慢性心力衰竭治疗的新时代

拮抗交感和神经内分泌的抗心力衰竭(简称"心衰")药物、心脏再同步化治疗、植入型心律转复除颤器、心室辅助装置以及心脏移植等明显改善了慢性射血分数降低的心衰(heart failure with reduced ejection fraction,HFrEF)患者预后. 其中,药物仍是大多数慢性心衰患者的最重要治疗手段,除...     

Selection of patients for heart transplantation in the current era of heart failure therapy

OBJECTIVES: We sought to assess the relationship between survival, peak exercise oxygen consumption (VO(2)), and heart failure survival score (HFSS) in the current era of heart failure (HF) therapy. BACKGROUND: Based on predicted survival, HF patients with peak VO(2) <14 ml/min/kg or medium- to high-risk HFSS are currently considered eligible for heart transplantation. However, these criteria were developed before the widespread use of beta-blockers, spironolactone, and defibrillators-interventions known to improve the survival of HF patients. METHODS: Peak VO(2) and HFSS were assessed in 320 patients followed from 1994 to 1997 (past era) and in 187 patients followed from 1999 to 2001 (current era). Outcomes were compared between these two groups of patients and those who underwent heart transplantation from 1993 to 2000. RESULTS: Survival in the past era was 78% at one year and 67% at two years, as compared with 88% and 79%, respectively, in the current era (both p < 0.01). One-year event-free survival (without urgent transplantation or left ventricular assist device) was improved in the current era, regardless of initial peak VO(2): 64% vs. 48% for peak VO(2) <10 ml/min/kg (p = 0.09), 81% vs. 70% for 10 to 14 ml/min/kg (p = 0.05), and 93% vs. 82% for >14 ml/min/kg (p = 0.04). Of the patients with peak VO(2) of 10 to 14 ml/min/kg, 55% had low-risk HFSS and exhibited 88% one-year event-free survival. One-year survival after transplantation was 88%, which is similar to the 85% rate reported by the United Network for Organ Sharing for 1999 to 2000. CONCLUSIONS: Survival for HF patients in the current era has improved significantly, necessitating re-evaluation of the listing criteria for heart transplantation.     

Prognostic significance of anemia in patients with chronic systolic heart failure secondary to Chagas' cardiomyopathy

The purpose of this study was to evaluate the prognostic significance of anemia on outcome of patients with chronic systolic heart failure secondary to Chagas’ cardiomyopathy, as no previous study has previously addressed this question. One-hundred-eight-six patients followed for chronic systolic heart failure secondary to Chagas’ cardiomyopathy at our Institution from January 2000 to December 2008 were studied. Forty-nine (26%) patients were found to have anemia; 37 (20%) were men and 12 (6%) were women. Mean hemoglobin level was 14.1 ± 1.2 g/L in patients with no anemia and 11.5 ± 1.2 g/L in patients with anemia.On a Cox proportional hazards multivariate analysis, anemia was a predictor of all-cause mortality neither in the univariate nor in the multivariate analysis. Mean serum sodium (Hazard ratio = 0.92; Beta-coefficient = −0.09; 95% confidence interval 0.89–0.96; p value < 0.005), and Beta-Blocker therapy (Hazard ratio = 0.40; 95% confidence interval 0.26–0.61; p value < 0.005) were retained as independent predictors of mortality for patients with Chagas’ cardiomyopathy with chronic heart failure. Probability of survival for patients with anemia, however, was significantly lower in patients with anemia in comparison to patients with no anemia, mainly in patients with advanced heart failure. Anemia is not an independent predictor of all-cause mortality in patients with Chagas’ cardiomyopathy with chronic systolic heart failure. Probability of survival is poorer in patients with anemia than in those without.     

老年冠心病慢性心力衰竭患者血清同型半胱氨酸的变化

目的: 研究同型半胱氨酸（HCY）与冠心病慢性心力衰竭（CHF）的关系。方法: 57例冠心病CHF患者（组）,按照心功能NYHA分级分为3个亚组:CHFⅡ级组、Ⅲ级组、Ⅳ级组;选择同期住院的无CHF的冠心病稳定型心绞痛(SAP)患者20例为SAP组;健康者20例作为健康对照组。所有观察对象均于住院次日清晨抽取空腹血测定同型半胱氨酸（HCY）、氮末端脑钠尿肽（NT-proBNP）。结果: ①CHF组患者血HCY浓度显著高于SAP组,且二者均高于健康对照组。②CHF组患者随CHF分级的增加,HCY水平逐步增高。③CHF组患者HCY的增加与NT-proBNP的增加呈正相关（r=0.583,P<0.05）。④CHF患者中HCY与左室射血分数值呈负相关（r=-0.482,P<0.05）,与左室舒张末内径呈正相关(r=0.561,P<0.05)。结论: 高同型半胱氨酸血症与冠心病CHF有关。     

Racial response to angiotensin-converting enzyme therapy in systolic heart failure

The treatment of heart failure with angiotensin-converting enzyme inhibitors has resulted in substantial improvements in morbidity and mortality due to heart failure. Varying reports in the literature have suggested that African Americans respond less well to angiotensin-converting enzyme inhibitors, but careful reanalysis of major clinical trials in heart failure, especially the Studies of Left Ventricular Dysfunction (SOLVD), demonstrates a similar mortality benefit for African Americans as for whites. Morbidity, measured as hospitalizations, may not be as favorably impacted. African Americans do respond to angiotensin-converting enzyme inhibitors as a preemptive strategy to prevent heart failure, but the incidence of heart failure is still higher in this population. Mechanisms for these potential nuances in the response to angiotensin-converting enzyme inhibitors are not yet clear. The exaggerated benefit of nitrates and hydralazine implicates alterations in nitric oxide homeostasis. Race is an inadequate model to explain the observed differences. Careful translational research focusing on genetic patterns of disease may help resolve these outstanding questions.     

Congestive heart failure in chronic kidney disease: disease-specific mechanisms of systolic and diastolic heart failure and management

There is a high burden of cardiac disease in the CKD population. Severe LVH, dilated cardiomyopathy, and coronary artery disease occur frequently and result in the manifestations of CHF,which is probably more important with respect to prognosis than symptomatic. Multiple risk factors for CVD include traditional risk factors and those unique to the CKD population. Furthermore, the distinctive aspects of CKD patients sometimes warrant special consideration in making management decisions. Nonetheless, interventions such as controlling hypertension, specific pharmacologic options, lifestyle modification, anemia management, and early nephrology referral are recommended when appropriate.     

Enhanced metabolic vasodilation secondary to diuretic therapy in decompensated congestive heart failure secondary to coronary artery disease

Since sodium and water retention have been implicated as major factors limiting maximal metabolic vasodilation in congestive heart failure (CHF), the effect of rigorous diuresis on maximal vasodilatory capacity was studied systematically in 9 subjects hospitalized with decompensated CHF. Peak reactive hyperemic blood flow, measured by straingauge plethysmography, was used as an index of maximal vasodilatory capacity. After 24 hours of diuresis and a 2.2-kg weight loss, maximal flow increased from 19.9 to 26.1 ml/min · 100 ml (p < 0.05). Despite a further 1.4-kg weight loss between 24 and 48 hours, maximal blood flow increased no more (26.1 to 25.8 ml/min · 100 ml). Since blood pressure did not change significantly, minimal forearm resistance and maximal conductance showed similar improvements. It is unlikely that vasoconstrictor hormone changes could account for this effect since a marked decrease in plasma norepinephrine occurred in only 2 of 8 subjects and plasma renin activity decreased in only 1 subject. As a group there was no significant change in norepinephrine level, which remained substantially above normal (1,525 to 1,148 pg/ml), or in plasma renin activity (12.3 to 18.9 ng/ml/hour). Because the improvement in vasodilator capacity reached a plateau by 24 hours despite continued diuresis, and because peak reactive hyperemic blood flow was still 32% below normal, it is suggested that a second mechanism besides sodium and water retention is responsible for a significant portion of the impaired peripheral vasodilation in CHF.     

心脏再同步化治疗对慢性收缩性心力衰竭患者肺功能的影响

目的探讨心脏再同步化治疗(CRT)对慢性收缩性心力衰竭(简称心衰)患者肺功能的影响。方法选取22例行CRT治疗慢性收缩性心衰患者,对比分析术前、术后6个月肺容量:肺总量(TLC)、残气量(RV)、肺活量(VC)、肺泡容量(AV);肺通气功能:用力肺活量(FVC)、第1秒用力呼气容积(FEV1)、呼气流量峰值(PEF)、呼气中期流量(FEF 25%~75%);肺弥散功能:CO弥散量变化,并分析与NYHA心功能分级、体重指数(BMI)、肾小球滤过率(GFR)、脑钠肽、左室射血分数、左房容积、右室收缩压(RVSP)相关性。结果CRT术后肺容量指标:TLC、RV、AV有显著提高[(6.0±1.2)L vs(5.7±1.3)L,(2.7±0.9)L vs(2.5±0.8)L,(4.9±1.0)L vs(4.8±1.0)L,P均0.05],并与NYHA分级呈负相关(r=-0.35,P0.05)。通气功能指标:FEF 25%~75%显著提升[(2.7±0.9)L vs(2.5±0.8)L,P0.05)],与BMI呈负相关(r=-0.53,P0.05);FVC增加[(3.5±0.6)L vs(3.2±0.8)L,P0.05)],与BMI(r=-0.35,P0.05)、RVSP(r=-0.30,P0.05)呈负相关,与GFR呈正相关(r=0.51,P0.05)。弥散功能较术前无显著性改变。结论 CRT可增加心功能不全患者肺容量,改善通气功能,但换气功能无明显影响。