Valsartan in the treatment of heart attack survivors

Survivors of myocardial infarction (MI) are at high risk of disability and death. This is due to infarct-related complications such as heart failure, cardiac remodeling with progressive ventricular dilation, dysfunction, and hypertrophy, and arrhythmias including ventricular and atrial fibrillation. Angiotensin (Ang) II, the major effector molecule of the renin-angiotensin-aldosterone system (RAAS) is a major contributor to these complications. RAAS inhibition, with angiotensin-converting enzyme (ACE) inhibitors were first shown to reduce mortality and morbidity after MI. Subsequently, angiotensin receptor blockers (ARBs), that produce more complete blockade of the effects of Ang II at the Ang II type 1 (AT1) receptor, were introduced and the ARB valsartan was shown to be as effective as an ACE inhibitor in reducing mortality and morbidity in high-risk post-MI survivors with left ventricular (LV) systolic dysfunction and and/or heart failure and in heart failure patients, respectively, in two major trials (VALIANT and Val-HeFT). Both these trials used an ACE inhibitor as comparator on top of background therapy. Evidence favoring the use of valsartan for secondary prevention in post-MI survivors is reviewed.     

容量和压力负荷及神经体液调节对血透析患者心力衰竭的影响

目的探讨容量负荷、压力负荷及神经体液调节对血液透析(HD)患者心力衰竭的影响。方法应用血液循环动力学信息检测仪对HD患者透析前进行血流动力学参数测定,比较充血性心力衰竭(CHF)组与无充血性心力衰竭(NCHF)组左室前、后负荷及血压等的变化。结果CHF组中心静脉压(CVP)、左室舒张末期容量(LDV)、心输出量(CO)、射血阻抗(ER)、主动脉弹性模量(OM)、收缩压(SBP)显著高于NCHF组,心肌顺应性、综合反射系数(SEC)明显低于NCHF组[(37.6±13.9)cm H2Ovs(18.4±6.3)cm H2O、(378±207)mlvs(279±114)ml、(15.5±6.2)L.min-1vs(10.8±3.1)L.min-1、(207±42)g.cm-4.s-1vs(176±36)g.cm-4.s-1、(14.3±5.3)N.cm-2vs(9.6±2.3)N.cm-2、(174±27)mmHgvs(155±26)mmHg、(16.9±9.1)vs(22.9±10.2)、(1.07±0.11)vs(1.17±0.10),P均0.01]。结论CHF患者LDV、ER、OM升高,心肌顺应性降低,微循环障碍是导致CHF的重要因素。     

Moexipril and left ventricular hypertrophy

Angiotensin-converting enzyme (ACE) inhibitors today are the standard therapy of patients with myocardial infarction and heart failure due to their proven beneficial effects in left ventricular remodeling and left ventricular function. ACE inhibitors have also been demonstrated to lead to regression of left ventricular hypertrophy (LVH). It is believed that the mechanism of action of LVH regression with ACE inhibitors arises from more than simple blood pressure reduction. LVH is an important risk factor for cardiovascular disease morbidity and mortality independent of blood pressure. Moexipril hydrochloride is a long-acting, non-sulfhydryl ACE inhibitor that can be taken once daily for the treatment of hypertension. Moexipril has now also been demonstrated to have beneficial effects on LVH and can lead to LVH regression.     

The role of aldosterone-antagonists in the treatment of congestive heart failure

The role of aldosterone-antagonists in the treatment of congestive heart failure. Despite the advances of the treatment of congestive heart failure, nearly half of the patients diagnosed with this disease five years ago are alive today. Experimental and human studies have demonstrated, that under special pathologic condition, the heart extracts aldosterone, and aldosterone extraction in the heart stimulates increased collagen turnover culminating in ventricular remodeling. Aldosterone blockade has been shown to be effective in reducing total mortality and hospitalization for heart failure in patients with systolic left ventricular dysfunction due to chronic heart failure (RALES study with spironolactone) and in patients with systolic left ventricular dysfunction post acute myocardial infarction (EPHESUS study with eplerenone). These clinical studies have shown that mineralocorticoid receptor activation remains important despite the use of angiotensin converting enzyme inhibitor or angiotensin receptor blocking agent and a beta blocker. In the ACC/AHA (and in the European and Hungarian) guidelines for the evolution and management of chronic heart failure, the indication of spironolactone was defined of Class Ila, Level of Evidence: B in CHF of stage C. The eplerenone (in US: INSPRA) was approved for the management of CHF patients after myocardial infarction with ejection fraction < 40%. Eplerenone, compared with spironolactone, is associated with a lower incidence of gynecomastia and other sex hormone-related adverse effect (breast pain, menstrual abnormalities). The spironolactone should not be used in patients with a creatinine above 220 mikromol/l. Despite the guidelines recommendation, spironolactone has been widely used in patients without consideration of their functional class or ejection fraction, without optimization of background treatment with ACE inhibitors and beta-blockers.     

个体化综合护理干预在重症心力衰竭患者中的应用效果

目的 探讨个体化综合护理干预对重症心力衰竭患者的疗效.方法 入选我院2009年4月至2013年6月收治的80例重症心力衰竭患者,随机分为两组.对照组40例给予常规内科治疗及护理,试验组40例给予常规内科治疗及个体化综合护理干预.观察两组患者治疗预后和心脏彩超的差异.结果 试验组再次住院率为35.0％,低于对照组的57.5％,差异有统计学意义（P＜0.05）;试验组死亡率2.5％,稍低于对照组的7.5％,无统计学差异（P＞0.05）;治疗后,试验组LVEF上升,同时其高于同期对照组,差异均有统计学意义（P ＜0.05）;试验组ESD下降,同时其低于同期对照组,差异均有统计学意义（P＜0.05）.结论 个体化综合护理干预对重症心力衰竭患者疗效显著,能够显著降低患者死亡率,同时减少患者再次住院的发生率,改善患者左心功能,延缓左室重构.     

血清FGF23水平与心肌梗死后心力衰竭患者心室重构的关系

目的探讨血清FGF23水平与心肌梗死后心力衰竭患者心室重构的关系。方法选择我院心血管内科2012年12月—2015年12月收治的90例慢性心力衰竭患者作为研究对象,根据患者心功能分级结果分为A组(心功能Ⅲ级,n=47)与B组(心功能Ⅳ级,n=43)。对心室重构参数,包括左室舒张末径(LVEDd)、舒张末容积(LVEDV)、室间隔舒张期厚度(IVSd)、左室收缩末容积(LVESV)、左室射血分数(LVEF)、左室后壁厚度(PWT)、左心质量指数(LVMI),行心脏彩超检查确定。并检测尿酸(UA)、血尿素氮(BUN)、低密度脂蛋白(LDL)、高密度脂蛋白(HDL)及人成纤维细胞生长因子23(FGF23)。结果A组UA、BUN、LDL、NT-BNP水平均低于B组,HDL高于B组(均P0.05)。两组LVEDd、IVSd、PWT之间的差异无统计学意义(P0.05)。A组LVEF高于B组(P0.05);LVMI与FGF23均低于B组(P0.05)。结论不同心功能分级患者的心室重构程度不同,血清FGF23浓度的改变参与慢性心力衰竭患者心室重构的病理生理过程,可作为慢性心力衰竭患者心室重构程度的生物学评估指标。     

Stem cell therapy in cardiovascular diseases

Myocardial infarction is the leading cause of congestive heart failure in the industrialized world. Current treatments fail to address the underlying scarring and cell loss, which are the causes of ischaemic heart failure. Recent interest has focused on stem cells, which are undifferentiated and pluripotent cells that can proliferate, potentially self-renew, and differentiate into cardiomyocytes and endothelial cells. Myocardial regeneration is the most widely studied and debated example of stem cell plasticity. Early reports from animal and clinical investigations disagree on the extent of myocardial renewal in adults, but evidence indicates that cardiomyocytes were generated in what was previously considered a postmitotic organ. So far, candidates for cardiac stem cell therapy have been limited to patients with acute myocardial infarction and chronic ischaemic heart failure. Currently, bone marrow stem cells seem to be the most attractive cell type for these patients. The cells may be delivered by means of direct surgical injection, intracoronary infusion, retrograde venous infusion, and transendocardial infusion. Stem cells may directly increase cardiac contractility or passively limit infarct expansion and remodeling. Early phase I clinical studies indicate that stem cell transplantation is feasible and may have beneficial effects on ventricular remodeling after myocardial infarction. Future randomized clinical trials will establish the magnitude of benefit and the effect on mortality after stem cell therapy.     

比索洛尔干预治疗高血压慢性心力衰竭左心室重构的研究

目的：探讨对于高血压慢性心力衰竭患者采用比索洛尔干预治疗后的临床效果及对其左心室功能的影响。方法：选择2011年1月-2012年5月本院收治的高血压慢性心力衰竭患者88例,应用随机法将其分为研究组与对照组,每组44例。对照组患者采用抗高血压及抗心衰常规方法进行治疗,而研究组患者在常规治疗基础上给予联合口服比索洛尔进行治疗。针对其两组患者治疗前后左心室重构指标、左心室收缩及舒张功能情况及临床疗效进行对比分析。结果：经治疗后,研究组左心室重构指标、左心室收缩及舒张功能较治疗前差异具有统计学意义（P〈0．05）,而较对照组差异则更加明显（P〈0．05）,就临床疗效研究组患者治疗显效数及治疗总有效率均明显高于对照组（P〈0．05）。结论：对于高血压慢性心力衰竭患者应用比索洛尔进行干预治疗其疗效显著。     

Progression and management of chronic heart failure

Current heart failure therapeutic guidelines are based on a new classification of the progression of the syndrome of chronic heart failure (CHF) that was proposed by ad hoc committees of the American College of Cardiology (ACC) and the American Heart Association (AHA).The new ACC/AHA classification depicts the progression of CHF in 4 stages that are labeled A to D. The 4 stages range from risk factors for CHF (A) to the presence of structural heart disease (B) and the development of symptoms (C). The last stage (D) is one of low cardiac output state despite optimal medical therapy. The merit of this new classification is to encourage tailoring of CHF therapy according to the stage of the syndrome. However, except for the final stage D that has clear therapeutic implications, the first 3 stages A, B and C do not have clear therapeutic implications. Moreover, these first 3 stages may inadvertently delay the diagnosis of CHF and fail to identify the important therapeutic target at each stage of CHF. A revised classification consisting of only 3 stages is proposed. These 3 stages are: 1) Left ventricular (LV) remodeling; 2) clinical heart failure and 3) low cardiac output state. These 3 stages have the advantage of delineating precise therapeutic targets at each stage thereby facilitating the management of patients with CHF by non-experts in the field.     

蛋白激酶C对小儿心衰作用的研究进展

蛋白激酶C家族作为第二信使在多条信号通路中发挥着重要作用,具有广泛的生物学效应.与细胞增殖、分化、凋亡、心肌肥大、心室重塑等有着密切联系.近几年国外有关蛋白激酶C与心血管疾病的相关报道日见增多,有关蛋白激酶C的研究越发受到人们的关注.该文就蛋白激酶C在心血管系统的研究进展作以介绍.     

影响慢性心力衰竭患者预后指标的研究进展

慢性心力衰竭是各种心血管疾病的终末阶段,它的发生和发展是一个复杂、连锁、动态的发展过程。一个世纪以来,从心肾学说、血流动力学学说、神经内分泌学说到心室重塑学说,人们对心力衰竭发病机制的认识越来越深刻。自从脑钠肽被成功、迅速应用于临床以来,涌现出许多新的生物标记物,被认为对心力衰竭进行危险分层、延缓病情进展、选择最佳治疗方案、改善患者的生活质量和提高生存率等有重要意义。现对近年来国内外对于影响慢性心力衰竭患者预后指标的研究新进展进行综述。     

Biventricular resynchronization in the management of severe cardiac insufficiency

Heart failure is a major problem of public health, it represents a frequent status among patients with heart disease, and its implications in term of mortality and cost are high. Non Pharmacological treatment of heart failure most commonly designed as cardiac resynchronization therapy (CRT) has demonstrate efficacy to improve functional class, exertion capacity, left ventricular ejection fraction, reduction of mitral regurgitation, and probably mortality at midterm. The most recent studies emphasize on the role of implantable cardioverter defibrillate or (ICD) combined with CRT to reduce mortality. More trials are needed to valid this concept.     

2型糖尿病患者心脏结构和功能变化及相关危险因素分析

目的探讨2型糖尿病患者心脏结构及功能的变化和引起心衰的相关危险因素,提高对糖尿病慢性心血管并发症的认识。方法随机选择170例2型糖尿病患者为研究对象,170例非糖尿病患者为对照组,并分别按是否合并心衰分为心衰患者和非心衰患者。比较2组患者左室后壁厚度(LVPWTH)、左室舒张末期内径(LVEDD)、左室收缩末期内径(LVESD)、左室射血分数(LVEF)和E/A的差异,采用Logistic回归分析引发心衰的相关危险因素。结果 2型糖尿病组LVPWTH、LVEDD、LVESD增加,LVEF减少,E/A降低,与对照组比较差异有统计学意义(p<0.05),其差异主要来自非心衰患者;回归分析显示,糖尿病病程、HbA1c达标情况及合并症高血压、冠心病、血脂异常等是2型糖尿病并发心衰的危险因素(均p<0.05)。结论糖尿病导致心脏重构以及收缩和舒张功能障碍,即使无临床心衰症状的患者,心脏结构及功能可能已经出现异常。因此,应注意早期进行心脏检查及心功能评价,积极防治相关危险因素,避免心衰的发生。     

Vital epidemiologic clues in heart failure

The epidemiologic investigation of heart failure evolution by the Framingham Heart Study has provided vital clues concerning the pathogenesis, predisposing conditions, other predictive risk factors, and indicators of deteriorating ventricular function related to the disease. This information is important in the early detection of those susceptible to heart failure who are candidates for preventive measures-of importance because the prevalence of the disease has not declined despite the recent therapeutic advances. Epidemiologic investigation has identified useful indicators for the disease including a low or falling vital capacity suggesting diastolic dysfunction, a rapid resting heart rate in compensation for a decreased stroke volume, and cardiomegaly indicating myocardial hypertrophy or dilatation. Hypertension and coronary disease remain the leading causes of the disease, and heart failure due to myocardial infarction has increased in prevalence. Hypertension and coronary disease often coexist in individuals who develop heart failure so that correction and prevention of these conditions deserve a high priority. Early detection and correction of insulin resistance is important because a threefold increase in the prevalence of diabetes in the general population has serious implications for the incidence of heart failure. In patients with hypertension, the occurrence of a myocardial infarction increases the risk of developing heart failure five to sixfold, whereas angina increases it less than twofold. In these patients, the presence of left ventricular hypertrophy increases the risk of developing heart failure two- to threefold. Heart failure-related mortality remains unacceptably high, despite improvements in treatment, indicating a need for early detection and treatment of predisposing conditions.     

Anti-aldosterone therapy in severe heart failure]

The mortality rate among patients with severe heart failure is still very high despite treatment with loop diuretics and angiotensin-converting enzyme (ACE) inhibitors. The 'randomized aldactone evaluation study' (RALES) has shown that 25 mg spironolactone added to this treatment was safe and reduced all-cause mortality by 30% in patients with severe (previous New York Heart Association (NYHA) functional class IV) heart failure due to systolic left ventricular dysfunction. Blockade of aldosterone in these patients may be necessary to overcome so-called aldosterone escape during chronic ACE-inhibition. The beneficial effects of spironolactone may relate to enhanced diuresis, anti-arrhythmogenic properties and direct effects on the myocardium and blood vessels. At present, addition of spironolactone may be appropriate for patients with severe heart failure, whereas patients with moderate heart failure may benefit more from beta-blockade.     

The less familiar side of heart failure: symptomatic diastolic dysfunction

Arrange for echocardiography or radionuclide angiography within 72 hours of a heart failure exacerbation. An ejection fraction >50% in the presence of signs and symptoms of heart failure makes the diagnosis of diastolic heart failure probable. To treat associated hypertension, use angiotensin receptor blockers (ARBs), angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, calcium channel blockers, or diuretics to achieve a blood pressure goal of <130/80 mm Hg. When using beta-blockers to control heart rate, titrate doses more aggressively than would be done for systolic failure, to reach a goal of 60 to 70 bpm. Use ACE inhibitors/ARBs to decrease hospitalizations, decrease symptoms, and prevent left ventricular remodeling.     

比索洛尔治疗稳定性心力衰竭的临床疗效

目的观察比索洛尔治疗稳定性心力衰竭的临床疗效。方法76例稳定性心力衰竭患者在常规治疗心衰的基础上,随机分成比索洛尔组39例和对照组37例,治疗组口服比索洛尔1.25～5.00mg/天,对照组口服安慰剂,疗程6个月。观察治疗前后心率、左室舒张末期内径、左室射血分数和6min步行距离。结果比索洛尔治疗组2个月后气促症状明显改善、心率明显下降(p<0.05);4个月后左室射血分数和6min步行距离明显改善(p<0.05),6个月后左室射血分数和6min步行距离明显进一步改善(p<0.01);6个月后左室舒张末期内径明显缩小(p<0.05)。安慰剂对照组治疗4月心率才显著下降(p<0.05),左室射血分数和6min步行距离治疗6月明显改善(p<0.05),左室舒张末期内径随访有缩小,但无统计学差异(p>0.05)。与对照组比较,比索洛尔治疗组因心衰再次入院、心血管死亡率、总死亡率复合终点明显减少(p<0.05)。结论比索洛尔治疗稳定性心力衰竭有效安全。     

贝那普利联合螺内酯治疗扩张型心肌病心力衰竭的临床分析

目的观察贝那普利和螺内酯治疗扩张型心肌病心力衰竭的有效性。方法将60例扩张型心肌病心力衰竭患者随机分成2组。对照组30例予以地高辛、氢氯噻嗪、倍他乐克等药物治疗,治疗组30例在此基础上加用贝那普利和螺内酯,两组均治疗6个月。结果两组比较,治疗组心功能、左心室射血分数有明显改善,心胸比、BNP下降,治疗组总有效率93%,对照组的总有效率为66%,两组差异有统计学意义(p<0.05)。结论贝那普利联合螺内酯治疗扩张型心肌病心力衰竭疗效显著且安全,并能改善心室重构。     

Valsartan in the treatment of heart failure or left ventricular dysfunction after myocardial infarction

The physiological role of the renin angiotensin aldosterone system (RAAS) is to maintain the integrity of the cardiovascular system. The effect of angiotensin II is mediated via the angiotensin type I receptor (AT1 ) resulting in vasoconstriction, sodium retention and myocyte growth changes. This causes myocardial remodeling which eventually leads to left ventricular hypertrophy, dilation and dysfunction. Inhibition of the RAAS with angiotensin converting enzyme (ACE) inhibitors after acute myocardial infarction has been shown to reduce cardiovascular morbidity and mortality. Angiotensin receptor blockers (ARBs) specifically inhibit the AT1 receptor. It has not been known until the performance of the VALIANT (valsartan in acute myocardial infarction trial) whether blockade of the angiotensin receptor with an ARB or combination of an ACE inhibitor and ARB leads to similar outcomes as an ACE inhibitor. The VALIANT trial demonstrated equal efficacy and non-inferiority of the ARB valsartan 160 mg bid compared with captopril 50 mg tds, when administered to high risk patients with left ventricular dysfunction or heart failure in the immediate post myocardial infarction period. The combination therapy showed no incremental benefit over ACE inhibition or an ARB alone and resulted in increased adverse effects. This review examines the role of valsartan in left ventricular dysfunction post myocardial infarction. We also discuss pharmacokinetics, dosing, side effects, and usage in the elderly.     

Heart failure in women

Congestive heart failure represents a growing health issue with significant morbidity, expense, and mortality. Unfortunately, despite heart failure affecting men and women equally, women historically have represented a minority in heart failure trials. Despite this disparity, treatment decisions rely heavily on these trials. Women with heart failure often have different clinical features than men, such as age of onset and comorbidities. Compared with men, women also demonstrate differences in remodeling and the response to injury, such as volume or pressure overload and myocardial infarction. We are only beginning to understand the clinical implications of these gender differences and their impact on pharmacologic treatments. After discussing these differences, a review of the agents useful in systolic failure is made, including angiotensin-converting enzyme inhibitors, b-blockers, digoxin, and aldosterone inhibition. Treatment of diastolic heart failure with empiric guidelines follows.