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.     

Hospitalized congestive heart failure after renal transplantation in the United States

PURPOSE: African Americans have increased risk for congestive heart failure (CHF) compared to Caucasians in the general population, but the risk of CHF in African American renal transplant recipients has not been studied in a national renal transplant population. METHODS: Therefore, 33,479 renal transplant recipients in the United States Renal Data System (USRDS) from 1 July, 1994 to 30 June, 1997 were analyzed in an historical cohort study of the incidence, associated factors, and mortality of hospitalizations with a primary discharge diagnosis of CHF [International Classification of Diseases-9 (ICD9) Code 428.x]. RESULTS: African American renal transplant recipients had increased age-adjusted risk of hospitalizations for congestive heart failure compared to African Americans in the general population [rate ratio 4.60, 95% confidence interval (CI) 4.59-4.62]. In logistic regression analysis, African American recipients had increased risk of congestive heart failure after renal transplantation, independent of other factors. Among other significant factors associated with congestive heart failure, the strongest were graft loss and allograft rejection. No maintenance immunosuppressive medications were associated with CHF. In Cox regression analysis patients hospitalized for CHF had increased all-cause mortality compared with all other recipients (hazard ratio 3.69, 95% CI, 2.23-6.10), but African American recipients with CHF were not at significantly increased risk of mortality compared to Caucasian recipients with CHF. CONCLUSIONS: African Americans recipients were at high risk for CHF after transplant independent of other factors. The reasons for this increased risk should be the subject of further study. All potential transplant recipients should receive particular attention for the diagnosis and prevention of CHF in the transplant evaluation process, which includes preservation of allograft function.     

维持性血液透析间期并发急性左心衰竭的防治对策

目的探讨维持性血液透析间期并发急性左心衰竭的防治对策。方法回顾性分析143例维持性血液透析患者进行14225例次血液透析,于透析间期出现急性左心衰竭126例次的治疗过程。结果血液透析间期急性左心衰竭的发生率为0.89%,抢救成功率为88.9%。结论使用紧急的血液透析治疗,快速超滤体内水分,疗效确切、迅速,是治疗维持性血液透析并发急性左心衰竭的首选方法之一,结合其他治疗方法,提高了抢救成功率。保证维持性血液透析患者的透析充分性,联合使用血管紧张素转换酶抑制剂、血管紧张素Ⅱ受体拮抗剂及β受体阻滞剂等有效降血压治疗等措施,是有效防治维持性血液透析患者并发急性左心衰竭的综合对策,能有效降低其发生率。     

维持性血液透析间期并发急性左心衰竭的防治对策

目的 探讨维持性血液透析间期并发急性左心衰竭的防治对策。方法 回顾性分析143例维持性血液透析患者进行14225例次血液透析，于透析间期出现急性左心衰竭126例次的治疗过程。结果 血液透析间期急性左心衰竭的发生率为0．89％，抢救成功率为88．9％。结论 使用紧急的血液透析治疗，快速超滤体内水分，疗效确切、迅速，是治疗维持性血液透析并发急性左心衰竭的首选方法之一，结合其他治疗方法，提高了抢救成功率。保证维持性血液透析患者的透析充分性，联合使用血管紧张素转换酶抑制剂、血管紧张素Ⅱ受体拈抗剂及β受体阻滞剂等有效降血压治疗等措施，是有效防治维持性血液透析患者并发急性左心衰竭的综合对策，能有效降低其发生率。     

Growth and correlates of nutritional status among infants with hypoplastic left heart syndrome (HLHS) after stage 1 Norwood procedure

BACKGROUND: Protein-energy malnutrition is common among infants with congenital heart disease. We hypothesized that infants with hypoplastic left heart syndrome (HLHS) are at risk for malnutrition. OBJECTIVE: To determine the prevalence of and risk factors for malnutrition in infants undergoing palliative surgery for HLHS. METHODS: Retrospective chart review of 50 infants with HLHS who underwent both stage 1 Norwood and bidirectional Glenn (BDG) procedures over 4.5 y. RESULTS: After a median hospital stay of 21 d, median discharge weight was 3.4 kg, unchanged from admission. Adjusting for weight on admission, children with longer length of hospital stay, longer intensive care unit stay, shorter duration of parental nutrition therapy, and higher diuretic dosage at discharge had a lower weight-for-age Z score at discharge (R2=0.85). On admission for BDG, median weight-for-age Z score was -2.0. After adjusting for weight on discharge from the initial hospitalization, children with fewer calories/ounce of their enteral nutrition at discharge, worse right ventricular function, more frequent readmissions, and higher oxygen saturation at discharge had a lower weight-for-age Z score at BDG (R2=0.49). CONCLUSIONS: Malnutrition is common in infants with HLHS after stage 1 palliation. Variables associated with more complex postoperative course and imbalance between systemic and pulmonary blood flow were all associated with poorer nutritional status. When adjusting for these factors, the use of parenteral nutrition and high calorie enteral feeds were associated with improved nutritional status. Aggressive parenteral and enteral nutritional therapy might help reduce the prevalence of growth faltering in infants who have HLHS.     

重视心肌梗死后心力衰竭的预防和治疗

半个世纪以来,急性心肌梗死(AMI)急性期的治疗经历了CCU前、CCU及血运重建三个时代,使住院病死率从30%降到15%并降至目前的5%～8%.尤其绿色通道的开展,使各级医院都积极关注尽早血运重建,确实取得了很大成效.但AMI后心脏重塑、心力衰竭的发生和发展也应是心脏科医生关注的又一重点,重塑常发生于AMI后3～6个月中,此阶段的药物治疗凸显重要,最重要的是β-受体阻滞剂和肾素-血管紧张素-醛固酮系统(RAAS)阻断剂的尽早和充分应用.     

重视心肌梗死后心力衰竭的预防和治疗

半个世纪以来，急性心肌梗死（AMI）急性期的治疗经历了CCU前、CCU及血运重建三个时代，使住院病死率从30％降到15％并降至目前的5％～8％。尤其绿色通道的开展，使各级医院都积极关注尽早血运重建，确实取得了很大成效。但AMI后心脏重塑、心力衰竭的发生和发展也应是心脏科医生关注的又一重点，重塑常发生于AMI后3～6个月中，此阶段的药物治疗凸显重要，最重要的是β-受体阻滞剂和肾素-血管紧张素-醛固酮系统（RAAS）阻断剂的尽早和充分应用。     

左心室射血分数对托伐普坦治疗心力衰竭疗效影响

目的新型口服利尿剂托伐普坦在临床使用中逐渐普及,其临床疗效也各不相同。本研究分析托伐普坦在治疗左心室不同射血分数心力衰竭中疗效,以便指导临床用药。方法选取2019-01-01-2019-05-31华西医院收治的常规利尿剂抵抗性心力衰竭患者59例作为研究对象,根据左心室射血分数不同,将心力衰竭分为射血分数保留的心力衰竭(heart failure with preserved ejection fraction,HFpEF)、射血分数中间值的心力衰竭组(heart failure with mid-range ejection fraction,HFmrEF)和射血分数降低的心力衰竭(heart failure with reduced ejection fraction,HFrEF),对比3组收缩压、舒张压、体质量、血钠浓度、血肌酐浓度、估算肾小球滤过率(estimated glomerular filtration rate,eGFR)、尿量和脑钠肽(brain natriuretic peptide,BNP)结果治疗后,HFpEF组、HFmrEF组和HFrEF组体质量分别为(55.28±10.01)、(52.19±11.83)和(59.07±16.52)kg,F=0.874,P=0.021;血钠浓度分别为(139.58±4.88)、(140.04±4.10)和(139.44±3.55)mmol/L,F=0.064,P=0.031;BNP水平分别为(5 558.33±8 563.68)、(11 536.00±9 241.80)和(6 012.53±5 996.53)pg/mL,F=1.915,P=0.019;24h尿量分别为(2 889.44±967.19)、(2 572.86±1 245.19)和(3 063.97±1 245.44)mL,F=0.551,P=0.043。进一步SNK-q检验显示,HFrEF组体质量、血钠浓度和BNP水平最高;HFpEF组24h尿量最多,均P<0.05。结论托伐普坦对不同射血分数的利尿剂抵抗性心力衰竭患者的治疗效果略有差异,其中HFpEF和HFrEF效果较好。     

Ross procedure instead of heart transplantation. Recovery potential of the dysfunctional myocardium in heart failure caused by congenital aortic valve insufficiency

The authors report a case of a child who presented in advanced valvular heart failure secondary to aortic regurgitation. Due to social circumstances heart transplantation was not a viable option, therefore a high risk pulmonary autograft aortic root replacement (Ross procedure) was performed. Following surgery a delayed but rather gratifying myocardial recovery was observed. CONCLUSION: This case represents the preserved recovery potential of the pediatric myocardium in end stage heart failure.     

急性左心衰并发呼吸衰竭无创呼吸机治疗效果分析

目的观察无创呼吸机治疗急性左心衰竭并发呼吸衰竭的效果。方法随机将56例急性左心衰竭合并呼吸衰竭患者分为无创呼吸机治疗组和常规治疗组,治疗2h后观察血气分析变化,比较气管插管率和死亡率。结果无刨呼吸机组治疗后患者PaO2和PaCO2均明显改善,常规组治疗后患者PaO2明显改善,无创组比常规组在PaO2和PaCO2方面改善明显。无创组病死率和气管插管率明显降低。结论无创呼吸机辅助通气治疗可使左心衰患者的动脉血氧分压迅速提高,二氧化碳分压下降,降低气管插管率和病死率,改善患者预后。     

大鼠异位心脏移植（Ono术式）的流程及经验体会

目的总结建立大鼠同种异位心脏移植模型的经验、方法及体会。方法行大鼠同种异位心脏移植（Ono术式）120例。其中预备实验60例,正式实验60例。结果预备实验手术成功率为45％,正式实验手术成功率为85％。正式实验整个手术时间为（74．3±17．1）min,供心缺血时间（29．6±t0．3）min,供心摘取时间约（7．9±4．2）min。移植心存活时间为（11．1±5．7）d;5例心脏移植后大鼠长期存活,最大体重达740g。结论成功制备大鼠心脏移植模型,良好手术技术和严格的围手术期处理同等重要。     

New medical therapies for the treatment of systolic heart failure

Heart failure is characterized by sodium and fluid retention, sympathetic overactivation, parasympathetic withdrawal, vasoconstrictor activation and cytokine elevation. New therapies for heart failure attempt to control neurohormonal activation and limit progressive left ventricular dysfunction. Nesiritide (human B-type natriuretic peptide) is a recently approved new vasodilator that has been given to almost 1000 patients in numerous clinical investigations, it belongs to a new class of heart failure drugs known as natriuretic peptides. Nesiritide decreases pulmonary capillary wedge pressure, systemic vascular resistance, mean right atrial pressure and pulmonary artery pressure, while improving cardiac index, stroke volume and heart failure symptoms. Many endothelin receptor antagonists are in various stages of development. Early clinical studies have demonstrated beneficial cardiovascular hemodynamic effects. Other new drugs for heart failure also include calcium sensitizers, neutral endopeptidase and vasopeptidase inhibitors, aldosteron receptor antagonists, vasopressin antagonists and cytokine inhibitors. All are being actively investigated and many show significant promise as beneficial therapies in the treatment of heart failure.     

呋塞米联合多巴胺治疗急性左心衰竭的效果观察

目的:观察呋塞米联合适量多巴胺持续静脉泵入治疗急性左心衰竭的临床疗效.方法:选取医院治疗的86例急性左心衰竭患者,随机分为观察组和对照组,各为43例,对照组常规予吸氧、西地兰、呋塞米、吗啡、氨茶碱、硝酸甘油治疗,观察组在常规治疗的基础上加予呋塞米联合适量多巴胺持续静脉泵入,比较两组患者心力衰竭缓解时间、机械通气比例、2周内病死率.结果:观察组心力衰竭缓解时间明显优于对照组(P<0.05);机械通气比例、2周内病死率低于对照组(P<0.05).结论:在常规治疗基础上加用呋塞米联合适量多巴胺持续静脉泵入治疗急性左心衰竭效果要显著优于常规药物治疗,值得临床广泛推广和应用.     

心肌内心电图在心脏移植术后的临床应用（附5例报告）

目的研究心肌内心电图在监测心脏移植术后排斥反应中的临床应用价值。方法采用双腔法行原位心脏移植手术，术中将电极植入所有病人的右心室心肌内，连接永久起搏器，手术后动态监测患者心肌内心电图QRS波振幅的变化。结果4例患者术后QRS波平均振幅较基数无降低，均长期存活，生活质量良好，1例患者术后第8目死于急性肾衰。结论心肌内心电图可以进行永久无创性监测心脏移植术后排异反应的发生，明显减少心内膜活检次数。     

Therapeutic effect of the latest extracorporal elimination procedure (Prometheus treatment) in acute liver failure caused by intoxication

INTRODUCTION: Despite intensive therapy the mortality of acute liver failure without organ transplantation is 60-90%. Because of organ shortage in liver transplantation, a significant number of patients dies while being on the waiting list. In order to diminish the mortality, various trials were introduced to remove the albumin-bound and water-soluble toxins in liver failure with the aim to support the spontaneous regeneration of the liver and maintaining the patients alive until liver transplantation. Prometheus treatment is a relatively new technique combining Fractionated Plasma Separation and Adsorption (FPSA) with a high-flux dialysis. During the procedure the patient's own separated albumin-rich plasma passes through special adsorbents making possible the elimination of albumin-bound toxins, while hemodialysis gets rid of water-soluble toxins. AIM: The authors' intention was to demonstrate the efficiency of Prometheus treatment in acute liver failure caused by intoxication. PATIENTS AND METHOD: Prometheus treatment was indicated in three patients who suffered from severe intoxication with paracetamol, potassium permanganate and Amanita phalloides, which resulted in a hepatic failure incurable with conservative therapy. RESULTS: Ten treatments were performed in the three female patients. No serious complication was observed. Due to the treatment the albumin-bound (indirect bilirubin p = 0.048; bile acid p = 0.001) and water-soluble (direct bilirubin p = 0.002; creatinine p = 0.007) toxins were significantly decreased. The level of ammonia, urea nitrogen, fibrinogen and antithrombin III did not change significantly. All the three patients were cured without liver transplantation. CONCLUSION: Prometheus treatment removes efficiently the accumulating toxins in acute liver failure. It is a safe elimination technique. In cases untreatable with conservative therapy it makes possible maintaining the patients alive until the liver regenerates spontaneously, or liver transplantation is feasible.     

Role of beta-blockers in the treatment of chronic heart heart failure

Role of beta-blockers in the treatment of chronic heart failure has been changed over a 25-year period from contraindication to an established indication. To date, controlled clinical trials performed in more than 13,000 patients with chronic heart failure have consistently shown that the long term administration of beta-blockers is associated with significant improvement in left ventricular function, clinical symptoms, and survival. This favorable clinical trial experiences support a recommendation that beta-blockers should be used in all heart failure patients with stable symptoms due to left ventricular systolic dysfunction unless contraindicated. Ongoing beta-blocker studies address further new topics, such as treatment of elderly patients and direct comparison of different agents. Although, the use of beta-blockers for heart failure tends to increase, implementation of the experiences from the clinical trials to the everyday practice still remains a challenge.     

Bisoprolol in the treatment of chronic heart failure

Bisoprolol fumarate is a highly selective beta-1 receptor blocker. Bisoprolol has been extensively studied in three large mortality trials in stable chronic heart failure (CHF) patients. The CIBIS trial enrolled 641 patients and demonstrated the good tolerability of bisoprolol in a large CHF population, without evidence for any harmful effect. The CIBIS-II study was the first large randomized, double-blind, placebo-controlled study demonstrating in 2647 patients a dramatic reduction in mortality with a beta-blocking agent in CHF patients. CIBIS-III demonstrated in 1010 patients the equivalence of 2 different therapeutic strategies in de novo CHF patients. There was no difference in morbidity and mortality between sub-groups of patients receiving first bisoprolol or enalapril. These three trials also demonstrated the good tolerability of bisoprolol fumarate. Other studies were either limited in number of patients or not randomized. However, these studies confirmed the good tolerability of bisoprolol in CHF patients, even in elderly population. Bisoprolol fumarate is a selective beta-1 receptor blocker that significantly reduced morbidity and mortality in stable CHF patients. Bisoprolol is well tolerated with few significant side effects in different large trials.