充血性心力衰竭患者血清尿酸浓度的变化及与高血压的关系

目的　观察充血性心力衰竭 (CHF)患者血清尿酸浓度的变化规律及与高血压的关系。方法　比较 CHF患者(77例 )与心功能代偿的心血管病患者 (5 4例 )的血清尿酸浓度 ;比较 CHF患者不同心功能状态下尿酸浓度 ;比较入院时用利尿剂及未用利尿剂患者的尿酸浓度 ;比较 18例 CHF患者心力衰竭控制前后的尿酸浓度 ;比较 CHF组中有高血压者 (30例 )与血压正常者 (4 7例 )的尿酸浓度。结果　 CHF组与心功能代偿组的血清尿酸浓度分别为(32 7.72± 98.5 7)和 (2 30 .6 4± 5 3.14) mmol/ L;CHF组心功能按 NYHA分级 、 、 级的尿酸浓度分别为(2 5 0 .2 6± 6 7.2 9)、(314.99± 77.6 0 )和 (4 0 9.0 6± 78.15 ) mm ol/ L;入院时用利尿剂及未用利尿剂患者的尿酸浓度无明显差异 (P>0 .0 5 ) ;18例 CHF患者心力衰竭控制前后的尿酸浓度分别为 [(34 3.71± 10 3.32 )和 (2 6 9.42± 87.6 5 )mm ol/ L (P<0 .0 5 ) ];CHF组中有高血压者与血压正常者的尿酸浓度分别为 (36 5 .74± 110 .6 6 )和 (30 3.45± 88.10 )mm ol/ L。结论　 CHF患者血清尿酸浓度增高 ,且随着心力衰竭加重而逐渐升高 ;CHF组中有高血压病者尿酸浓度高于血压正常者     

Uric acid in chronic heart failure: a marker of chronic inflammation

Background Chronic heart failure is associated with hyperuricaemia andelevations in circulating markers of inflammation. Activationof xanthine oxidase, through free radical release, causes leukocyteand endothelial cell activation. Associations could thereforebe expected between serum uric acid level, as a marker of increasedxanthine oxidase activity, and markers of inflammation. We haveexplored these associations in patients with chronic heart failure,taking into account the hyperuricaemic effects of diuretic therapyand insulin resistance. Methods and Results Circulating uric acid and markers of inflammation were measuredin 39 male patients with chronic heart failure and 16 healthycontrols. All patients underwent a metabolic assessment, whichprovided a measure of insulin sensitivity (intravenous glucosetolerance tests and minimal modelling analysis). Compared tocontrols, patients with chronic heart failure had significantlyhigher levels of circulating uric acid, interleukin-6, solubletumour necrosis factor receptor (sTNFR)-1, soluble intercellularadhesion molecule-1 (ICAM-1, allP<0·001), E-selectinand sTNFR2 (bothP<0·05). In patients with chronicheart failure, serum uric acid concentrations correlated withcirculating levels of sTNFR1 (r=0·74), interleukin-6(r=0·66), sTNFR2 (r=0·63), TNF(r=0·60)(allP<0·001), and ICAM-1 (r=0·41,P<0·01).In stepwise regression analyses, serum uric acid emerged asthe strongest predictor of ICAM-1, interleukin-6, TNF, sTNFR1and sTNFR2, independent of diuretic dose, age, body mass index,alcohol intake, serum creatinine, plasma insulin and glucose,and insulin sensitivity. Conclusions Serum uric acid is strongly related to circulating markers ofinflammation in patients with chronic heart failure. This isconsistent with a role for increased xanthine oxidase activityin the inflammatory response in patients with chronic heartfailure.     

充血性心力衰竭、慢性肾衰竭与贫血三者之间的关系

目的探讨充血性心力衰竭(CHF)、慢性肾衰竭(CKI)和贫血三者之间的关系.方法将74例CKI患者分为心衰组(33例)和非心衰组(41例);按血红蛋白(Hb)水平分为≥90 g/L组(21例)和(<90)g /L组(53例);按内生肌酐清除率(Ccr)分为>10 ml/min组(15例)和≤10 ml/min组(59例).检测Hb和红细胞压积(HCT),计算Ccr,测量血压(BP),心脏彩超探测左心房内径(LAD)、左心室间隔(IVST)、左心室后壁厚度(LVPWT)和射血分数(EF).结果 CKI心衰组和非心衰组比较,Hb、HCT、Ccr、LAD、IVST、LVPWT和EF有明显差异(P<0.01).心衰治疗前、后比较,Hb、HCT和BP有明显差异(P<0.01).Hb≥90 g/L组与Hb<90 G/L组比较,Ccr、BP、LAD、IVST、LVPWT和EF有明显差异(P<0.01).Ccr>10 ml/min组与Ccr≤10 ml/min组比较,Hb、HCT、IVST、LVPWT、LAD、EF和BP有明显差异(P<0.01).结论 CHF、CKI和贫血三者常并存,彼此关联.治疗应三者兼顾,方能取得较好疗效.     

Diuretics for the treatment of acute decompensated heart failure

Diuretics have been a mainstay for the treatment of acute decompensated heart failure (ADHF) for the past four decades, though their short-term gains have been questioned recently given their potential long-term deleterious systemic effects. The methods of diuretic administration as well as the optimal dosing regimen of these agents are both areas that have been increasingly coming under scrutiny. The lack of rigorous clinical trials examining diuretic use in ADHF, however, has led to a general adoption of non-evidence based treatment algorithms for this patient population. Though the use of intravenous vasodilators for the treatment of decompensated heart failure has grown tremendously over the last few years, the fact remains that diuretics are still indispensable for alleviating congestive symptoms. Given this reality and until further information is available about the most ideal utilization of these medications, diuretics will continue to represent a double-edged sword for physicians treating this disease process.     

Haemodynamic and clinical effects of ularitide in decompensated heart failure.

AIMS: Ularitide is a synthetic form of urodilatin, a natriuretic peptide produced in the kidney with vasodilating, natriuretic, and diuretic effects, that offers promise for the management of decompensated heart failure (DHF). We assessed the efficacy and safety of ularitide in treating patients with DHF. METHODS AND RESULTS: In this Phase II randomized, double-blind, placebo-controlled trial, 221 DHF patients received either placebo (n=53) or ularitide at 7.5 ng/kg/min (n=60), 15 ng/kg/min (n=53), or 30 ng/kg/min (n=55) as a 24-h continuous infusion. At 6 h, ularitide demonstrated a significant decrease in pulmonary capillary wedge pressure (P=0.052, P=0.000004, P=0.000002, respectively) and improved dyspnoea score in the 7.5, 15, and 30 ng/kg/min ularitide group (P=0.0026, P=0.0026, P=0.0013, respectively). Ularitide reduced systemic vascular resistance and increased cardiac index for the 15 and 30 ng/kg/min groups (P=0.017, P=0.00002, respectively). Systolic blood pressure (BP) decreased dose dependency. Heart rate and serum creatinine were unchanged through day 3. Most frequently reported drug-related adverse events through day 3 in all ularitide groups were dose-dependent BP decrease and hypotension. CONCLUSION: Ularitide lowered cardiac filling pressures and improved dyspnoea without apparent early deleterious effects on renal function in DHF patients. These results suggest that ularitide may play a role in the management of DHF.     

慢性心力衰竭合并肾功能不全相关危险因素分析

目的分析慢性心力衰竭(CHF)患者合并肾功能不全的临床特点,探讨CHF患者伴发肾功能不全的危险因素。方法收集就诊于本院心内科的CHF患者385例,其中男性211例,女性174例,平均年龄69.62±8.59岁。采用回顾性对照研究的方法,按照肾小球滤过率估计值(eGFR)将CHF患者分为肾功能不全组[eGFR60 mL/(min·1.73 m~2)]和非肾功能不全组[eGFR≥60 mL/(min·1.73 m2)]。分析比较两组患者的一般资料、心脏基础疾病、伴随疾病、对比剂应用史、心脏超声参数、肾功能指标、血脂、N末端B型利钠肽前体(NT-proBNP)、D-二聚体、血红蛋白、尿微量白蛋白等实验室检查结果。多因素Logistic回归分析CHF患者合并肾功能不全的危险因素。结果385例CHF患者中合并肾功能不全的发生率约为42.1%。单因素分析结果显示,年龄、NYHA心功能分级、高血压病、贫血、糖尿病、心房颤动在肾功能不全组和非肾功能不全组之间的差异有统计学意义(P0.05);肾功能不全组血清肌酐、尿素氮、尿酸、胱抑素C和NT-proBNP水平较非肾功能不全组升高;左心室射血分数和血红蛋白水平较非肾功能不全组降低,差异有统计学意义(P0.05)。多因素Logistic回归分析显示,年龄(OR 1.543,95%CI1.067~2.231)、NYHA心功能分级(OR 1.840,95%CI 1.054~3.212)、高血压病史(OR 1.967,95%CI 1.175~3.292)以及胱抑素C(OR 1.989,95%CI 1.027~3.851)与肾功能不全的发生独立相关。结论 CHF患者合并肾功能不全的发生率较高,高龄、NYHA心功能Ⅳ级、高血压病史以及血清高胱抑素C水平是CHF患者合并肾功能不全的独立危险因素。     

心脏再同步化治疗在严重心力衰竭中的应用

心力衰竭是各种心脏病的终末阶段,用心脏再同步化(CRT)的技术治疗中重度心力衰竭患者是一个新的治疗方法。CRT又名心房同步双心室起搏装置,近年来一系列短期和长期的临床试验已报道了这项治疗的临床效益,认为是严重心力衰竭合并心电学异常患者的一种理想的非药物辅助治疗选择。文章综述了心脏再同步化治疗的机制,相关的临床试验,临床思考和存在的技术问题,同时强调该方法目前还处于探索研究阶段,但已显示其光明的前景。     

老年心衰患者血清尿酸水平的探讨

目的探讨老年心力衰竭患者的血清尿酸水平的意义.方法采用日本7020日立全自动生化仪速力法测定58例老年心力衰竭患者的血清尿酸.结果按心功能级别分组的血尿酸水平Ⅰ～Ⅱ级组(10例)261.59±70.13μmol/L;Ⅲ级组(15例)334.88±92.06μmol/L;Ⅳ级组(33例)459.58±105.6μmol/L.3组血清尿酸水平差异非常显著(P<0.01),心功能越差,血清尿酸水平越高(P<0.01);男女两组血清尿酸值比较,差异有显著意义(P<0.05).结论检测血清尿酸水平,为判断老年心力衰竭患者病情及其预后,提供一个有意义的生化指标.     

心力衰竭老年患者肾功能不全的预后指标分析

目的探讨血清胱抑素C(cystatin C,CysC)和氨基末端脑钠肽前体(N-terminal pro-brain natriuretic peptide,NT-proBNP)及肿瘤坏死因子-α(tumor necrosis factor-α,TNF-α)、白细胞介素(interleukin,IL)-1β、IL-6、IL-8、IL-23浓度对合并早期肾功能不全老年人心力衰竭预后的影响。方法回顾性分析2014年2月至2016年6月在华北石油管理局总医院心内科住院诊治的老年心力衰竭患者112例的临床资料。根据估计肾小球滤过率(estimated glomerular filtration rate,e GFR)结果将入选患者分为肾功能正常组(n=62)和肾功能不全组(n=60),检测两组患者血清CysC和NT-proBNP及TNF-α、IL-1β、IL-6、IL-8、IL-23的浓度,记录患者主要不良心血管事件(major adverse cardiovascular event,MACE)的发生情况,并进行相关性分析。结果肾功能不全组患者的血清CysC、NT-proBNP、TNF-α、IL-1β、IL-6、IL-8、IL-23浓度显著高于肾功能正常组患者,差异有统计学意义(P<0.05)。肾功能不全组患者的eGFR显著高于肾功能正常组,差异有统计学意义(P<0.05)。两组患者血清尿酸、尿素氮、肌酐及脂蛋白浓度比较,差异无统计学意义(P>0.05)。肾功能不全组患者的恶性心律失常、脑卒中、心源性死亡、再次心力衰竭、再发冠状动脉事件等MACE发生率为5.0%,肾功能正常组为24.2%,两组比较差异有统计学意义(P<0.05)。在肾功能不全组患者中,Spearman检验显示患者MACE的发生与CysC、NT-proBNP、TNF-α、IL-1β、IL-6、IL-8、IL-23都有显著正相关性(P<0.05)。结论NT-proBNP及TNF-α、IL-1β、IL-6、IL-8、IL-23在合并早期肾功能不全老年心力衰竭患者中呈现高表达状况,与患者预后状况显著相关,对肾功能不全合并心力衰竭的临床诊断有重大意义。     

左旋卡尼汀对心力衰竭患者血清游离脂肪酸浓度的影响

目的 :探讨左旋卡尼汀 （L - CN ）治疗充血性心力衰竭 （CHF）的临床疗效及对血清游离脂肪酸 （FFA ）浓度的影响。方法 :CHF患者 5 0例 ,分为 L - CN组 （2 5例 ）和对照组 （2 5例 ）。对照组采用常规药物治疗 ,L - CN组常规药物加L - CN治疗 ,采用酶比色法测定治疗前、后血清 FFA浓度 ,并观察心功能改变情况。结果 :CHF患者治疗后血清中FFA浓度较治疗前明显下降 （P<0 .0 5或 P<0 .0 1） ,且 L - CN组 FFA浓度在治疗后显著低于对照组 （P<0 .0 5 ） ;治疗后两组心功能较治疗前明显改善 ,L - CN组心功能改善程度较对照组更明显 ,L - CN组治疗显效率及总有效率均高于对照组 （P<0 .0 5 ）。结论 :L - CN治疗不但能改善心功能 ,而且能降低血清 FFA水平。     

充血性心力衰竭患者预后因素探讨

目的：探讨充血性心力衰竭（CHF）患者的预后因素。方法：前瞻性研究163例CHF患者临床、心电图及血流动力学的预后价值，用多因素Cox回归模型分析各因素对预后的影响。结果：平均随访29个月，心脏性死亡59例，其中猝死34例，泵衰竭死亡19例，心肌梗死死亡6例；多因素分析示，平均主动脉压、平均肺动脉压和QTc是心脏性死亡的独立危险因素；生存率分析示，平均主动脉压≤12kPa，平均肺动脉压≥3．33kPa，QTc≥440ms，射血分数≤25％及有束支阻滞者，生存率显著降低。结论：低血压、QTc延长及伴肺动脉高压者预后不良，治疗中应防止过度降压和延长心肌复极。     

Additive haemodynamic effects of piroximone and prostacyclin in severe chronic heart failure

This study was undertaken to assess the haemodynamic effectsof the combined infusion of prostacyclin and piroximone, a phosphodiesteraseinhibitor, in 18 patients with severe congestive heart failure.Right heart catheterization was performed with a Swan-Ganz thermodilutioncatheter and arterial blood pressure was monitored using a radialline. After baseline haemodynamic measurements, prostacyclinwas administered in all patients at the incremental infusionrate of 2, 4, 6 and 8 and 10 ng. kg^–1. min^–1 during15min each. After recovery of baseline haemodynamics, patientswere randomly assigned to the piroximone infusion rate of 5or 10µg. kg^–1. min^–1 or placebo. After 24h piroximone or placebo infusion, the same prostacyclin protocolwas applied. Prostacyclin infusion added to piroximone resultedin a significant improvement in haemodynamics, as compared tothe group receiving prostacyclin added to placebo. As comparedto the curve observed with the placebo infusion, 10 ng. kg^–1.min^–1 prostacyclin infusion resulted in a further increasein cardiac index, by 41 and 38% (P<0·01) at the piroximone-infusionrates of 5 and 10 ng. kg^–1. min^–1, respectively,whereas systemic vascular resistance decreased by 25 and 21%,respectively (P<0·01). Additionally, a further decreasein pulmonary capillary wedge pressure by 13 and 11% (P<0·05)and in pulmonary vascular resistance by 21 and 19% (P<0·05)was observed at the piroximone-infusion rates of 5 and 10µig.Kg^–1. min^–1, respectively. Consequently, strokework index increased significantly, as compared to the groupreceiving prostacyclin added to placebo. This haemodynamic improvementoccurred without significant changes in heart rate and meanarterial pressure. Thus, this study shows that in patients withsevere congestive heart failure, short-term infusion of prostacyclinis safe and has additive haemodynamic effects on phosphodiesteraseinhibitors.     

慢性充血性心力衰竭患者胰岛素抵抗的临床观察

观察38例慢性充血性心力衰竭（CHF）患者和25例正常人血胰岛素水平及胰岛素敏感性指数（IAI）的变化，以探讨胰岛素抵抗（IR）在CHF的作用。结果显示：CHF患者的空腹血糖、空腹血胰岛素（FIS）、IAI明显高于对照组（均P＜0．01），不同心功能分级组间IAI差异显著（P＜0．05～0．01）。提示：①CHF患者存在IR和高胰岛素血症（HIS）已与心衰程度有关；②IR和HIS可能是CHF继发性病理生理变化，并可能对CHF发展演变及临床处理产生一定影响。     

慢性心力衰竭患者血清尿酸水平与心房颤动发生的关系及预测价值

目的 探讨慢性心力衰竭患者血清尿酸(SUA)水平与心房颤动(房颤)发生的关系及预测价值.方法 回顾性分析湖北地区2000年1月1日至2010年5月31日期间心力衰竭住院患者(包括多次入院患者的首次和末次入院)临床资料,所有患者均电话随访.按随访结果将患者分为房颤组和无房颤组、死亡组和存活组.单因素和多因素Cox分析心力衰竭患者房颤的危险因素,多元Logistic回归分析和ROC曲线评价SUA水平对房颤预测的敏感性和特异性.结果 入选的16681例患者中,房颤6807例.多因素分析显示SUA水平与房颤密切相关.平均随访5年后,多元Logistic回归分析显示SUA水平(HR 1.084,95％ CI 1.017-1.144,P＜0.001)、利尿剂(HR 1.549,95％ CI 1.246-1.854,P＜0.001)和心功能(NYHA分级,HR 1.237,95％ CI 1.168-1.306,P＜0.001)是房颤发生的独立预测因子.ROC曲线显示SUA增加房颤发生的敏感性和特异性(Wald x2 1494.88,P＜0.001;95％ CI 57.7％-60.0％).结论 SUA水平与心力衰竭患者房颤的发生有密切关系.     

Alcohol abuse and heart failure

Alcoholic patients who consume >90 g of alcohol a day for >5 years are at risk of developing asymptomatic alcoholic cardiomyopathy (ACM). Those patients who continue to drink may become symptomatic and develop signs and symptoms of heart failure (HF). This distinct form of congestive HF is responsible for 21–36% of all cases of non‐ischaemic dilated cardiomyopathy in Western Society. Without complete abstinence, the 4 year mortality for ACM is close to 50%. This short review summarizes the experimental and clinical evidence regarding the role of alcohol in the pathophysiology of ACM and HF.     

缬沙坦对心力衰竭患者血浆细胞因子浓度的影响

目的 :探讨重度充血性心力衰竭 (CHF)患者血浆中细胞因子浓度的变化及其对缬沙坦干预的反应。方法 :选择CHF患者 80例 (CHF组 )和健康体检者 4 0例 (对照组 ) ,采用放免法测定血浆肿瘤坏死因子 (TNF α)、白细胞介素 1(IL 1)和白细胞介素 6 (IL 6 )的浓度 ;然后将CHF组随机分为常规治疗组和加用缬沙坦组各 4 0例 ,1个月后再测定上述指标。结果 :CHF组 3种细胞因子浓度均高于对照组 (P <0 .0 1) ;CHF越重 ,细胞因子的浓度越高 (P <0 .0 1) ;不同病种所致同级CHF的细胞因子浓度无明显差别 (P >0 .0 5 ) ;缬沙坦能改善心功能 ,降低上述细胞因子的浓度 (P <0 .0 1)。结论 :细胞因子在重度CHF的发展中起重要作用 ,而且与基础病无关 ;缬沙坦在改善心功能的同时 ,也降低细胞因子的血浆浓度。