慢性心力衰竭治疗质量指标体系的建立

目的 建立一套适合中国慢性心力衰竭治疗质量评价的指标体系,为下一步慢性心衰治疗质量评价提供量化工具.方法 检索PubMed、EMBASE等数据库,同时参考〈慢性心力衰竭诊断治疗指南〉筛选出候选指标.选择来自北京、上海、哈尔滨的15名专家组成专家组.应用德尔菲法咨询专家意见,根据专家打分的均数和选择率确定最终的指标体系.纳入标准为：均数≥3.5,选择率≥50.0%.结果 发放专家咨询表15份,专家积极系数为100%,每份均符合要求.经过三轮Delphi,由最初52个候选指标筛选出22个指标,构成慢性心衰治疗质量评价的指标体系,包括2个结构指标,18个过程指标（15个院内指标,3个出院指标）,2个结局指标.指标体系中,均数〉4分的有12个,选择率≥80.0%的9个.利尿剂的均数和选择率最大,分别为4.7和100%;院内感染率≤7%的均数和选择率最小,分别为3.5和53.3%.指标均数的范围为3.5~4.7,选择率的范围为53.3%~100.0%.结论 本研究建立的慢性心力衰竭治疗质量评价指标体系与国外相关组织建立的稍有不同,符合我国国情,能全面客观的评价慢性心衰的治疗质量,发现其中的不足,以促进我国慢性心衰治疗质量的改善.     

Whole-body protein metabolism in chronic heart failure: relationship to anabolic and catabolic hormones

BACKGROUND: Patients with chronic heart failure frequently experience profound wasting during the course of the disease, a condition termed cardiac cachexia. Although protein is the primary structural and functional component of most tissues, few studies have examined the effect of heart failure on protein metabolism. Moreover, no study has assessed the relationship of protein turnover to hormonal alterations thought to promote cachexia. Thus, our goal was to determine if whole-body protein metabolism is altered in heart failure patients and to assess the relationship of protein kinetics to circulating levels of anabolic and catabolic hormones. METHODS: We measured whole-body protein metabolism using 13C-leucine, body composition, and circulating anabolic and catabolic hormone levels in 10 patients with chronic heart failure and 11 elderly controls. RESULTS: No differences in leucine rate of appearance, oxidation, or nonoxidative disposal were noted between heart failure patients and controls. However, in a subgroup of patients characterized by increased resting energy expenditure for their metabolic body size (n = 4; > or = 20% above that predicted from fat-free mass), leucine rate of appearance (mean +/- SE; 146 +/- 6 micromol/min), an index of protein breakdown, tended to be higher compared with patients with normal resting energy expenditure (n = 5; 120 +/- 8 micromol/min) and controls (127 +/- 4 micromol/min; p = .06). Alterations in anabolic/catabolic hormone balance did not explain increased protein breakdown in this subgroup, and no correlations were found between hormone levels and protein breakdown in the heart failure group as a whole. In contrast, increased circulating interleukin-6 soluble receptor (r = 0.829; p < .01) and reduced insulin-like growth factor-I (r =-.751; p < .05) levels were related to greater rates of leucine oxidation in heart failure patients. CONCLUSION: Our results demonstrate that, although increased protein turnover is not a generalized feature of heart failure, there is a subgroup of patients characterized by resting hypermetabolism and increased protein breakdown. Moreover, hormonal alterations related to the heart failure syndrome were related to increased protein oxidation.     

Older people with heart failure and general practitioners: temporal reference frameworks and implications for practice

The aim of the study was to identify the time experiences of older patients and general practitioners (GPs). Secondary analysis of qualitative data collected from two longitudinal studies, one in the United Kingdom (UK) and the other in New Zealand (NZ), was carried out. The UK study involved interviews with 44 older people with heart failure and nine focus group discussions with primary health professionals during 2004-2005. The NZ study involved 79 interviews with 25 older people with heart failure and 30 telephone interviews with GPs during 2008-2009. Temporal reference frameworks function as background expectations and influence how patients and GPs experienced time and act as time controls. The key themes identified were: clock time was evident in how it structured the consultations; both patients and GPs valued needing time and for some GPs this involved creating space for emotional time. There were also tensions between needing time and wasting time; being known over time was important to both patients and GPs. For older people with heart failure improving their quality of care is essential and time is integral to this, not only the clock time and length of consultations. Identifying temporal reference frameworks provides an understanding that there are multiple times and exposes the influence of these in the lives of both the older people and GPs.     

探讨美托洛尔治疗老年性慢性心力衰竭

目的研究美托洛尔在老年性慢性心力衰竭治疗中的剂量及耐受性。方法对NYHA分级心功能Ⅱ～Ⅳ级129例老年患者在常规心衰治疗基础上加用美托洛尔，从极小剂量开始，逐渐增加剂量，目标分别为：①心率下降到55～60次／min（不低于50次／min）；②稍加剂量心功能下降Ⅰ级以上；③收缩压不低于90mmHg（ImmHg=0、133kPa）。结果美托洛尔平均维持量为（80．7±34．1，mg／d）（6．25～200mg／d）。其中88例（66．O％）达心率目标，44例（34．2％）达心衰目标，本研究血压无显著变化。随访患者多因不适当减量或停用美托洛尔。结论在治疗期间内，心力衰竭（NYHAⅡ级～Ⅳ级）患者对美托洛尔耐受性较好。     

慢性心力衰竭患者医院感染相关因素的病例对照研究

目的 探讨慢性心力衰竭患者合并医院感染的影响因素及预防对策.方法 调查950例慢性心力衰竭患者,比较合并医院感染组与无医院感染组在年龄、性别、侵入性诊疗操作、心功能分级等指标差异进行统计学分析.结果 950例患者中发生医院感染90例占9.47％,医院感染组年龄平均为(61.45±13.78)岁、侵入性诊疗操作占35.6％、心功能Ⅲ～Ⅳ级占47.8％、应用抑酸制剂占34.4％、预防应用抗菌药物占40.0％、住院时间(21.84±8.25)d,高于无医院感染组的(54.24±11.45)岁、11.3％、10.7％、9.8％、29.5％、(16.45±3.56)d,差异均有统计学意义(P＜0.05),是医院感染的相关因素.结论 慢性心力衰竭患者医院感染率较高,影响因素较多,应针对上述因素实施相应的对策,将高危人群纳入重点监测范围,避免不必要侵入性操作,合理使用抗菌药物,及时有效地纠正基础疾病.     

血清降钙素原对慢性心力衰竭急性发作患者的临床评估价值

目的 评估血清降钙素原（PCT）升高与尚无明确细菌感染证据的慢性心力衰竭急性发作患者临床基础特征及预后的关系。方法 对2015年2月-2017年12月于邯郸市中心医院住院的慢性心力衰竭急性发作患者进行前瞻性研究。根据PCT水平分为PCT升高组及PCT正常组,对比两组患者入院后的临床基础特征,应用logistic回归分析PCT升高的原因;比较入院后规范治疗48 h后的效果、30 d内全因死亡/再住院发生率。结果 共纳入593例慢性心力衰竭急性发作患者,其中PCT正常组521例,PCT升高组72例。logistic回归分析表明,心率增快、肺水肿、白细胞计数、血尿素氮（BUN）与PCT升高呈正相关,白细胞计数相关性最大[OR=2.19（95%CI：1.76~2.73）,P<0.001];而血红蛋白及血清蛋白与PCT的升高呈负相关。标准化治疗48 h后,PCT正常组有67.9%的患者症状明显改善,高于PCT升高组的55.6%,差异有统计学意义（P=0.037）。PCT升高组患者30 d全因死亡/再住院率（30.6%）高于PCT正常组（18.8%）,差异有统计学意义（P=0.02）。结论 尽管心力衰竭程度一致,但血清PCT水平升高的慢性心力衰竭急性发作患者治疗效果差、预后不佳,提示可能存在未诊断或者潜在的细菌感染。     

慢性心力衰竭患者血浆硫化氢水平的变化及临床意义

目的 检测慢性心力衰竭(CHF)患者血浆硫化氢水平变化情况,并探讨其相关临床意义.方法 选择118例CHF患者,按照NYHA心功能分级标准分级:Ⅱ级34例、Ⅲ级54例、Ⅳ级30例,按随机数字表法分为常规治疗组和硝普钠治疗组,每组59例.另选择30例健康体检者作为对照组.治疗前后采用去蛋白法测定血浆硫化氢水平.结果 CHF患者血浆硫化氢水平为(32.45±3.86) μ mol/L,低于健康体检者的(54.26±5.63)μmol/L,差异有统计学意义(P＜0.05).心功能Ⅱ、Ⅲ、Ⅳ级CHF患者血浆硫化氢水平分别为(43.26±4.73)、(31.87±4.12)、(23.66±3.54)μ mol/L,各分级间比较差异有统计学意义(P＜0.05).常规治疗组和硝普钠治疗组治疗前血浆硫化氢水平分别为(31.66±3.75)、(33.04±4.02)μmol/L,两组比较差异无统计学意义(P＞0.05);常规治疗组和硝普钠治疗组治疗后血浆硫化氢水平分别为(36.83±4.32)、(44.54±4.68)μmol/L,两组比较差异有统计学意义(P＜0.05);两组治疗后血浆硫化氢水平均较本组治疗前显著升高,差异有统计学意义(P＜0.05).常规治疗组显效11例,有效14例,总有效率为42.4％(25/59);硝普钠治疗组显效22例,有效18例,总有效率为67.8％(40/59),两组总有效率比较差异有统计学意义(P＜0.05).结论 血浆硫化氢水平的异常可能参与了CHF的发生、发展过程,并与CHF病情的严重程度密切相关,升高血浆硫化氢水平可以显著改善CHF患者的临床预后.     

慢性心力衰竭患者心率震荡现象的临床意义

目的 探讨慢性心力衰竭(CHF)患者窦性心率震荡(HBT)的临床意义.方法 30例CHF患者(CHF组)及28例非器质性心脏病患者(对照组)行24 h动态心电图检查.根据NYHA心功能分级,将CHF组分为轻度CHF组(Ⅰ～Ⅱ级)16例及重度CHF组(Ⅲ～Ⅳ级)14例;CHF组中缺血性心脏病18例及非缺血性心脏病12例.分析比较各组HRT的初始值(TO)及震荡斜率(TS)两项指标.结果 CHF组TO值[(0.43±0.83)%]较对照组[(-1.49±1.00)%]明显增高(P＜0.05),CHF组TS值[(2.67±0.66)ms/RRI]较对照组[(8.52±2.09)ms/RRI]明显降低(P＜0.05).重度CHF组TO值[(0.79±0.67)%]较轻度CHF组[(0.12±0.86)%]明显增高(P=0.026),重度CHF组TS值[(2.88±0.79)ms/RRI]较轻度CHF组[(2.40±0.35)ms/RRI]明显增高(P=0.045).缺血性心脏病与非缺血性心脏病患者TO及TS值比较差异无统计学意义(P＞0.05).CHF组中TO及TS值同时异常(TO≥0,TS≤2.5 ms/RRI)占53.3%(16/30),而TO或TS值仅1项异常占40.0%(12/30),CHF组HRT检测异常率为93.3%(28/30).结论 CHF患者HRT现象明显减弱,HRT可作为CHF严重程度的有效观测指标,对CHF患者预后的预测起指导作用.     

Improvement of primary care for patients with chronic heart failure: a pilot study

Background  

Many patients with chronic heart failure (CHF) receive treatment in primary care, but data have shown that the quality of care for these patients needs to be improved. We aimed to evaluate the impact and feasibility of a programme for improving primary care for patients with CHF.     

Medical nutrition therapy in chronic kidney failure: integrating clinical practice guidelines

This review updates earlier published recommendations and integrates current clinical practice guidelines for nutritional care in chronic kidney disease as recommended by the National Kidney Foundation Kidney Dialysis Outcome Quality Initiative (K/DOQI). The scope covers chronic kidney disease in adults prior to kidney failure (Stages 1–4), chronic kidney failure with hemodialysis or peritoneal dialysis replacement therapy (Stage 5), and management after kidney transplantation. Multiple diet parameters are necessary to provide optimal nutritional health, including monitoring of calories, protein, sodium, fluid, potassium, calcium, and phosphorus, as well as other individualized nutrients. Emphasis is placed on continuity of care within changing kidney function and treatment modality status. The rising incidence of chronic kidney disease will increase the probability of the non-renal specialist dietetics professional delivering care to this patient population.     

美托洛尔对慢性心力衰竭伴慢性心房颤动患者的影响

目的探讨地高辛联用美托洛尔对慢性心力衰竭(CHF)伴慢性心房颤动(AF)患者的疗效。方法选择CHF伴慢性AF 106例,随机分为美托洛尔组(美托洛尔加常规治疗52例)和常规组(54例),2组均常规使用地高辛、利尿剂、血管紧张素转换酶抑制剂(ACEI)、抗凝剂,观察2组1月疗效并随访1年期间因心脏原因的再住院率、死亡率。结果治疗1月后,美托洛尔组显著降低静息心室率(HR)和运动前后即刻心室率差值(HD)及增加6m in步行距离(S),显著改善心功能NYHA分级,增加左室射血分数(LVEF),显著改善生活质量(QOL);常规组显著降低HR,但降低HD不明显,增加S,改善心功能NYHA分级,LVEF增加,也能改善QOL。随访1年,美托洛尔组和常规组相比,因心力衰竭再住院率较低(19.2%vs 42.6%,P<0.05)死亡率亦较低(11.5%vs 20.4%,P<0.05),两组存活的病例,常规组NYHA分级、S、LVESV、LVEDV、LVEF、QOL评分与美托洛尔组相比,明显恶化(P<0.05)。结论在常规使用利尿剂、ACEI、抗凝剂治疗的基础上,地高辛联用美托洛尔其1月疗效与单用地高辛相近,但1年后疗效却明显优于单用地高辛。     

心房颤动对慢性心力衰竭患者的预后影响

目的 探讨心房颤动(房颤)对慢性心力衰竭(慢性心衰)患者预后的影响.方法 选择2005年1月至2006年12月二所三甲医院心内科收治的461例慢性心衰患者,根据住院期间心脏基础节律分为窦性节律组(窦律组)和房颤组,进行为期3年的电话随访;终点事件包括全因死亡、心衰加重再住院.结果 房颤组中高龄、女性及左室射血分数正常患者占有较高比例;与窦律组比较房颤组的病因主要为瓣膜性疾病,而窦律组则为冠心病;随访结果显示房颤组的终点事件发生率明显高于窦律组(P ＜0.01);Cox回归分析对其它因素校正后发现,房颤(RR =1.311,95％ CI:1.002-1.715,P＜0.05)、年龄(RR=1.014,95％ CI:1.004-1.024,P＜0.01)是影响慢性心衰患者3年预后的主要因素.结论 房颤及高龄是慢性心衰患者远期不良预后加重的主要因素.     

老年慢性心力衰竭合并医院获得性肺炎的临床特点观察

目的 探讨老年慢性心力衰竭患者合并医院获得性肺炎的临床特点.方法 回顾性分析1100例老年慢性心力衰竭患者的临床资料.结果 1100例患者合并医院获得性肺炎130例,发生率11.82％,临床表现咳嗽、咳痰70例,单纯发热20例,无发热及呼吸系统症状者40例;白细胞计数≥10×109/L和(或)中性粒细胞比例＞0.70％的75例;痰培养分离出病原菌98株,铜绿假单胞菌检出率最高,占30.61％,其次肺炎克雷伯菌,占22.45％,真菌占10.21％;年龄大、住院时间长、心功能差、存在侵入性操作、预防应用抗菌药物等均是医院感染的危险因素;医院获得性肺炎组死亡率为10.77％,高于无医院获得性肺炎组的2.06％.结论 老年慢性心力衰竭医院获得性肺炎发生率高,感染症状部分不典型,造成病情加重,因此胸部X线检查应作为检查常规;规范性使用抗菌药物、侵入性操作、缩短住院时间以减少或避免医院获得性肺炎的发生.     

美托洛尔治疗风湿性心脏病慢性心力衰竭效果研究

目的 探讨美托洛尔对风湿性心脏病慢性心力衰竭患者血压水平及心功能的影响.方法 选取本院2016年3月-2018年4月收治的70例风湿性心脏病慢性心力衰竭患者,随机分为对照组与观察组,各35例.对照组采用常规治疗,在对照组基础上,观察组予以美托洛尔治疗.比较两组临床疗效、血压水平、心功能.结果 对照组治疗总效率为65.7...     

生脉注射液治疗老年慢性心力衰竭疗效的观察

目的 通过观察生脉注射液对老年慢性心力衰竭的症状及心功能的影响,评价其临床应用的疗效.方法 我院收治的慢性心力衰竭患者77例,随机分为生脉注射液治疗组40例和常规治疗组37例.生脉注射液治疗组在常规治疗心力衰竭的基础上,静脉滴注生脉注射液40ml,1次/d,14d为一疗程.治疗前后观察心排血量(CO)、心脏指数(CI)、左室射血分数(LVEF)、血压、静息心率的变化及临床症状的改善.结果 生脉注射液治疗组总有效率87.50%,常规治疗组总有效率64.86%,生脉注射液治疗组CO、CI及LVEF均较治疗前显著改善,心功能改善情况优于常规治疗组(P＜0.05).结论 在常规治疗的基础上加用生脉注射液,可以更好的改善慢性心力衰竭患者的临床症状及左心室收缩功能,提高治疗效果.     

生脉注射液治疗老年慢性心力衰竭疗效的观察

目的通过观察生脉注射液对老年慢性心力衰竭的症状及心功能的影响,评价其临床应用的疗效。方法我院收治的慢性心力衰竭患者77例,随机分为生脉注射液治疗组40例和常规治疗组37例。生脉注射液治疗组在常规治疗心力衰竭的基础上,静脉滴注生脉注射液40ml,1次/d,14d为一疗程。治疗前后观察心排血量(CO)、心脏指数(CI)、左室射血分数(LVEF)、血压、静息心率的变化及临床症状的改善。结果生脉注射液治疗组总有效率87.50%,常规治疗组总有效率64.86%,生脉注射液治疗组CO、CI及LVEF均较治疗前显著改善,心功能改善情况优于常规治疗组(P<0.05)。结论在常规治疗的基础上加用生脉注射液,可以更好的改善慢性心力衰竭患者的临床症状及左心室收缩功能,提高治疗效果。     

Use of echocardiography among patients with heart failure: practice variations in Hungarian hospitals.

OBJECTIVE: To evaluate some factors, such as demographic factors, disease severity, dissemination of practice guidelines, and hospitals providing medical care, influencing the use of echocardiography among patients with congestive heart failure. DESIGN: A 'before-after' controlled epidemiological study based on hospital documentation. SETTING AND PARTICIPANTS: A total of 1222 admitted patients with a diagnosis of chronic heart failure from six voluntarily participating hospitals representing each level of in-patient care in Hungary. INTERVENTIONS: Implementation of clinical practice guidelines about heart failure developed by the US Agency for Health Care Policy and Research. RESULTS: The echocardiography was performed in slightly more than 50% of all cases in the total. The use of echocardiography was different according to age, sex, and hospitals, but no significant difference was found in disease severity and between the two periods of time (before and after the dissemination of the guidelines). CONCLUSIONS: This study reveals the existing differences in the use of echocardiography and the lack of essential changes after the dissemination of the guidelines. The distribution and implementation of guidelines needs further investigation.     

稳心颗粒治疗慢性心力衰竭的临床效果观察

慢性心力衰竭(CHF)是常见的心血管疾病之一.我们在常规西医治疗的基础上,加服中药稳心颗粒治疗CHF35例,取得了一定疗效.