B型脑钠肽与不同病因心力衰竭的研究进展

B型脑钠肽(BNP)是心力衰竭的重要标记物,在不同病因导致的心力衰竭中,其浓度有所不同,但对于心力衰竭的预后评估和治疗起到指导作用.BNP的基因重组药物对于急性心力衰竭,特别是急性冠脉综合征导致的心力衰竭有很好的疗效,但对于慢性心力衰竭的长期预后影响需进一步验证.     

急性心力衰竭的病因、诊断、鉴别诊断及临床评估

急性心力衰竭是一个临床综合征。常突然起病,需紧急治疗。急性心力衰竭可以是新发的、或慢性心力衰竭的恶化,急性心力衰竭有多种病因及诱发因素。B型利钠肽、氨基末端B型钠尿肽原有助于诊断及提示预后,对急性心力衰竭患者的临床评估能了解病情的严重程度及预后。     

脑钠肽在心血管疾病中的应用进展

脑钠肽是一种具有多种生理活性的多肽。可以评判心力衰竭,预测急性冠脉综合征、心力衰竭、心房纤颤患者的预后。此外,对心力衰竭和急性心肌梗死治疗也有显著疗效。     

急性心力衰竭的治疗现况

急性心力衰竭(AHF)是由于心功能异常导致症状和体征急性发作的临床综合征,病情进展快、预后差.除一般紧急处理外,及时有效的药物治疗和准确熟练的外科手术对挽救患者生命至关重要,本文对近年来急性心力衰竭的治疗进展作一综述.     

贫血与急性冠脉综合征的关系

既往有不少研究证实,贫血不但恶化慢性心力衰竭的病情,而且与急性冠脉综合征的预后有关,可使患者近、远期不良事件的发生率提高。本文就贫血与急性冠脉综合征的关系作一综述。     

脑尿钠肽在充血性心力衰竭以外的一些疾病中的研究进展

脑尿钠肽被公认为是心力衰竭的重要标志物,在心力衰竭的诊断、治疗和预后评估中发挥着重要作用。但随着对脑尿钠肽研究的深入,人们发现脑尿钠肽在其它一些疾病中（如急性冠状动脉综合征、心律失常、肺部疾病、肾脏疾病等）也有不同程度的升高,并有其相应的变化规律和临床意义。在这里我们就脑尿钠肽在充血性心力衰竭外的这些疾病中的研究进展作简单综述,以更全面理解脑尿钠肽的变化规律,更好使用脑尿钠肽指导临床治疗。     

急性心力衰竭内科治疗现状与展望

急性心力衰竭(AHF)是指由于心脏结构或功能的异常,引起心排量的急剧降低,导致组织器官低灌注和急性淤血的一组临床综合征.临床上以急性左心衰最为常见,急性右心衰则较少见,但两者都常危及生命,必须紧急施救和治疗.值得注意的是,近年来AHF病人中舒张性心力衰竭(心衰)的比例正逐年增加,尤其是在＞65岁的老年人中;其预后并非以往所认为的舒张性心衰病人的预后好于收缩性心衰,而是相似.因此,对广大临床医生来说,及时掌握AHF的治疗进展至关重要.     

心肌肌钙蛋白与急性心力衰竭患者的预后

心肌肌钙蛋白为急性冠状动脉综合征的诊断和预后提供了信息，但是它在急性失代偿性心力衰竭中的作用尚不清楚。本研究旨在明确心肌肌钙蛋白水平升高与急性失代偿性心力衰竭住院患者发生不良事件的关系。     

妊娠高血压综合征合并急性左心衰竭19例分析

目的 对妊娠高血压综合征合并急性左心衰竭的诱发因素和临床治疗进行分析.方法 对2003年1月-2011年12月,在医院确诊为妊娠高血压综合征合并急性左心衰竭的19例孕产妇进行回顾分析.结果 19例患者均积极治疗心力衰竭诱发因素,积极降压,同时进行利尿、扩血管、强心等治疗.其中15例患者积极治疗下,在心力衰竭得到控制6 h～10 h后行剖宫产术;其余4例在控制心力衰竭的同时,行剖宫产术.最终,19例患者均好转出院,21名新生儿存活.结论 能够诱发妊娠期高血压综合征合并急性左心衰的因素,主要有多胎妊娠、低蛋白血症、贫血和感染等.治疗上以尽早去除诱发因素,积极控制高血压及纠正心力衰竭,适时终止妊娠为关键.     

脑利钠肽在急性冠状动脉综合征临床应用中的价值

脑利钠肽是一种主要从心室分泌的多肽类心脏激素,近年来,脑利钠肽在心力衰竭的诊治中已得到专家共识,成为国际公认的诊断心力衰竭的血浆标志物。最近的研究结果显示,脑利钠肽在急性冠状动脉综合征的诊断、治疗、危险分层以及预后等方面均有重要的意义,可以作为急性冠状动脉综合征的指标。现就脑利钠肽在临床应用中的意义做一概述。     

Prognostic factors in patients hospitalized with acute heart failure syndrome

Each year,there are over one million hospitalizations for acute heart failure syndrome(AHFS)in the United States alone, with a similar number in Western Europe.These patients have very high short-term(2-6 months)mortality and readmission rates,while the healthcare system incurs substantial costs,Until recently,the clinical characteristics,management patterns,and outcomes of these patients have been poorly understood and,in consequence,risk stratification for these patients has not been well defined.Several risk prediction models that can accurately identify high-risk patients have been developed in the last year using data from clinical trials,large registries or administrative databases.Use of multi-variable risk models at the time of hospital admission or discharge offers better risk stratification and should be encouraged,as it allows for appropriate allocation of existing resources and development of clinical trials testing new treatment strategies for patients admitted with AHFS.The emerging observation that the prognosis for the ensuing three to six months may be obtained at presentation for AHFS has major implications for development of future therapies.     

Epidemiology of acute heart failure syndromes

Acute Heart Failure is a heterogeneous set of syndromes associated with significant morbidity and mortality. There are several classifications of acute heart failure syndromes (AHFS) based on pathophysiology or clinical presentation. In the USA and in Europe, AHFS are the first cause of hospitalization of the elderly, and the leading health care cost. Despite this clinical and social importance, AHFS have received little attention from clinicians and researchers. Recently published epidemiological studies described clinical presentation, characteristics and treatment of over 100,000 patients hospitalized with AHFS. These studies also underlined the poor, short, and medium term prognosis, especially for the most severe patients admitted to an intensive care unit, with in-hospital mortality of 28%. Further epidemiological and clinical research is needed to improve our understanding of AHFS, thereby enhancing patient care.     

Clinical development of pharmacologic agents for acute heart failure syndromes: a proposal for a mechanistic translational phase

Hospitalization for acute heart failure syndromes (AHFS) predicts a poor prognosis, with postdischarge mortality and rehospitalization rates reaching 45% within 60 to 90 days. Despite the use of evidence-based therapies and adherence to national process measures, these event rates have largely remained the same over the past decade. Given the current and growing burden of AHFS, there exists a substantial unmet need for novel therapies that improve outcomes. However, attempts to improve symptoms and/or reduce postdischarge events have failed to produce positive results, either because of safety and/or efficacy. These negative results may be related to the drug itself, the protocol in terms of patient selection and/or end points, and/or the trial execution. Although experts may not agree on the exact reasons to explain the lack of success to date of phase III trials in AHFS, there is agreement that clinical benefits observed in phase II trials were not reproduced in phase III trials. A different approach may be needed. In November of 2009, a meeting was held at the Food and Drug Administration with the primary purpose of identifying the reasons why benefits observed during phase II did not translate into benefits in phase III to improve future trial design. Although multiple domains of trial design were discussed, the participants identified a lack of in-depth understanding of novel molecules before pivotal trials in AHFS as a possible contributor to the disappointing results of recent large trials. In this brief report, we outline the T1 or translational phase of research for AHFS clinical development as an important first step toward greater success in AHFS clinical trials.     

Why,when, and how to assess pulmonary congestion in heart failure: pathophysiological,clinical, and methodological implications

Acute heart failure syndrome (AHFS) is a major public health problem. It is defined as gradual or rapid change in heart failure (HF) signs and symptoms, which often results in an unplanned hospitalization and a need for urgent therapy. Many evidence-based pharmacologic, device, and surgical treatment for HF are available or under development. Despite these new treatments and improvement in survival, hospitalizations in HF have steadily increased over the last 30 years, and the post-discharge prognosis of patients hospitalized with AHFS remains poor (Gheorghiade et al. Circulation 112:3958–3968, 2005; Fonarow et al. Rev Cardiovasc Med 4:S21–30, 2003). Most hospitalizations for AHFS are related to “congestion” rather than to low cardiac output. The definition, identification, quantification, and monitoring of congestion are therefore essential in AHFS. The purpose of this article is: (1) to characterize the different types of hemodynamic, clinical, and pulmonary congestion in AHFS; (2) to focus on the different possible ways to assess pulmonary congestion (probably the most important, and up to now the most diagnostically elusive of the three types of congestions); (3) to propose new possible ways to implement objective and user-friendly measures of pulmonary congestion in clinical and scientific decision-making in AHFS in the near future.     

Acute heart failure syndromes: clinical scenarios and pathophysiologic targets for therapy

Acute heart failure syndromes (AHFS) represent the most common discharge diagnosis in patients over age 65 years, with an exceptionally high mortality and readmission rates at 60–90 days. Recent surveys and registries have generated important information concerning the clinical characteristics of patients with AHFS and their prognosis. Most patients with AHFS present either with normal systolic blood pressure or elevated blood pressure. Patients who present with elevated systolic blood pressure usually have pulmonary congestion, a relatively preserved left ventricular ejection fraction (LVEF), are often elderly women, and their symptoms develop typically and abruptly. Patients with normal systolic blood pressure present with systemic congestion, reduced LVEF, are usually younger with a history of chronic HF, and have symptoms that develop gradually over days or weeks. In addition to the abnormal hemodynamics (increase in pulmonary capillary wedge pressure and/or decrease in cardiac output) that characterize patients with AHFS, myocardial injury, which may be related to a decrease in coronary perfusion and/or further activation of neurohormones and renal dysfunction, probably contributes to short-term and post-discharge cardiac events. Patients with AHFS also have significant cardiac and noncardiac underlying conditions that contribute to the pathogenesis of AHFS, including coronary artery disease (ischemia, hibernating myocardium, and endothelial dysfunction), hypertension, atrial fibrillation, and type 2 diabetes mellitus. Therefore, the targets of therapy for AHFS should be not only to improve symptoms and hemodynamics but also to preserve or improve renal function, prevent myocardial damage, modulate neurohumoral and inflammatory activation, and to manage other comorbidities that may cause and/or contribute to the progression of this syndrome.     

Overview of emerging pharmacologic agents for acute heart failure syndromes

BACKGROUND: Several therapies commonly used for the treatment of acute heart failure syndromes (AHFS) present some well-known limitations and have been associated with an early increase in the risk of death. There is, therefore, an unmet need for new pharmacologic agents for the early management of AHFS that may improve both short- and long-term outcomes. AIM: To review the recent evidence on emerging pharmacologic therapies in AHFS. METHODS: A systematic search of peer-reviewed publications was performed on MEDLINE, EMBASE and Clinical Trials.gov from January 1990 to August 2007. The results of unpublished or ongoing trials were obtained from presentations at national and international meetings and pharmaceutical industry releases. Bibliographies from these references were also reviewed, as were additional articles identified by content experts. RESULTS: Cumulative data from large studies and randomised trials suggest that therapies with innovative mechanisms of action may safely and effectively reduce pulmonary congestion or improve cardiac performance in AHFS patients. CONCLUSION: Some investigational agents for the management of AHFS are able to improve haemodynamics and/or clinical status. In spite of these promising findings, no new agent has demonstrated a clear benefit in terms of long-term clinical outcomes compared to placebo or conventional therapies.     

Bayesian adaptive trial design in acute heart failure syndromes: Moving beyond the mega trial

Over the last 2 decades, early treatment for patients presenting with acute heart failure syndromes (AHFS) has changed very little. Despite strikingly different underlying disease pathophysiology, presenting signs and symptoms, and precipitants of AHFS, most patients are treated in a homogeneous manner with intravenous loop diuretics. Inhospital studies of new therapies have produced disappointingly neutral results at best. Patients continue to be enrolled in trials long after initial therapy, at a time when vital signs have improved, symptoms have changed, and initiating pathophysiologic processes, such as myocardial and renal injury, have already begun. The "one-size-fits-all" approach to inhospital AHFS trials have been recognized as one potential contributor to the disappointing trial results seen to date. Studies designed to tailor the therapeutic approach to ascertain which treatment modalities are most effective depending on patient phenotypes have not been previously conducted in AHFS because this objective is not traditional in clinical trial design. Utilizing Bayesian adaptive designs in trials of early AHFS provides an opportunity to personalize therapy within the constraints of clinical research. Bayesian adaptive design is increasingly recognized as an efficient method for obtaining valid clinical trial results. At its core, this approach uses existing information at the time of trial initiation, combined with data accumulating during the trial, to identify treatments most beneficial for specific patient subgroups. Based on accumulating evidence, the study then "adapts" its focus to critical differences between treatments within patient subgroups. Bayesian adaptive design is ideally suited for investigating complex, heterogeneous conditions such as AHFS and affords investigators the ability to study multiple treatment approaches and therapies in multiple patient phenotypes within a single trial, while maintaining a reasonable overall sample size. Identifying specific treatment approaches that safely improve symptoms and facilitate early discharge in patients who traditionally are admitted, often for prolonged periods of time, are necessary if we aim to reverse the disappointing trend in clinical trial results. In this study, AHFS clinical researchers and biostatisticians with expertise and experience in designing "personalized medicine" trials describe the development of a Bayesian adaptive design for an emergency department-based AHFS trial.     

急性心力衰竭症候群相关药物治疗进展

急性心力衰竭症候群患者耗费了大量的医疗资源,对其本人、家庭和社会带来了巨大的经济负担。在传统药物基础上,利钠肽、醛固酮受体拮抗剂、钙增敏及钾通道开放剂、内皮素和血管加压素拮抗剂等新药的应用对于这类患者治疗疗效的提高引起了广泛的关注。现对此作一简单介绍。     

Istaroxime, a first in class new chemical entity exhibiting SERCA-2 activation and Na–K-ATPase inhibition: a new promising treatment for acute heart failure syndromes?

Acute heart failure syndromes (AHFS) are associated with the rapid onset of heart failure (HF) signs and symptoms. Hospitalizations for AHFS continue to rise and are associated with significant mortality and morbidity. Several pharmacological agents are currently approved for the treatment of AHFS, but their use is associated with an increase in short-term mortality. There is a need for new agents that can be given in the acute setting with increased efficacy and safety. Istaroxime is a unique agent with both inotropic and lusitropic properties which is currently being studied for the treatment of AHFS. Istaroxime inhibits the sodium–potassium adenosine triphosphatase (ATPase) and stimulates the sarcoplasmic reticulum calcium ATPase isoform 2 (SERCA-2) thereby improving contractility and diastolic relaxation. Early data from human studies reveal that istaroxime decreases pulmonary capillary wedge pressure (PCWP) and possibly improves diastolic function without causing a significant change in heart rate (HR), blood pressure, ischemic or arrhythmic events. Most commonly reported side effects were related to gastrointestinal intolerance and were dose related. In conclusion, istaroxime is a novel agent being investigated for the treatment of AHFS whose mechanism of action and cellular targets make it a promising therapy. Further studies with longer infusion times in patients with hypotension are required to confirm its efficacy and safety.     

Acute heart failure syndromes and coronary perfusion

Acute heart failure syndromes (AHFS), with a high post-discharge mortality and rehospitalization rate, represent a significant public health burden. The treatment of patients hospitalized with AHFS often includes the use of vasoactive medications such as inotropes and vasodilators. Although such agents are frequently used, their safety and efficacy remain controversial. A significant number of patients with heart failure have underlying coronary artery disease and may be at greater risk from hemodynamic alterations that can diminish coronary perfusion. In AHFS, the relationship among vasoactive medications, coronary perfusion, and potential myocardial injury needs further investigation. Newer techniques now available to evaluate coronary perfusion should provide guidance for the evaluation of existing and future vasoactive therapies for AHFS.