高血压心力衰竭血浆肾上腺素质素及紧张素的变化

目的：探讨高血压的心力衰竭过程中肾上腺髓质素（ＡＤＭ）及肾上腺紧张素（ＡＤＴ）的变化及作用。方法：采用特异性放射免疫法（ＲＩＡ）测定２５例正常人、５０例原发性高血压患者（１３例高血压、１２例高血压左室肥厚、２５例高血压心力衰竭）血浆中ＡＤＭ及ＡＤＴ的浓度。结果：（１）随着高血压心脏损害的加重。ＡＤＭ明显增加,而ＡＤＴ变化不大。（２）随着高血压心力衰竭中ＮＹＨＡ分级增高,ＡＤＭ／ＡＤＴ比值变低,ＡＤＴ浓度明显增加,ＡＤＭ代偿速度变慢。结论：ＡＤＭ代偿缓慢和ＡＤＴ分泌过度是高血压心力衰竭过程中血管活性肽调节紊乱的一个特点。     

Increase in plasma adrenomedullin in patients with heart failure characterised by diastolic dysfunction

OBJECTIVE—To investigate the relation between plasma adrenomedullin and the severity of diastolic dysfunction in patients with heart failure.
DESIGN—Prospective study.
SETTING—University teaching hospital.
PATIENTS—77 patients (mean (SEM) age 66.3 (1.2) years; 75% male) who were being followed in the outpatient clinic after admission to hospital for acute heart failure.
INTERVENTIONS—Same day echocardiography with Doppler studies; determination of venous adrenomedullin concentration by radioimmunoassay.
MAIN OUTCOME MEASURES—Plasma adrenomedullin concentration and its correlation with systolic and diastolic function.
RESULTS—31 patients (40%) had isolated diastolic dysfunction (ejection fraction > 50%), and the remaining 46 had a depressed ejection fraction (< 50%). Of the patients with diastolic dysfunction, 17 had a restrictive filling pattern. In all but one of these there was coexisting systolic failure (χ² = 10.7, p = 0.001). Patients with systolic heart failure and a restrictive filling pattern (group 1, n = 16) had a higher plasma adrenomedullin than those with systolic failure and a non-restrictive filling pattern (group 2, n = 30) or with isolated diastolic heart failure and a non-restrictive filling pattern (group 3, n = 30) (mean (SEM): 91.7 (21.1) v 38.4 (8.8) v 34.0 (6.5) pmol/l, both p < 0.05). All heart failure values were higher (p < 0.01) than the control value (6.9 (1.2) pmol/l). Ejection fraction and left ventricular dimensions were similar in groups 1 and 2. Plasma adrenomedullin did not correlate with ejection fraction or New York Heart Association functional class. Stepwise multiple regression analysis showed that the presence of a restrictive filling pattern was the only independent variable associated with a high plasma adrenomedullin.
CONCLUSIONS—Plasma adrenomedullin concentrations in patients with heart failure are determined by the presence of diastolic dysfunction, and are especially raised in the presence of a restrictive filling pattern. There appears to be no correlation with systolic dysfunction.


     

原发性高血压和心力衰竭患者血浆肾上腺髓质素和高敏C反应蛋白变化的研究

目的探讨血浆肾上腺髓质素(ADM)、高敏C反应蛋白(hs-CRP)的浓度变化,在原发性高血压(EH)、心力衰竭过程中的变化及意义。方法选取21例健康体检者(对照组)及59例老年EH患者,其中32例单纯EH(高血压组)、27例EH合并心力衰竭(心力衰竭组),用放射免疫法测定血浆ADM,用胶乳免疫增强比浊法测hs-CRP的浓度。结果高血压组患者血浆ADM及hs-CRP的浓度较对照组明显升高;心力衰竭组血浆hs-CRP、ADM浓度较对照组明显升高;在心力衰竭组和高血压组中,不同心功能分级和高血压分级的患者随心功能衰竭加重和高血压级别的升高,血浆hs-CRP及ADM的浓度均有所升高;患者血浆hs-CRP浓度及ADM浓度呈正相关。结论血浆ADM、hs-CRP合成增加是原发性高血压、心力衰竭过程中血管活性物质调节紊乱的特点,可以作为观察高血压、心力衰竭过程中心功能变化的指标。     

Body mass index, prognosis and mode of death in chronic heart failure: results from the Valsartan Heart Failure Trial

AIMS: To assess the relationship between body mass index (BMI), mortality and mode of death in chronic heart failure (CHF) patients; to define the shape of the relationship between BMI and mortality. METHODS AND RESULTS: We performed a post-hoc analysis of 5010 patients from the Valsartan Heart Failure Trial. The end-points of the study were all-cause and cardiovascular mortality. Mortality rate was 27.2% in underweight patients (BMI<22 kg/m2), 21.7% in normal weight patients (BMI 22-24.9 kg/m2), 17.9% in overweight patients (BMI 25-29.9 kg/m2) and 16.5% in obese patients (BMI>30 kg/m2) (p<0.0001). The rates of non-cardiovascular death did not differ among groups. The risk of death due to progressive heart failure was 3.4-fold higher in the underweight than in the obese patients (p<0.0001). Normal weight, overweight and obese patients had lower risk of death as compared with underweight patients (p=0.019, HR 0.76, 95% CI 0.61-0.96; p=0.0005, HR 0.68, 95% CI 0.55-0.84; p=0.003, HR 0.67, 95% CI 0.52-0.88, respectively) independently of symptoms, ventricular function, beta-blocker use, C-reactive protein and brain natriuretic peptide levels. CONCLUSIONS: In CHF patients a higher BMI is associated with a better prognosis independently of other clinical variables. The relationship between mortality and BMI is monotonically decreasing.     

急性心力衰竭时充血：评估和治疗

目前,急性心力衰竭的住院率和病死率仍居高不下,常危及生命,对患者做出准确及时的评估并积极治疗是抢救成功的关键。根据临床症状、体征及相关实验室检查做出临床评估,并采用相关药物及非药物治疗进行紧急处理,以降低急症死亡率。     

Symptoms and Signs of Heart Failure at Admission and Discharge and Outcomes in the Sub-Saharan Acute Heart Failure (THESUS-HF) Registry

Background

Symptoms and signs of heart failure (HF) are the most common reasons for admission to hospital for acute HF (AHF) and are used routinely throughout admission to assess the severity of disease and response to therapy.

Elevated NT-proBNP levels should be interpreted in elderly patients presenting with dyspnea

Background

B-type natriuretic peptide (BNP) assay is a useful tool in order to diagnose dyspnea due to congestive heart failure (CHF). On the other hand many other diseases could affect BNP levels. The aim of this study was to investigate a group of elderly patients admitted to an Internal Medicine unit because of dyspnea.

Patients and methods

NT-proBNP was assessed in 132 consecutive patients aged 80 ± 6 years because of dyspnea. History data, anthropometric, clinical and biochemical parameters were collected. Renal function was assessed by the CKD-EPI formula. Diagnosis of pulmonary disease such as infections and chronic obstructive disease was considered and was analyzed as a single parameter. Statistical analysis was carried out dividing patients with high NT-proBNP from those with normal NT-proBNP according to the Januzzi cut-off.

Results

NT-proBNP was higher than the normal reference values in 68.7% of patients and its levels increased in the 5 different stages of chronic kidney disease. Subjects with high NT-proBNP had lower haemoglobin levels (11.6 ± 2.1 vs 12.8 ± 1.9 g/dl, p = 0.003), higher prevalence of atrial fibrillation (54.3 vs 25%, p = 0.001), and lower prevalence of pulmonary diseases (29.7 vs 57.5%, p = 0.005). Logistic regression analysis showed that NT-proBNP levels were independently associated with haemoglobin (OR 1.307 95% CI 1.072-1.593, p = 0.008) and pulmonary diseases (OR 3.069 95% CI 1.385-6.801, p = 0.006).

Conclusions

A disease different from CHF appears to affect NT-proBNP plasma levels. Therefore, determination of its levels does not seem to help clinicians in the definition of dyspnea in elderly people with different comorbidities.     

Plasma adrenomedullin relation with Doppler-derived dP/dt in patients with congestive heart failure

BACKGROUND: Increased circulating adrenomedullin (AM) concentration has been reported in congestive heart failure (HF) and considered as a possible marker of cardiac dysfunction. HYPOTHESIS: The study was undertaken to assess the relationship between circulating AM concentration and left ventricular (LV) functional state, estimated by echo-Doppler techniques in patients with mild to moderate HF and different degrees of LV dysfunction. METHODS: Plasma AM, B-type natriuretic peptide (BNP), and N-terminal (NT) proBNP levels were measured in 55 patients with HF (New York Heart Association [NYHA] I n = 8, II n = 26, III n = 21) and in 20 controls; dP/dt was calculated by the Doppler tracing of the mitral regurgitation jet. RESULTS: The study was completed in 51 patients. Adrenomedullin levels were higher than in controls (19.2 +/- 1.4 vs. 13.3 +/- 0.7, p < 0.005) and elevated in proportion to NYHA functional class. B-type natriuretic peptide and NT-proBNP were 344 +/- 67 vs. 12 +/- 2 pg/ml and 2196 +/- 623 vs. 52 +/- 4 pg/ml, respectively (p < 0.0001); dP/dt was better related to AM (r = 0.582, p < 0.001) than to the other peptides. Adrenomedullin was significantly (p < 0.001) different between patients grouped according to the dP/dt cut-off predictive of event-free survival. CONCLUSIONS: The combination of depressed contractility and increased AM may provide a clue for further characterization of the severity of LV dysfunction in HF, independent of baseline LV ejection fraction.     

急性心力衰竭的现状及治疗进展

急性心力衰竭已成为威胁人类健康迫切需要解决的大问题,住院率及病死率均较高。近年来,在传统药物基础上新型正性肌力药物左西孟旦、新型血管扩张剂奈西利肽及血管加压素拮抗剂托伐普坦能有效改善患者的血流动力学及充血症状,可能为急性心力衰竭患者带来新的希望;非药物治疗方面无创通气、左室辅助装置及超级滤过装置正成为药物治疗的有益补充。     

Prognostic Significance of ECG Abnormalities for Mortality Risk in Acute Heart Failure: Insight From the Sub-Saharan Africa Survey of Heart Failure (THESUS-HF)

ObjectiveThe aim of this study was to assess the predictive utility of 12-lead electrocardiogram (ECG) abnormalities among Africans with acute heart failure (HF).Methods and ResultsWe used the Sub-Saharan Africa Survey of Heart Failure, a multicenter prospective cohort study of 1,006 acute HF patients, and regression models to relate baseline ECG findings to all-cause mortality and readmission during a 6-month follow-up period. Of 814 ECGs available, 523 (49.0% male) were obtained within 15 days of admission, among which 97.7% showed abnormalities. Mean age was 52.0 years and median follow-up was 180 days, with 77 deaths (Kaplan-Meier 17.5%) through day 180 and 63 patients with death or readmission to day 60. QRS width, QT duration, bundle branch block, and ischemic changes were not associated with outcomes. Increasing ventricular rate was associated with increasing risk of both outcomes (hazard ratio [HR] 1.07 per 5 beats/min increase for 60-day death or readmission, 95% confidence interval [CI] 1.02–1.12; P = .0047), and the presence of sinus rhythm was associated with lower risk (HR 0.58, 95% CI 0.34–0.97; P = .0385). There was a strong association between survival and heart rate in patients in sinus rhythm, with heart rate >119 beats/min conveying the worst mortality risk.ConclusionsECG abnormalities are almost universal among Africans with acute HF, which may add to the immediate diagnosis of patients presenting with dyspnea. Although some ECG findings have prognostic value for risk of adverse outcomes, most of them are nonspecific and add little to the risk stratification of these patients.     

The Comparison of Medical Therapy,Pacing, and Defibrillation in Heart Failure (COMPANION) trial in perspective

The Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) trial is one of several randomized trials that has demonstrated an improvement in morbidity and mortality with biventricular pacemakers and/or implantable defibrillators. Although the results of the COMPANION trial overlap with other trials investigating cardiac resynchronization therapy (CRT) and implantable cardioverter-defibrillators (ICDs), there are several unique aspects of the trial that warrant special attention. This review focuses on COMPANION in light of other CRT trials, and includes a discussion on the patient population enrolled, design challenges of the trial, the cost-effectiveness of CRT and CRT-D, and results of subanalyses using data collected during the trial.     

冠心病患者血浆肾上腺髓质素和同型半胱氨酸水平的研究

目的检测冠心病(CHD)患者外周静脉血浆中肾上腺髓质素(ADM)和同型半胱氨酸(HCY)浓度并探讨其临床意义。方法 30例CHD病人和30例正常对照者,用放射免疫分析法检测其静脉血浆ADM浓度,用高效液相色谱及荧光法检测其相应总的HCY浓度。结果CHD病人静脉血浆ADM和HCY浓度均显著高于对照组(39.46±2.21 ng/L比17.35±1,72ng/L,P<0.001和23.47±0.75umol/L比10.72±0.45umol/L,P<0.001),血浆ADM浓度与HCY浓度间呈显著正相关(r=0.92.P相似文献   

Differential hormonal profiles of adrenomedullin and proadrenomedullin N-terminal 20 peptide in patients with heart failure and effect of treatment on their plasma levels

BACKGROUND: Adrenomedullin (AM) is a potent vasodilatory peptide discovered in human pheochromocytoma tissue. Proadrenomedullin N-terminal 20 peptide (PAMP) processed from an AM precursor is also a novel hypotensive peptide which inhibits catecholamine secretion from sympathetic nerve endings. HYPOTHESIS: The present study sought to examine the relationships between the two peptides and other clinical parameters by measuring the plasma AM and PAMP concentrations in 98 patients with heart failure. METHODS: In all, 98 patients [65 men and 33 women, aged 58.2 +/- 11.0 years, mean +/- standard deviation (SD)] with heart failure and 26 healthy volunteers (12 men and 14 women, aged 54.1 +/- 8.6 years) were examined in this study. Heart failure was secondary to previous myocardial infarction in 58 patients, valvular disease in 28, cardiomyopathy in 9, and congenital heart disease in 3. All patients were classified into two groups of class I or II (Group 1) and class III or IV (Group 2) according to the New York Heart Association (NYHA) functional classification. RESULTS: Both plasma AM and PAMP concentrations in the patients were significantly higher than those in healthy volunteers. In addition, plasma AM and PAMP concentrations in patients in class III or IV of New York Heart Association (NYHA) classification were significantly higher than those in NYHA class I or II. The elevated plasma concentrations of these peptides in patients in NYHA class III or IV significantly decreased in response to the treatment for 7 days. There was a significant correlation between plasma AM and PAMP, though the plasma concentration of PAMP was one-fifth to one-seventh of that of AM in patients and controls. The plasma AM concentration correlated significantly with the plasma concentrations of atrial and brain natriuretic peptides, epinephrine, and right atrial pressure, whereas such a relationship was not noted for the plasma PAMP concentration. CONCLUSIONS: Judging from the difference in not only the biological actions but also the hormonal profiles between AM and PAMP, they may differentially modulate the cardiovascular system in patients with heart failure, although they are processed from the same precursor.