螺内酯对老年人重度心力衰竭的疗效

目的 探讨小剂量醛固酮拮抗剂螺内酯治疗老年人重度慢性充血性心力衰竭(coneestiv eheart faiture，CHF)的疗效和安全性。方法 采用随机、单育、安慰剂对照、平行组试验。入选老年重度CHF患者152例，随机分为螺内酯组(A组)和对照组(B组)，均予标准三联抗心衰治疗，A组联用螺内酯(20～40mg／d)，B组联用安慰剂。治疗前和治疗后2周、4周、8周分别进行心功能(NYHA)分级评估，心电图、超声心动图、血常规、生化等检查，并进行对照。结果 治疗8周后A、B两组心功能分级、无创心排量指标均显著改善(P＜0．05)；与B组比较，A组改辱更显著(P＜0．05)。无肝、肾功能损害及血脂、血糖升高，未见高血钾症，毒副作用少。结论 应用螺内酯治疗老年人重度CHF疗效肯定、安全性好、值得推广。     

正性肌力药物治疗充血性心力衰竭

对正性肌力药物治疗充血性心力衰竭进行综述,其中包括洋地黄类和非强心甙类正性肌力药物,着重分析新近开发的药物,如多巴胺类、磷酸二酯酶抑制剂及钙增敏剂。     

米力农治疗重度充血性心力衰竭

目的观察小剂量米力农重度充血性心力衰竭的疗效及安全性。方法心功能Ⅲ、Ⅳ级的重度心衰住院患者60例,随机分为A、B两组,每组各30例。A组为多巴酚丁胺对照组,B组为米力农治疗组。结果 A组显效8例,有效11例,无效11例,总有效率66.7%;B组显效24例,有效4例,无效2例,总有效率93.3%;A组总有效率高于B组,但无显著统计学差异。用超声心动图所测心搏量(SV)、心排血量(CO)、心脏指数(CI),B组各指标明显改善,具有显著统计学差异,而且心律失常发生数减少,未见明显药物不良反应。结论米力农治疗重度充血性心力衰竭安全有效,值得临床广泛应用。     

卡维地洛治疗慢性充血性心力衰竭临床观察

目的:探讨卡维地洛治疗慢性充血性心力衰竭的疗效及安全性。方法:68例慢性充血性心力衰竭患者,随机分为两组,常规抗心衰药物治疗者为对照组,在此基础上加用卡维地洛治疗者为治疗组,卡维地洛用法从小剂量开始,根据血压、心率渐加大剂量,疗程3~6个月,观察治疗前后的临床疗效,左室射血分数、左室舒张末期内径、左室收缩末期内径及心率的变化。结果:治疗组总有效率为94.4%,对照组为59.4%,两组比较有显著性差异(P<0.05);治疗组治疗后,左室射血分数、左室舒张末期内径、左室收缩末期内径及心率均改善,与对照组比较,有显著性差异(P<0.05)。结论:在常规治疗慢性充血性心力衰竭的基础上,加用卡维地洛,可进一步提高疗效,改善心功能,安全有效。     

Atrial natriuretic peptide during acute treatment of congestive heart failure

Summary. Atrial natriuretic peptide (ANP) induces potent diuretic/natriuretic, vasorelaxing and aldosterone inhibitory effects. Increased plasma levels in congestive heart failure (CHF) have been reported. The aim of this study was to investigate plasma immunoreactive ANP (ir-ANP) levels during acute treatment of CHF. Seven patients with CHF underwent cardiac catheterization. Ir-ANP plasma levels were followed up to two h after administration of an orally given phosphodiesterase inhibitor (Milrinone); a substance with positive inotropic and peripheral vasodilating properties. In all patients cardiac output increased and cardiac filling pressures decreased markedly. Initially high ir-ANP plasma levels decreased. Our patients did not have an increased blood volume. It is concluded that plasma ir-ANP levels in the pulmonary artery rapidly decrease when atrial pressure is reduced. These data suggest that atrial pressure is the major determinant for release of ir-ANP in man and that the ability to respond quickly to changes in cardiac filling pressures is maintained in patients with severe CHF. Plasma ir-ANP levels may also become useful as an index of the degree of heart failure and serve as a tool in monitoring response to drug therapy.     

充血性心力衰竭的药物治疗

药物治疗是充血性心力衰竭（CHF）的主要治疗手段。正确的药物治疗能产生有益的疗效，而个体化的治疗方案是治疗成功的关键。既往的治疗是以应用利尿剂，洋地黄制剂和限制钠盐为基础的“三联疗法”，以后增加了血管扩张剂，改为“四联疗法”，随着医学的发展，目前的治疗趋势是强调应用经过循证医学证实可以降低死亡率的药物，包括血管紧张素转换酶抑制剂（ACEI），β受体阻滞剂和醛固酮拮抗剂，上述三种药物加上利尿剂和洋地黄制剂的“五联疗法”已成为CHF的普遍的治疗方法，从而达到有效地去除病因，去除诱发因素和控制心力衰竭的目的。     

抗心衰标准三联疗法联合应用美托洛尔治疗老年人慢性充血性心力衰竭

目的　探讨 β 肾上腺素能受体阻滞剂美托洛尔治疗老年人慢性充血性心力衰竭 (congestiveheartfailure ,CHF)的有效性和安全性。方法　采用多中心、随机、单盲、安慰剂对照、平行组试验。入选老年CHF患者 2 36例 ,随机分为美托洛尔组 (A组 )和对照组 (B组 ) ,均予标准抗心衰治疗 (依那普利、速尿、地高辛 ) ;A组联用美托洛尔 6 .2 5～15 0mg/d ,B组联用与美托洛尔外观相同的淀粉安慰剂。观察治疗前和治疗后 1个月、6个月、12个月时的临床指标变化 ,评价其临床有效性和安全性。结果　与B组比较 ,A组心率、血压下降迅速且持久 (P <0 .0 5 ) ;无创心排量指标和临床心功能分级于 6个月时亦显著改善 (P <0 .0 5 ) ,12个月时改善更显著 ;总心脏事件的发生率于 12个月时也显著减少 (P <0 .0 5 )。结论　长期应用美托洛尔可明显改善老年人CHF患者的心脏功能 ,提高患者的生活质量和生存率 ,安全可靠     

The safety of spironolactone treatment in patients with heart failure

INTRODUCTION: Spironolactone is increasingly being used in the treatment of heart failure. However, it has been associated with cases of hyperkalaemia. The common use of angiotensin-converting enzyme (ACE) inhibitors and angiotensin-2 receptor (AT2) antagonists in heart failure increases the risk of hyperkalaemia. OBJECTIVE: To identify the risk of spironolactone withdrawal, hyperkalaemia and severe hyperkalaemia in patients prescribed spironolactone together with either an ACE inhibitor or an AT2 antagonist. METHODS: Retrospective identification and analysis of patients co-prescribed an ACE inhibitor or an AT2 antagonist with spironolactone. Patients' records were linked to their biochemical results and the doses of spironolactone, ACE inhibitor and AT2 antagonists received by them. RESULTS: We found that a higher proportion of patients in our cohort stopped taking spironolactone compared with the Randomised Aldactone Evaluation Study and a higher proportion developed hyperkalaemia, a predicted adverse effect of spironolactone combination with an ACE inhibitor or an AT2 antagonist. Patients with diabetes mellitus and those with a haematocrit below 0.36, were more likely to develop hyperkalaemia than those without these traits. CONCLUSIONS: Spironolactone is a common cause of hyperkalaemia when used in combination with either an ACE inhibitor or an AT2 antagonist. This reinforces the need for care when extrapolating the results of clinical trials to daily clinical practice.     

指南对老年慢性充血性心力衰竭住院患者药物治疗的影响

目的 分析老年慢性充血性心力衰竭(CHF)患者药物治疗随指南发布发生变化的情况.方法 选择1990年1月至2007年7月确诊且≥60岁的CHF住院病例3 174例次,根据美国心脏病学会/美国心脏病协会(ACC/AHA)指南发布的时间按每6年一组分为3组,对患者的治疗药物进行回顾性分析.结果 入选病例占同期CHF住院病例的79.2%(3 174/4 010),其中男1 639例次,女1 535例次;年龄60～98岁,平均(71.94±7.07)岁.1990年至1 995年(A组)、1996年至2001年(B组)、2002年至2007年(C组)CHF患者的年龄(岁)逐年增长(68.99±6.71、71.56±6.86、73.79±7.01,F=91.142,P＜0.01);前3位病因均为冠心病(55.3%、64.5%、81.8%)、肺源性心脏病(21.9%、19.3%、5.5%)、风湿性心脏病(16.5%、10.3%、7.5%),3种病因间比较差异有统计学意义(x2=217.979,P＜0.01);入院时美国纽约心脏协会(NYHA)心功能分级Ⅲ、Ⅳ级居多(Ⅲ级1 561例次,Ⅳ级1 433例次,x2=75.828,P＜0.01);预后以好转为主(88.9%、88.3%、92.7%,x2=35.002,P＜0.01).硝酸酯类、β受体阻滞剂、血管紧张素受体拮抗剂、醛固酮拮抗剂的应用逐年代增多(均P＜0.05);洋地黄类应用则逐渐减少(均P＜0.05).血管紧张素转换酶抑制剂和β受体阻滞剂主要用于冠心病,分别为81.3%(1 698/2 088)和87.8%(768/875).结论 指南的发布对老年CHF患者的药物治疗产生了积极影响,老年CHF患者应及时应用对预后有积极意义的治疗药物.     

抗心衰丸治疗充血性心力衰竭疗效观察

目的：观察中药抗心衰丸治疗充血性心力衰竭（心衰）的疗效。方法：７８例充血性心衰患者随机分为２组。在强心、利尿、扩血管药治疗的基础上，治疗组（４８例）加用自拟纯中药抗心衰丸治疗，每次９ｇ口服，每日３次；对照组（３０例）口服巯甲丙脯酸２５ｍｇ，每日３次。２组均治疗２周（１个疗程）后观察比较疗效。结果：治疗组总有效率（９３．７５％）与对照组（７３．３３％）比较有显著性差异（χ２＝９．０９，Ｐ＜０．０５）；心脏收缩间期、左室射血分数和心率等心功能指标的改善，治疗组均优于对照组（Ｐ＜０．０１和Ｐ＜０．００１）。结论：中药抗心衰丸治疗充血性心衰具有益气温阳、活血利水及改善心脏功能的作用，临床疗效较好     

63例充血性心力衰竭患者的中西医结合治疗探讨

目的 :探讨中西医结合方法治疗充血性心力衰竭 (CHF)的效果。方法 :采用卡托普利联用参麦注射液治疗 CHF6 3例 ,并设单纯应用西医综合治疗的 6 2例为对照组。结果 :治疗组显效率为 74 .6 0 % ,总有效率93.6 5 % ,显著高于对照组 33.87%和 72 .5 8% (P均 <0 .0 1) ;治疗顽固性 CHF显效率 6 4 .0 0 % ,总有效率88.0 0 % ,明显高于对照组 (P<0 .0 1和 P<0 .0 5 ) ;治疗组随访 0 .5～ 1.5年 ,其 CHF复发率分别为 11.11%和34.92 % ,明显低于对照组 32 .2 6 %和 5 9.6 8% (P均 <0 .0 5 )。结论 :卡托普利联用参麦注射液治疗 CHF有显著疗效 ,不但能改善症状 ,还可降低复发率 ,改善预后     

血浆脑钠肽前体N-末端片段对心衰和呼吸困难的诊断价值

目的探讨心力衰竭患者及肺源性呼吸困难患者血浆脑钠肽前体水平检测的临床意义。方法采用罗氏Elecsys2010全自动电化学发光免疫分析仪测测定112例心衰患者、肺源性呼吸困难患者37例及20例正常人血浆NT-proBNP,心衰患者同时测定左室舒张末横径（LVEDD）、左室射血分数（LVEF）。结果心源性呼吸困难组NT-proBNP水平显著高于肺源性呼吸困难组及对照组（P〈0.01）。血浆NT-proBNP水平在心功能Ⅱ级、Ⅲ级、Ⅳ级两两比较（P〈0.01）,LVEF、LVEDD在3组间两两比较（P〈0.05）,均有统计学差异。NT-proBNP水平与LVEDD呈正相关（r=0.78,P〈0.01）,而与LVEF呈负相关（r=-0.69,P〈0.01）。结论血浆NT-proBNP定量测定对呼吸困难的鉴别诊断以及心衰的诊断、预后评估具有很高的临床价值。     

地高辛加倍他乐克治疗充血性心力衰竭伴快速型心房颤动的疗效观察

目的观察地高辛与倍他乐克联用在充血性心力衰竭（Congestive heart failure，CHF）伴快速型心房颤动（Atrial fibrillation，AF）的治疗效果。方法将68例CHF伴快速型AF患者随机分为治疗组（43例）和对照组（25例）。对照组常规使用地高辛、利尿剂、扩血管药物、血管紧张素转换酶抑制剂（angiotensin converting enzyme inhibitor，ACEI）等抗心衰治疗，治疗组在常规治疗基础上加服倍他乐克片6．25—12．5mg一日二次，开始口服，以后每周调整一次剂量，逐渐加至最大耐受量。结果治疗组与对照组比较，心室率明显降低，P〈0．01；治疗组治疗前后左室射血分数（LVEF）明显改善，（P〈0．05）；治疗组与对照组比较，LVEF无明显改善（P〉0．05）。结论在利尿剂、扩血管药物、ACEI等治疗基础上，倍他乐克与地高辛联治疗CHF伴快速型AF取得了较好的疗效。     

Clinical factors associated with hyperkalemia in patients with congestive heart failure

BACKGROUND: Patients with congestive heart failure (CHF) are at risk for hyperkalemia because of coexisting comorbidities and use of multiple medications that impair potassium (K) excretion such as angiotensin converting enzyme (ACE) inhibitors. OBJECTIVE: To identify clinical factors associated with hyperkalemia on initial presentation in patients hospitalized for CHF. DESIGN: A case-control study. SETTING: Two university-affiliated tertiary-care hospitals. SUBJECTS: Using ICD-9 code for CHF, CHF admissions with hyperkalemia on presentation (cases) were identified from a population of 938 non-dialysis-dependent CHF patients. CHF admissions with normokalemia on presentation were used as controls. Hyperkalemia was defined as serum K > or = 5.6 mmol/L, and normokalemia as serum K > or = 3.5 and < or =5.5. METHODS: Data were collected on demographic characteristics, clinical variables, comorbidity and medication use. Factors associated with hyperkalemia on initial presentation were examined. RESULTS: Mean age did not differ between cases [76 years, standard deviation (SD) = 12] and controls (75 years, SD = 12) (P = 0.824). Mean potassium levels for cases and controls were 6.2 mmol/L (range 5.6 to 8.2) and 4.3 mmol/L respectively (P < 0.001). On multivariate analysis, diabetes mellitus [odds ratio (OR) = 2.42, 95% confidence interval (CI) = 1.04-5.59], creatinine clearance <40 mL/min (OR = 8.36, CI = 2.73-25.56), use of spironolactone (OR = 4.18, CI = 1.27-13.79), and use of ACE inhibitors (OR = 2.55, CI = 1.06-6.13) were independently associated with hyperkalemia. CONCLUSIONS: In CHF patients, hyperkalemia on presentation is independently associated with diabetes, creatinine clearance <40 mL/min, use of spironolactone, and use of ACE inhibitors. Recommendations for use of spironolactone and ACE inhibitors in CHF, and the intensity of serum K monitoring need to be clarified to account for patients at higher risk for hyperkalemia.     

Eplerenone in the treatment of chronic heart failure

There has been a recent revival of interest in aldosterone receptor antagonists for the treatment of chronic heart failure. This was largely triggered by fresh insights into the role of aldosterone in a number of key pathophysiological processes, including fibrosis and remodeling, inflammation, and the potentiation of catecholamine effects. The therapeutic efficacy of spironolactone (Aldactone^®, Pfizer) in severe chronic heart failure was established by the Randomized Aldactone Evaluation Study, but hormonal side effects (gynecomastia) associated with the drug posed a problem. More recently, the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study has provided firm support for the use of eplerenone (Inspra?, Pfizer) in heart failure following acute myocardial infarction in addition to neurohormonal blockade with angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers and β-blockers. This strategy can be expected to benefit both mortality and morbidity. Due to the fact that eplerenone is a selective aldosterone receptor antagonist, it does not cause troublesome hormonal side effects. This is an important feature of the drug that is likely to help maintain compliance.     

血清肌钙蛋白Ⅰ对充血性心力衰竭预后的影响

目的 现察慢性充血性心力衰竭患者不同血清肌钙蛋白Ⅰ(cTnI)浓度与1年病死率的关系.方法 入选2008年1～12月在我院心内科住院的诊断为慢性充血性心力衰竭患者225例,根据住院测定的cTnI浓度将患者分为正常组与异常组,异常组再分为轻度增高组、中度增高组、增高组,记录其住院期间及随访1年发生的心脏性事件.结果 225例患者随访1年发生心脏性事件58例(25.8%),异常组病死率依次高于正常组(60.0%>40.8%>24.0%>18.4%,P<0.01).logistic回归分析显示,cTnI为慢性充血性心力衰竭预后不良的相关因素.结论 cTnI增高是随访1年发生心脏性事件的危险因素(P<0.05),是死亡的预测因子.血清cTnI>0.10 μg/L的慢性充血性心力衰竭患者为高危人群.     

充血性心力衰竭时室性心律失常的临床研究

回顾性分析278例充血性心力衰竭患者室性心律失常的临床意义。结果表明,随着心功能的恶化,低血钾水平更易发生室性早搏(P<0.001);扩张型心肌病对低血钾高度敏感,与其它病因组(冠心病、高血压和风心病组)比较有显著的统计学意义(P≤0.01)。建议在治疗充血性心力衰竭时应密切注意电解质的动态平衡,适量的补充钾盐和镁剂可以减少室性心律失常的发生和改善心功能。     

大剂量螺内酯与糖皮质激素联合治疗重症慢性心力衰竭的临床观察

目的探讨顽固性慢性充血性心力衰竭(CHF)时,在常规治疗的基础上加用大剂量螺内酯与泼尼松,观察对水、Na 、K 代谢及心功能的影响。方法54例严重CHF患者(心功能Ⅲ~Ⅳ级,D期),随机分为对照组(27例)与研究组(27例),对照组采用常规治疗(包括螺内酯20 mg/d),研究组在常规治疗基础上,螺内酯60 mg/d,泼尼松40 mg/d连续应用30天。分析治疗后两组患者的一般临床情况、左室射血分数(EF)、血清Na 、K 、肌酐及24小时尿量、尿Na 、尿K 的变化。结果两组患者在治疗后尿量及EF显著增加,但研究组患者用药后尿量较对照组增加更明显,研究组长血清Na 7天及30天均高于对照组,7天Na (138.03±3.97)mmol vs(134.48±5.18)mmol/L,30天Na (137.17±3.57)mmol/L vs(134.00±4.46)mmol/L(均P<0.05);血清K 7天及30天亦均高于对照组,7天K (4.07±0.42)mmol/L vs(3.73±0.33)mmol/L,30天K (4.18±0.49)mmol/L vs(3.79±0.44)mmol/L(均P<0.05);而治疗后研究组血清肌酐7天及30天低于对照组,差异有统计学意义,7天K (92.93±28.65)mmol/L vs(123.19±30.79)mmol/L,30天K (90.07±30.32)mmol/Lvs(115.00±40.61)mmol/L(均P<0.05),尿Na 高于对照组(P<0.05)。结论常规治疗的基础上,适量应用糖皮质激素及大剂量螺内酯可使重症CHF患者在保持K 、Na 平衡及有效血容量的基础上能更明显地减轻过重的水负荷,改善心功能。