急性心力衰竭临床诊断和治疗的若干进展

急性心力衰竭(AHF)是常见急危重症,病死率和致残率极高.近年来AHF的临床研究进展主要集中在生物学标记物与AHF诊断、病情严重程度、预后评估以及新药物治疗等方面,本文简要述及生物学标记物和新药物治疗.     

Novel biomarkers in heart failure: usefulness in clinical practice

Biomarkers have become an increasingly important tool in clinical practice, helping to improve patient care. In heart failure (HF), brain natriuretic peptide and N-terminal prohormone of the brain natriuretic peptide have been widely applied in prognosis, clinical diagnosis and treatment. Recently, several novel biomarkers have been examined on their efficacy to improve diagnosis, determine the pathophysiologic state of HF, improve clinical decision making, clinical outcome, guide treatment and assess prognosis of HF patients. In this special report, the authors summarize the usefulness and significance of the most promising novel biomarkers in patients with HF.     

Overweight and obesity in the context of heart failure: implications for practice and future research

Heart failure (HF) is a major cardiovascular disorder, public health concern, and growing epidemic that affects approximately 5,000,000 people in the United States with 550,000 new cases reported annually. The clinical and economic impact of HF is associated with high hospitalization and early readmission rates. Recognizing factors that contribute to increasing the risk for HF, particularly the persistent rise in prevalence of overweight and obesity, may be imperative to reducing the burdens of this poorly prognostic disease process. Overweight and obesity have been associated with increased morbidity and mortality, and have incited extensive interest in therapeutic interventions. However, within the last decade, studies have illustrated the positive effects of overweight and obesity on survival after the onset of HF, which has prompted a variance of opinion within the healthcare community. This article reviews data supporting both the negative and positive effects of overweight and obesity in relationship to HF with implications for future research, and describes recommendations for practice as it relates to lifestyle modification through diet, exercise, and cognitive-behavioral therapy.     

Angiotensin-converting enzyme inhibitors in congestive heart failure: clinical practice guidelines

Angiotensin-converting enzyme (ACE) inhibitors are, at present, the cornerstone of therapy for congestive heart failure. Nevertheless, international literature and regional data have reported their underutilisation in the practice of cardiology. Despite the abundance of consensus conferences, none deal specifically with a therapeutic strategy using ACE inhibitors. In this context, clinical practice guidelines on the management of systolic heart failure with ACE inhibitors have been drafted in Lorraine by hospital cardiologists. The guidelines were formulated using a standardised procedure, combining a literature analysis and the opinions of experts. Seventeen guidelines were finally adopted, under four headings: indications and contraindications for ACE inhibitors; dosages and approaches to treatment monitoring; the management of adverse effects; and contraindications for concomitant therapy. The drafting of the clinical practice guidelines is the first step in a quality improvement programme, initiated in 1999 in the cardiology wards of the region.     

The decision making of heart failure specialist nurses in clinical practice

Aims and objectives. To explore decision processes and types of decisions made by heart failure specialist nurses. Background. Heart failure specialist nurses are key to the management of patients with heart failure in the community. In previous studies heart failure specialist nurses have reported difficulty in developing decision making skills. Cognitive continuum theory can be used to examine the relationship between decision tasks and the processes used by heart failure specialist nurses to make decisions. Design. A qualitative study using non‐participant observation and semi‐structured interviews. Methods.  Six heart failure specialist nurses were observed while they carried out consultations with three patients each (n = 18). Twelve heart failure specialist nurses were interviewed about their decision making in practice. Data were analysed using thematic content analysis. Results. Two areas of decision making were identified by heart failure specialist nurses as key; pharmacological management and managing patients in the palliative phase of their condition. Pharmacological management decisions involved the trading off of risks and benefits of titrating medication, with nurses using internalised guidelines to inform their practice. In contrast, nurses relied on support from other health care professionals when making decisions about a patient’s need for palliative care. Conclusions. Medication titration decisions have a mixture of intuition and analysis inducing features making them amenable to the use of decision tools. The timing of the need for palliative care is less predictable, suggesting an intuitive approach to decision making may be more appropriate. Relevance to clinical practice. There are several strategies that could be used to improve the match between the decisions that heart failure specialist nurses take and the decision processes they use. These include the development of more tailored decision support tools for medication titration decisions and the provision of structured decision aids for assessing patients’ need for palliative care.     

Advanced practice nursing for congestive heart failure

Congestive heart failure (CHF) is an enormous burden on society and the health care system. The role of the advanced practice nurse (APN) in CHF is multifaceted and combines inpatient, outpatient, and community patient care skills. Case management and quality management have been traditional focuses, with a high level of practice impact on patient care. Outcomes management in the APN role for CHF care is the future for measurable outcomes and maximum impact on organizational values. Because outcomes management is an evolving field for the APN, focus on a chronic disease such as CHF is a very valuable tool for implementation.     

The bright future for clinical nurse specialist practice

This article discusses the past, present and future of Clinical Nurse Specialist (CNS) practice and education and identifies how 4 major shifts will impact CNS practice: 1) the APRN Consensus Paper, 2) the Affordable Care Act, 3) the Institute of Medicine's 'Future of Nursing' paper, and finally 4) the journey to Magnet status for many institutions. Each of these documents and/or themes has had, and will continue to have, a major impact on the future of CNS practice. The future is bright for CNSs as the role has an extremely important part to play in ensuring high quality patient outcomes.     

Dealing with problems in clinical practice

The identification of problems and how they are dealt with is affected by the individual perspectives of all parties involved. Mike Lowry discusses how groups of nurses often have difficulty accepting that problems exist and suggests ways they might go about identifying and dealing with them.     

Sexual problems in heart failure patients.

Sexual problems can affect quality of life of patients with advanced heart failure. At this moment sexual problems in patients with heart failure are described in a few studies, however, no data are available on a European sample. The objective of this study was to report on the occurrence of sexual problems in patients with advanced heart failure and to study the relationship of sexual problems with demographic and clinical variables and overall quality of life. Data of 73 patients with heart failure, (mean age 70 years, 80% male), living with a spouse, collected at 3 points in time were analysed. It was found that symptoms of heart failure do effect the sexual relationships. Patients report marked changes in sexual function as a result of their disease. Even in a recovery period of 9 months after discharge patients report considerable changes in frequency of sexual activity, sexual interest, satisfaction and sexual performance as a result of heart failure. Most patients did not report problems in their relationship as a result of heart failure or as a result of sexual problems. Sexual adjustment was related to functional status, number of co-morbidities and age. Better sexual adjustment was also related to a higher quality of life.     

A clinical pathway for congestive heart failure

This study has shown improved outcomes with the use of a clinical pathway. However, under PPS additional ways for coordination among healthcare providers and patients need to be developed to ensure improved care beyond those focusing on the use of the pathway. One recommendation is the use of telehealth.     

Statins and clinical outcomes in heart failure

HMG-CoA (3-hydroxy-3-methylglutaryl-CoA) reductase inhibitors (statins) are well-established therapies in the prevention and treatment of cardiovascular disease, reducing all-cause mortality and cardiovascular events in many disease states. Studies have also suggested that statins given to patients after myocardial infarction improve event-free survival even in short time frames; however, evidence for the benefit of statins in established HF (heart failure) has not been demonstrated with the same rigour of a randomized clinical trial setting. In fact, clinical data examining the effect of statins in HF have been limited by the retrospective or observational nature of these analyses, examination of incompletely validated surrogate end points, small prospective studies in subgroups of HF subjects, and non-uniform doses and different statins being used. In this review, we examine the evidence for the effect of statins on mortality in HF, taking into account theoretical arguments, appropriateness of surrogate markers, animal data and analysis of the predominantly retrospective clinical data that is currently available.     

Prospects for gene transfer for clinical heart failure

Congestive heart failure is an inexorable disease associated with unacceptably high morbidity and mortality. Preclinical results indicate that gene transfer using various proteins is a safe and effective approach for increasing function of the failing heart. In the current review, we provide a summary of cardiac gene transfer in general and summarize findings using adenylyl cyclase 6 as therapeutic gene in the failing heart. We also discuss the potential usefulness of a new treatment for congestive heart failure, paracrine-based gene transfer.     

心力衰竭的治疗与研究进展

编者按　随着国人寿命延长 ,我国人口老龄化的速度加快 ,6 0岁以上人口已占总人口的 10 %左右 ,而且预计到 2 0 2 0年 ,我国将进入典型的老龄化社会。面对滚滚而来的银色浪潮冲击 ,老年人的健康与保健问题日益得到重视 ,老年疾病的防治与康复 ,也成为临床医学中的一个重要部分。同是一种疾病 ,老年人与非老年人虽有共性之处 ,但老年患者却有其特殊性 ,病情往往复杂多变 ,误诊率比较高。为帮助临床医生熟悉掌握老年疾病的特殊性 ,减少诊断治疗中的偏差和错误 ,本期特辟“老年病误诊误治专栏”。在常见老年病中 ,心血管病是影响老年人健康最主要的疾病 ,而老年人心力衰竭的治疗一直是比较棘手的问题。为此 ,本栏特邀请到我国知名的老年心血管病专家、北京协和医院特需医疗部顾问纪宝华教授谈谈心力衰竭治疗的最新进展 ,亦请该部郑文洁医师和王子时教授就老年人舒张期心力衰竭做一文献综述 ,希望对读者有所启示。