-BMIPP) imaging was performed in 25 patients with CHF and in 10 control subjects. Myocardial 123I-BMIPP images were obtained 30 min and 4 h after tracer injection. The heart-to-mediastinum (H/M) ratio of 123I-BMIPP uptake and the washout rate of 123I-BMIPP from the myocardium were calculated. Patients were given enalapril for 6 months, and 123I-BMIPP imaging was repeated. H/M ratios on early and delayed images were lower in CHF patients than in normal controls (P<0.01). The washout rate of 123I-BMIPP from the myocardium was faster in CHF patients than in controls (P<0.01). As the severity of the New York Heart Association (NYHA) functional class increased, the H/M ratio decreased and the washout rate increased. The washout rate of 123I-BMIPP was inversely correlated with left ventricular fractional shortening (R=-0.62, P<0.01). ACE inhibition with enalapril increased the H/M ratio on delayed images (P<0.05) and reduced the washout rate of 123I-BMIPP (P<0.05) in CHF patients. These data suggest that: (1) angiotensin II-mediated intracellular signalling activation may be a possible mechanism for the decreased myocardial uptake and enhanced washout of 123I-BMIPP in heart failure patients; and (2) the improvement in fatty acid metabolism by ACE inhibition may represent a new mechanism for the beneficial effect of this therapy in heart failure.     

Correlation of radiographic cardiothoracic ratio with cardiac function in patients with acute congestive heart failure

Objective: Plain film radiographs are routinely used as a part of the emergency department evaluation of patients with acute congestive heart failure. Determination of the cardiothoracic ratio (CT ratio) may provide insight into the severity and mechanism of the cardiac dysfunction. This study was designed to correlate the determined CT ratio with measures of systolic and diastolic function in patients with decompensated congestive heart failure (CHF). Methods: The CT ratio was retrospectively calculated from the routine upright anteroposterior plain film radiographs obtained during the evaluation of patients with acute CHF. Likewise, values for the diastolic time intervals such as isovolumic relaxation times and filling times (measures of diastolic dysfunction, IVRT, FT) and the Heather Index (a measure of systolic contractility, HI) were obtained from the tracings obtained by impedance cardiography (IC). These functional measures were then independently correlated with the CT ratio by multiple regression analysis. The degree of left ventricular hypertrophy (LVH) as determined by EKG voltage was also correlated to cardiac function measures for comparison. Results: In 45 patients there was no significant correlation (P < 0.05) of the measured IVRT and FT with the corresponding CT ratio. The HI was also significantly inversely correlated with the CT ratio (r = –0.36, P < 0.05). By comparison, the degree of LVH was not significantly related to the measures of systolic function but was highly correlated to the IVRT. Conclusion: CT ratios determined from plain film radiographs appear to correlate well with measures of cardiac systolic function and may be useful in determining the severity and mechanism of CHF in the acute setting.     

Evidence for pre- to postsynaptic mismatch of the cardiac sympathetic nervous system in ischemic congestive heart failure.

Pre- and postsynaptic cardiac sympathetic function is altered in ischemic congestive heart failure (CHF). Whether there is a presynaptic-to-postsynaptic mismatch or whether mismatch is related to adverse cardiac events is unknown. METHODS: In 13 patients with ischemic CHF and 25 aged-matched healthy volunteers, presynaptic function was measured by PET of (11)C-meta-hydroxyephedrine ((11)C-mHED), a norepinephrine (NE) analog. Postsynaptic function, beta-adrenergic receptor (BAR) density (B'(max)), was measured by imaging (11)C-CGP12177. Myocardial blood flow (MBF) was measured by imaging (15)O-water. Each heart was analyzed both globally and regionally, excluding infarcted regions, and a mismatch score, defined as the ratio of B'(max) to NE uptake (PS(nt))(,) was used to indicate mismatch of post- and presynaptic function. RESULTS: Global and regional MBF was not different between CHF and healthy subjects. The global measure of PS(nt) was lower in CHF (0.32 +/- 0.34) than that in healthy subjects (0.81 +/- 0.33, P < 0.0001) and in all 12 regions. Global B'(max) tended to be lower in CHF than that in healthy subjects (10.0 +/- 6.4 pmol/mL vs. 13.4 +/- 4.2, P = 0.056) and in all 12 regions. The global mismatch score (B'(max):PS(nt)) in CHF patients was significantly greater than that in healthy subjects (50.3 +/- 50.7 vs. 19.3 +/- 9.7, P = 0.005) and also greater in 11 of 12 regions. After 1.5 y of follow-up, 4 individuals had an adverse outcome (CHF death, new or recurrent sudden death, or progressive CHF leading to transplantation). Three of the 4 had mismatch scores > 3 times that of the healthy subjects or the CHF patients without an adverse outcome. CONCLUSION: Mismatch between pre- and postsynaptic left ventricular sympathetic function is present in patients with severe CHF and may be more marked in those with adverse outcomes.     

Sudden cardiac death in patients with congestive heart failure: Toward a unified rational treatment approach

Summary  The problem of SCD in patients with CHF is complex and multifactorial; its solution seems best addressed with a multidisciplinary approach in which heart failure and electrophysiologic factors are continuously evaluated (Table 2). This type of collaboration with optimal CHF therapy and avoidance of antiarrhythmic drugs (except for amiodarone when necessary) has reduced the total and SCD 1-year mortality in status 2 patients awaiting heart transplantation to approximately 15% and 10%, respectively, in several recent series.^52,53 The challenges remaining for nuclear cardiology include the following. (1) Can better techniques be identified to risk stratify patients, particularly those with nonischemic cardiomyopathy? What is the incremental value of measuring variables such as infarct size, EF (left and right ventricular), and ventricular volumes in predicting response to ICD or antiarrhythmic drug therapy⁵⁴? Identification of high-risk groups may justify aggressive treatment with amiodarone or ICD therapy even if these strategies are not helpful in the general CHF population.⁵⁵ (2) Can nuclear imaging techniques be used to identify all patients who would benefit from coronary revascularization? Does the benefit of CABG extend to patients who do not have an increase in EF after surgery either by reducing SCD risk or preventing progressive LV dilation? The optimal care of an extremely needy and growing proportion of patients awaits the answers to these questions. Future trials of therapy for sudden death in patients with CHF will require continued active participation of the nuclear cardiology community.     

Serial lung and IVC ultrasound in the assessment of congestive heart failure

Background

Management of congestive heart failure (CHF) is dependent on clinical assessments of volume status, which are subjective and imprecise. Point-of-care ultrasound (POCUS) is useful in the diagnosis of CHF, but how POCUS findings correlate with therapy remains unknown. This study aimed to determine whether the changes in clinical evaluation of CHF with treatment are mirrored with changes in the number of B lines on lung ultrasound (LUS) and inferior vena cava (IVC) size. In this prospective observational study, investigators performed serial clinical and ultrasound assessments within 24 h of admission (T1), day 1 in hospital (T2) and within 24 h of discharge (T3). Clinical assessments included an evaluation of the jugular venous distension (JVD), hepatojugular reflux (HJR), pulmonary rales and a clinical congestion score was calculated. Ultrasound assessment included the IVC size and collapsibility, and the number of B lines in an 8-point scan.

Results

Fifty consecutive patients were recruited with a mean age of 71.2 years (SD 12.7). Mean clinical congestion score on admission was 5.6 (SD 1.4) and declined significantly over time to 1.3 (0.91), as did the JVP, HJR and pulmonary rales. No significant changes were found in the IVC size between T1 [1.9 (0.65)] and T3 [2.0 (0.50)] or in the IVC collapsibility index [T1 0.3 (0.19) versus T3 0.25 (0.16)]. The mean number of B lines decreased from 11 (6.1) at T1 to 8.3 (5.5) at T3, although this decrease did not reach statistical significance. Spearman correlation between JVP and HJR versus IVC collapsibility and total B lines did not yield significant results.

Conclusions

Clinical exam findings correlate over time during the management of CHF, whereas LUS and IVC results did not. The number of B lines did decrease with therapy, but did not reach statistical significance likely because the sampled population was small and had only mild heart failure. Further studies are warranted to further explore the use of lung ultrasound in this patient population.

     

Measurement of effective renal plasma flow in congestive heart failure

In the management of patients with congestive heart failure (CHF), it is often desirable to have precise knowledge of overall renal function, including the effective renal plasma flow (ERPF). It has long been recognized that ERPF is diminished in CHF. Since glomerular filtration rate is often decreased to a much lesser extent, other noninvasive procedures such as the measurement of creatinine clearances may not be entirely suitable. ERPF determination by the single plasma sampling (SPS) method affords a rapid, simple, noninvasive, and economical technique that is quite accurate and reproductible. A SPS method has been well-tested in patients following renal transplantation plus a wide variety of nephrological disorders. We have been concerned whether the SPS method would be valid in volume expanded patients.In 28 determinations of ERPF in patients with CHF, and in five patients who did not have CHF, we have found the SPS estimation of ERPF to yield results that are not clinically significantly different from those obtained by the detailed compartmental analysis method. The volumes of ¹³¹I-orthoiodohippurate (OIH) distribution were found to be somewhat higher in CHF than in controls, but fractional rate constants were proportionately lower so that intercompartmental flow rates and OIH concentrations were not different from controls. Therefore, the SPS estimation of ERPF is valid in patients with CHF and may be useful in monitoring the renal effects of various hemodynamic and pharmacological interventions.     

Renal uptake of 99mTc-sulfur colloid in congestive heart failure

Renal uptake of 99mTc-sulfur colloid during liver and spleen imaging was observed in 4 patients; all had moderate to severe congestive heart failure. Four similar patients with this association have been reported. Although the exact mechanism of colloid uptake by the kidneys is not known, an association with congestive heart failure seems likely.     

卡托普利联合螺内酯治疗充血性心力衰竭40例

随着对充血性心力衰竭发病机制的进一步认识,对充血性心力衰竭的治疗也有了新的进展。充血性心力衰竭使动脉及肾血流量减少,交感神经兴奋、神经体液调节异常肾素-血管紧张素-醛固酮系统（RAAs）激活,致使血管紧张素Ⅱ（AngⅡ）及醛固酮（ALD）水平增加,产生一系列对心肌的损害,对血管及神经体液调节不平衡,使心脏发生重构心衰加重。故对充血性心力衰竭的治疗,不仅要纠正心泵功能,更应兼顾神经内分泌的改变。应用血管紧张素转换酶抑制（ACEI）及ALD拮抗剂治疗充血性心力衰竭,观察其临床疗效。现就联合应用卡托普利和螺内酯治疗充血性心力衰竭46例报告如下。     

Effects of perindopril on cardiac sympathetic nerve activity in patients with congestive heart failure: comparison with enalapril

Purpose The production of aldosterone in the heart is suppressed by the angiotensin-converting enzyme (ACE) inhibitor perindopril in patients with congestive heart failure (CHF). Moreover, perindopril has been reported to have more cardioprotective effects than enalapril.Materials and methods Forty patients with CHF [left ventricular ejection fraction (LVEF) <45%; mean 33±7%] were randomly assigned to perindopril (2 mg/day; n=20) or enalapril (5 mg/day; n=20). All patients were also treated with diuretics. The delayed heart/mediastinum count (H/M) ratio, delayed total defect score (TDS) and washout rate (WR) were determined from ¹²³I-meta-iodobenzylguanidine (MIBG) images, and plasma brain natriuretic peptide (BNP) concentrations were measured before and 6 months after treatment. The left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV) and LVEF were also determined by echocardiography.Results After treatment, in patients receiving perindopril, TDS decreased from 39±10 to 34±9 (P<0.01), H/M ratios increased from 1.62±0.27 to 1.76±0.29 (P<0.01), WR decreased from 50±14% to 42±14% (P<0.05) and plasma BNP concentrations decreased from 226±155 to 141±90 pg/ml (P<0.0005). In addition, the LVEDV decreased from 180±30 to 161±30 ml (P<0.05) and the LVESV decreased from 122±35 to 105±36 ml (P<0.05). Although the LVEF tended to increase, the change was not statistically significant (from 33±8% to 36±12%; P=NS). On the other hand, there were no significant changes in these parameters in patients receiving enalapril.Conclusion Plasma BNP concentrations, ¹²³I-MIBG scintigraphic and echocardiographic parameters improved after 6 months of perindopril treatment. These findings indicate that perindopril treatment can ameliorate the cardiac sympathetic nerve activity and the left ventricular performance in patients with CHF.     

去势对心肌梗死后雄兔心衰心功能的影响

目的 观察去势对心肌梗死后心衰雄兔心功能的影响。方法 将32只4～5月龄健康雄性新西兰大白兔随机分为心肌梗死组(MI组,行冠状动脉结扎术,n=24)和假手术组(n=8)。MI组独立笼养3周后存活模型兔20只,随机分为2组,去势组(行去势术,n=10)和假去势组(n=10)。第0、3、15周复查血清游离睾酮(FT)、硫酸脱氢表雄酮(DHEAS)浓度,并测量左室射血分数(LVEF),第15周检测心脏腔径大小。结果 心肌梗死3周后血清FT和DHEAS水平显著下降。心肌梗死15周时,与假手术组比较,MI组雄激素水平下降、心重占体重百分比、体重校正的左右心室舒张末内径、室壁厚度均增加。去势组雄激素水平和体重下降较假去势组更明显。与假去势组和去势前比较,去势组LVEF无改善。结论 去势对心衰雄兔心功能无有益影响。