心力衰竭患者地高辛血药浓度监测及分析

目的 探讨对应用地高辛的心力衰竭患者进行血药浓度监测的必要性.方法 选择2010年3月至2013年3月于解放军第一一三医院收治的300例心力衰竭患者,均给予地高辛进行治疗,服药时间均超过5个半衰期.将所有患者根据地高辛剂量分为A组（0.125 mg/d地高辛,193例）和B组（0.250 mg/d地高辛,107例）.采用荧光偏振免疫法对患者的地高辛血药浓度进行测定,对地高辛不同给药剂量的血药浓度监测结果、不同地高辛口服剂量与临床疗效的关系、不同地高辛血药浓度与临床疗效的关系进行分析和比较.结果 A组血药浓度＜ 0.8 μg/L和0.8～1.4 μg/L的患者比例均明显多于B组[13.0％ 25例）比1.9％（2例）,24.4％（47例）比7.5％（8例）],差异均有统计学意义（Х^2=10.33、13.09,P＜0.05）;而A组血药浓度＞ 2.0μg/L的患者比例明显少于B组[4.1％（8例）比37.4％（40例）],差异有统计学意义（Х^2=45.74,P＜0.05）.A组有效率为80.3％（155/193）,明显高于B组（65.4％,70/107）,差异有统计学意义（Х^2=8.14,P＜0.05）;A组中毒发生率为7.8％（15/193）,明显低于B组（16.8％,18/107）,差异有统计学意义（Х^2 =5.76,P＜0.05）.地高辛血药浓度＜0.8 μg/L组患者的无效率明显高于地高辛血药浓度0.8 ～1.4、1.5 ～2.0、＞2.0 μg/L组[81.5％（22/27）比36.4％（20/27）、0、0],差异有统计学意义（Х^2=42.03、137.60、137.60,P＜0.05）;地高辛血药浓度1.5 ～2.0 μg/L组有效率明显高于地高辛血药浓度＜0.8、0.8～1.4、＞2.0μg/L组[94.1％（160/170）比18.5％（5/27）、63.6％（35/55）、52.1％（25/48）],差异有统计学意义（Х^2=116.20、27.89、44.85,P＜0.05）;地高辛浓度＞2.0μg/L组的中毒发生率明显高于地高辛血药浓度＜0.8、0.8 ～1.4、1.5～2.0μg/L组[47.9％ （23/48）比0、0、5.9％ （10/170）],差异有统计学意义（Х^2=62.98、62.98、44.85,P＜0.05）.结论 对心力衰竭患者使用地高辛进行治疗时,对患者的血药浓度进行监测是非常必要的,根据监测结果实时调节给药剂量,以保证患者的治疗效果,同时预防药物过量导致中毒.     

Racial/ethnic disparities in measure calculations for Part D Star Ratings among Medicare beneficiaries with diabetes,hypertension, and/or hyperlipidemia

BackgroundPrevious literature reported racial/ethnic disparities in the measure assessment of diabetes medication adherence in the Medicare Part D Star Ratings program.ObjectiveThis study examined the likelihood of inclusion in measure calculation across racial/ethnic groups for adherence metrics in Part D Star Ratings among individuals with diabetes, hypertension, and/or hyperlipidemia.MethodsThis was a retrospective cross sectional analysis of a 10% random sample of 2017 Medicare claims linked to Area Health Resources Files. Inclusion in measure calculation was determined based on inclusion/exclusion criteria in adherence metrics for adherence medications for diabetes, hypertension, and hyperlipidemia in Part D Star Ratings developed by the Pharmacy Quality Alliance. Logistic regression and multinomial logistic regression were used to adjust for patient/community characteristics.ResultsThe study sample size was 2 707 216. Compared to Non-Hispanic White (White) beneficiaries, minorities were more likely to be excluded from measure calculation among individuals with 1 condition. For example, among individuals with hypertension, compared to White individuals, the adjusted odds ratios for exclusion for Black, Hispanic, Asian/Pacific Islander and other individuals were 1.46 (95% confidence interval, or CI = 1.42–1.50), 1.38 (95% CI = 1.33–1.43), 1.28 (95% CI = 1.21–1.35), and 1.08 (95% CI = 1.02–1.15), respectively. Among individuals with more than 1 chronic condition, minorities were more likely to be included in fewer calculations for medication adherence measures. For example, among individuals with all 3 conditions, the adjusted relative risk ratios for Black, compared to White, beneficiaries for being included in 0, 1, and 2 measures, versus all 3 measures, were 2.14 (95% CI = 1.99–2.30), 1.49 (95% CI = 1.41–1.56), 1.20 (95% CI = 1.18–1.23), respectively.ConclusionsCompared to White beneficiaries, racial/ethnic minorities are more likely to be excluded from the calculation for adherence measures among individuals with diabetes, hypertension, and/or hyperlipidemia. Future studies should examine whether such disparities exacerbate existing racial/ethnic disparities in health outcomes and devise solutions for these disparities.     

Relationships between health literacy and heart failure knowledge,self-efficacy,and self-care adherence

BackgroundIt has been argued that only 12% of adults have the necessary health literacy to manage their health care effectively, which can lead to difficulties in self-care activities, such as medication adherence. Prior research suggests that health literacy may influence knowledge, self-efficacy and self-care, but this has not been fully examined.ObjectiveTo test a model to explain the relationships between health literacy, heart failure knowledge, self-efficacy, and self-care.MethodsPrior to receiving clinic-based education, newly referred patients to 3 heart failure clinics completed assessments of health literacy, heart failure knowledge, self-efficacy, self-care, and demographics. Structural equation modeling was completed to examine the strength of the inter-variable relationships.ResultsOf 81 participants recruited, data from 63 patients were complete. Health literacy was independently associated with knowledge (P < 0.001). Health literacy was not related to self-care. Self-efficacy was independently-associated with self-care adherence (P = 0.016). No other relationships were statistically significant. The model had good fit (comparative fit index = 1.000) and explained 33.6% of the variance in knowledge and 27.6% in self-care.ConclusionsHealth literacy influences knowledge about heart failure but not self-care adherence. Instead, self-efficacy influenced self-care adherence. Future research should incorporate additional factors that may better model the relationships between health literacy, knowledge, self-efficacy, and self-care.     

缬沙坦联合传统降压药物辅治高血压病合并慢性心力衰竭疗效观察

目的评估缬沙坦联合多种传统降血压药物辅治高血压病合并慢性心力衰竭(CHF)的临床效果,寻找最佳治疗方案。方法选取231例高血压病合并慢性心力衰竭患者,随机分为对照组112例和试验组119例。2组起始治疗时均口服缬沙坦80mg/d,1周后对照组随机加用氢氯噻嗪25mg/d(HCT亚组,n=55)或贝那普利5mg/d(ACEI亚组,n=57);而试验组1周后开始加用氨氯地平5mg/d。记录患者入组前与随访1年后的左室射血分数(LVEF)和6min步行试验距离,同时记录随访期间的心血管事件(CVE)发生情况。结果各组随防1年后LVEF水平、6min步行距离均优于入组前(P<0.05或P<0.01);试验组LVEF水平、6min步行距离及CVE发生率均优于ACEI亚组和HCT亚组(P<0.05)。各组不良反应均较轻微。结论缬沙坦联合氨氯地平辅治高血压病合并慢性心力衰竭效果确切,预后良好。     

Effect of coverage gap on healthcare utilization among Medicare beneficiaries with chronic obstructive pulmonary disorder

Objective: To evaluate the association between the Medicare coverage gap with hospitalization, emergency room (ER) visits, and time to hospitalization in chronic obstructive pulmonary disease (COPD) patients.

Methods: Retrospective cohort study using data from a Medicare Advantage (MA) plan. Patients with ≥1 claim for COPD at baseline, ≥65 years, continuous 24-months enrollment and without any cancer/end stage renal disease diagnosis were eligible. Patients not reaching the coverage gap (no coverage gap) were matched and compared to those reaching the coverage gap and those reaching catastrophic coverage in separate analyses. Chi-square tests and Cox proportional hazards model were used to compare outcomes across matched cohorts.

Results: In total, 3142 COPD patients were identified (79% no coverage gap, 10% coverage gap, and 11% catastrophic coverage). Compared to the no coverage gap group, a larger number of beneficiaries in the coverage gap group had ≥1 hospitalization (26% vs 32%, p?<?.05), ≥ 1 ER visits (43% vs 49%, p?<?.05), and ≥1 hospitalization/ER (total visit) (47% vs 54%, p?<?.05), respectively. Compared to the no coverage gap group, a greater number of beneficiaries in catastrophic coverage had ≥1 ER visit (45% vs 53%, p?<?.05) or ≥1 total visits (48% vs 56%, p?<?.05), respectively. Time to hospitalization was shorter among those entering the coverage gap as compared to the no coverage gap [Hazards Ratio (HR)?=?1.5; p?=?.040].

Conclusions: COPD patients entering the coverage gap and catastrophic coverage were associated with increased utilization of healthcare services. Entering the coverage gap was also associated with shorter time to hospitalization as compared to the no coverage gap.     

Relationship between patient copayments in Medicare Part D and vaccination claim status for herpes zoster and tetanus-diphtheria-acellular pertussis

Objective: To assess the relationship between copay amount and vaccination claim submission status for tetanus-diphtheria-acellular pertussis (Tdap) and herpes zoster (GSK study identifier: HO-14-14319).

Methods: Retrospective analyses were performed using vaccination administrative claims data in patients aged ≥65 years with ≥1 claim for Tdap or zoster vaccines between 2012 and 2014. To avoid confounding by other financial responsibility, analyses were conducted among patients in the copayment phase of insurance. The impact of patient copay amount on vaccination claim status (“canceled” vs. “paid”) was evaluated by logistic regression separately for Tdap and zoster, adjusting for patient and provider characteristics.

Results: A total of 81,027 (39.2% with canceled claims) and 346,417 patients (56.8% with canceled claims) were included in the Tdap and zoster analyses, respectively. Mean (standard deviation) copay for canceled vs. paid claims was $37.2 (18.4) vs. $31.1 (20.1) for Tdap and $64.9 (36.9) vs. $53.5 (38.8) for zoster. The adjusted odds ratios (ORs) for a canceled Tdap vaccine claim, compared with Objective: To assess the relationship between copay amount and vaccination claim submission status for tetanus-diphtheria-acellular pertussis (Tdap) and herpes zoster (GSK study identifier: HO-14-14319).

Methods: Retrospective analyses were performed using vaccination administrative claims data in patients aged ≥65 years with ≥1 claim for Tdap or zoster vaccines between 2012 and 2014. To avoid confounding by other financial responsibility, analyses were conducted among patients in the copayment phase of insurance. The impact of patient copay amount on vaccination claim status (“canceled” vs. “paid”) was evaluated by logistic regression separately for Tdap and zoster, adjusting for patient and provider characteristics.

Results: A total of 81,027 (39.2% with canceled claims) and 346,417 patients (56.8% with canceled claims) were included in the Tdap and zoster analyses, respectively. Mean (standard deviation) copay for canceled vs. paid claims was $37.2 (18.4) vs. $31.1 (20.1) for Tdap and $64.9 (36.9) vs. $53.5 (38.8) for zoster. The adjusted odds ratios (ORs) for a canceled Tdap vaccine claim, compared with $0 copay, were 1.19 ($1–25 copay), 1.76 ($26–50 copay), 2.42 ($51–75 copay) and 2.40 ($76–100 copay), all p?<?.001. The adjusted ORs for a canceled zoster vaccine claim, compared with $0 copay, were 1.02 ($1–25), 1.39 ($26–50), 1.66 ($51–75), 2.07 ($76–100) and 2.71 (>$100), all p?<?.001 except for $1–25 (p?=?.172).

Conclusions: High patient copay is a barrier to Tdap and zoster vaccinations in Medicare Part D patients. Providing vaccines at low or no copay may improve vaccination rates in these adults.

GSK study identifier: HO-14-14319.     

冠心病心力衰竭并发肾衰竭的风险预测

目的探讨冠心病心力衰竭并发肾衰竭的风险因素,据此构建多重 logistic回归模型。方法回顾性分析 2018年 9月至 2022年 7月河南省直第三人民医院收治的 478例冠心病心力衰竭病人的临床资料,按照 7∶3的比例将其分为建模组( n= 335)与验证组( n=143)。根据肾衰竭并发情况又将建模组病人进一步分为并发组与未并发组,采用单因素及多因素 logistic回归分析法分析建模组冠心病心力衰竭病人并发肾衰竭的风险因素,并建立多重 logistic回归模型。采用受试者操作特征曲线(ROC曲线)、 Hosmer-Lemeshow拟合优度检验、决策曲线( DCA)对模型进行内外部检验。结果 478例冠心病心力衰竭病人中有 113例并发肾衰竭( 23.64%),建模组 335例病人中有 86例并发肾衰竭( 24.48%),验证组 143例病人中有 31例并发肾衰竭(21.68%);并发组年龄 ≥60岁、美国纽约心脏病协会(NYHA)心功能分级 Ⅳ级、原发性高血压史、糖尿病史、心房颤动史、利尿剂服用、左室后壁厚度(LVPWT)>11 mm、左室射血分数(LVEF)≤45%、血尿素氮( BUN)>6 mmol/L、血肌酐( Scr)>133 μmol/L、血尿酸>420 μmol/L、胱抑素 C(CysC)>1.10 mg/L、N末端 B型利钠肽前体( NT-proBNP)>3 000 ng/L、血红蛋白( Hb)<110 g/L的占比均高于未并发组( P<0.05);共线性诊断显示 LVPWT、LVEF、BUN、血尿酸、 NT-proBNP存在共线性问题,在此基础上行多因素 logistic回归分析,结果显示年龄 ≥60岁、 NYHA心功能分级 Ⅳ级、原发性高血压史、糖尿病史、心房颤动史、利尿剂服用史、 LVEF ≤45%、BUN>6 mmol/L、Scr>133 μmol/L、CysC>1.10 mg/L、Hb<110 g/L均是冠心病心力衰竭病人并发肾衰竭的危险因素( P<0.05);根据logistic回归分析结果构建的风险预测 logistic回归模型,经内部检验, ROC曲线下面积为 0.84［95%CI:(0.78,0.89)］,灵敏度、特异度分别为 81.82%、77.42%,而 Hosmer-Lemeshow拟合优度检验显示 P=0.787;利用验证组数据实施外部检验, ROC曲线下面积为 0.83［95%CI:(0.76,0.89)］灵敏度、特异度分别为 80.00%、77.00%,而 Hosmer-Lemeshow拟合优度检验显示 P=0.776;DCA曲线显示,当阈值概率为 0~0.9ogistic回归模型对冠心病心力衰竭病人并发肾衰竭风险预测的净收益时,l,更高。结论老年、 NYHA心功能分级 Ⅳ级、原发性高血压史、糖尿病史、心房颤动史、利尿剂服用史、 LVEF≤45%、BUN>6 mmol/L、Scr>133 μmol/L、CysC>1.10 mg/L、Hb<110 g/L均是冠心病心力衰竭病人并发肾衰竭的危险因素,根据此结果而建立的风险预测 logistic回归模型具有较好的预测价值,能够帮助临床工作者早期筛选并发肾衰竭的高风险人群,以便及时予以干预,降低肾衰竭发生率。     

卡维地洛对慢性心力衰竭心功能的影响

目的　探讨卡维地洛对慢性心力衰竭患者心功能的影响。方法 :将 6 0例慢性心力衰竭患者双盲随机分为两组 ,卡维地洛组 (A组 ) 30例 ,美托洛尔组 (B且 ,对照组 ) 30例。两组病人基础临床特征相似 ,应用彩色超声心动图测量病人治疗前、后 6个月射血分数 (EF)左室短轴缩短分数 (FS)及左心室腔径容积变化 ,并观察患者的 NYHA心动能、血压的变化。结果　治疗 6个月后 ,A组的 EF和 FS比 B组明显增高。 (EF:0 .4 6± 0 .2 3%比 0 .39± 0 .18% ,P<0 .0 1) (FS:2 5 .0± 1.6 4 %比 2 2 .3± 1.36 % ,P<0 .0 1)左室舒张末径 (L VDd)和左室收缩末径 (L VDs)均比治疗前缩短分别为 (L VDd:5 0 .0± 0 .76 m m比 37.0± 0 .34mm) (L VDs:5 3.0± 0 .4 7mm比 4 0 .0± 0 .15 mm) ,P均 <0 .0 1。左室舒张末期容积 (L VEDV)和左室收缩末期容积 (L VESV)均比治疗前缩小分别为 [10 4± 0 .15 ) ml比 (31.15±0 .77) ml和 (119± 0 .19) ml比 (34.17± 0 .6 7) ml,均 P<0 .0 1],治疗 6个月后两组患者的 NYHA心功能分级改善。治疗期间 ,卡维地洛组无心衰恶化 ,美托洛尔组有 2例因心衰恶化住院。结论　卡维地洛与美托洛尔对慢性心力衰竭均有较好的疗效 ,前者更优于后者。     

机械通气抢救急性左心衰竭伴呼吸衰竭的临床观察

目的 评价机械通气治疗急性左心衰竭的疗效.方法 对32例常规治疗无效的重症急性左心衰竭患者加用机械通气治疗,观察通气前后HR、RR、平均动脉压(MAP)、动脉血气分析指标(pH、PaO2、SaO2、PaCO2)的变化及临床症状的改善情况.结果 机械通气治疗后,32例患者中28例病情好转,4例死亡.通气1 h后RR由(33.6±7.8)次/min 降至(21.3±3.2)次/min(P＜0.05),HR由(117.8±17.5)次/min降至(86.7±10.5)次/min(P＜0.05),MAP由(96.4±5.2)mm Hg降至(83.9±7.8)mm Hg(P＜0.05).通气前及通气后1 h查血气,SaO2由(75.8±8.6)%升高至(95.6±3.7)%(P＜0.01),PaO2由(49.8±8.7)mm Hg升高至(85.3±6.1)mm Hg(P＜0.01),pH、PaCO2无显著变化.结论 机械通气是治疗急性左心衰竭伴呼吸衰竭安全有效的方法.     

白藜芦醇改善慢性心力衰竭预后的临床观察

目的观察白藜芦醇对冠心病慢性心力衰竭(CHF)预后的影响。方法将114例CHF患者随机分成治疗组(59例)、对照组(55例)。所有患者均常规治疗,治疗组加用白藜芦醇4mg,每晚1次。治疗2个月后复查血脂常规、C反应蛋白(CRP)、左室射血分数(LVEF)。观察所有患者的住院次数、总日数、病死率。结果治疗组与对照组比较,治疗2个月后,血清总胆固醇(TC)、低密度脂蛋白胆固醇(LDL-C)、CRP均有不同程度的降低,LVEF则有明显提高。治疗组与对照组比,住院次数和总日数减少,但差异无统计学意义(P>0.05);病死率明显降低,两组相比差异有统计学意义(P<0.01)。结论白藜芦醇治疗冠心病CHF能够改善患者的预后。     

托拉塞米治疗慢性心力衰竭临床观察

目的观察托拉塞米治疗慢性心力衰竭的疗效及安全性。方法 118例患者随机分为托拉塞米治疗组及呋塞米组,两组基础用药一致,比较两组治疗后的体重下降、水肿变化、心功能变化及不良反应。结果两组均可使慢性心力衰竭患者体重下降,水肿减轻,心功能改善,两组对比差异无统计学意义;不良反应发生率两组比较差异无统计学意义,但托拉塞米组低钾发生率低于呋塞米组。结论托拉塞米对慢性心力衰竭疗效肯定,可改善心功能,减轻水肿,特别适用于同时存在低钾的慢性心力衰竭的患者。     

无创呼吸机在心力衰竭治疗中的应用

目的探讨无创呼吸机（BiPAP）在救治急性左心力衰竭中的应用价值。方法60例急性左心力衰竭患者随机分为治疗组与对照组各30例,治疗组在常规抗心力衰竭治疗基础上联用呼吸机面罩正压通气治疗,对照组为常规抗心力衰竭治疗,测定治疗前后动脉血pH、PaO2、PaCO2,观察血压、心率、呼吸及临床症状,并进行分析。结果治疗组治疗后pH、PaO2、PaCO2、心率、呼吸、血压均较明显改善（P〈0．05）,治疗显效率46．67％（14例）,明显高于对照组30．00％（9例）（P〈0．05）;治疗组总有效率93．33％（28例）,对照组总有效率73．33％（22例）,治疗组有效率较对照组明显增高（P〈0．05）。结论无创呼吸机对急性左心力衰竭的治疗有一定效果。     

慢性心力衰竭患者心率变异性与心功能的相关性研究

目的 探讨慢性心力衰竭(CHF)患者心率变异性(heart rate variability,HRV)的特点及与心功能的相关性.方法 对59例CHF患者和65例健康对照者,行24小时动态心电图(Holter)监测,对比分析其HRV,并比较不同程度CHF患者HRV的差异.结果 HRV指标中,CHF组低频功率与高频功率比值...     

卡维地洛治疗慢性心力衰竭的疗效观察

目的探讨卡维地洛对慢性心力衰竭患者的临床疗效。方法选择慢性心力衰竭患者92例,并随机分为治疗组49例和对照组43例。对照组接受常规治疗（利尿剂、血管紧张素转换酶抑制剂、洋地黄）,治疗组在常规治疗的基础上加用卡维地洛。观察2组患者治疗前、治疗后6个月的心功能、左心室舒张末期容积、射血分数、6min步行距离情况。结果治疗6个月后,与对照组比较,治疗组心功能、左室舒张末期容积、射血分数及6min步行距离改善明显,差异有统计学意义（P〈0.05或P〈0.01）。结论卡维地洛能明显减缓慢性心力衰竭患者的病情进展,提高心力衰竭患者的运动耐量和生活质量。