脑钠肽显著升高的左室射血分数保存的心衰1例

左心室射血分数（left ventricular ejection fraction,LVEF）保存的心力衰竭（heart failure with preserved ejection fraction,HFpEF）是近年来逐渐受到重视的心力衰竭类型,其发病率逐年升高,致死率和致残率居高不下,目前在发病机制、诊断、治疗方面仍然存在很多不确定之处,为当下心力衰竭领域的研究热点。脑钠肽（brain natriuretic peptide, BNP） 和氨基末端脑钠肽前体（N- terminal pronatriuretic peptide,NT-proBNP）主要由心室肌细胞分泌,在左心室射血分数减低的心力衰竭患者（heart failure with reduced ejection fraction,HFrEF）诊断中有着重要意义。HFpEF 患者中BNP、NT-pro- BNP 升高,但通常都低于HFrEF 心力衰竭患者。我们报道了1 例单纯的HFpEF 患者,心力衰竭症状体征明显,血浆BNP 浓度显著升高,心脏超声证实为重度舒张功能不全,经利尿治疗后好转。     

射血分数保留心力衰竭与2型糖尿病的研究进展

随着人口老龄化及动脉粥样硬化性心血管疾病（arteriosclerotic cardiovascular disease,ASCVD）发病率的提高,心力衰竭的患病率逐年增加。射血分数保留心力衰竭（heart failure preserved ejection fraction,HFpEF）是其中重要的分型,而2型糖尿病（type 2 diabetes mellitus,T2DM）是导致HFpEF的重要病因之一。本综述通过回顾临床指南和临床研究中HFpEF的诊断要点,从人口学特征、心血管病预后和全因死亡率等不同角度,对比大型流行病学研究中HFpEF与射血分数受损心力衰竭（heart failure reduced ejection fraction,HFrEF）的差异;同时,全面描述并分析HFpEF合并T2DM的临床特征、流行病学表现、发病机制及预后表现。     

射血分数中间值心力衰竭的研究进展

心力衰竭是心脏疾病发展的终末阶段。既往研究根据左心室射血分数将心力衰竭分为两种类型：射血分数保留的心力衰竭（HFpEF）和射血分数降低的心力衰竭（HFrEF）。而2016年欧洲心脏病学会（ESC）心力衰竭指南根据左心室射血分数将心力衰竭分为HFrEF、射血分数中间值心力衰竭（HFmrEF）及HFpEF。本文通过对HFrEF、HFmrEF及HFpEF的流行病学、临床特征、病理生理学、预后及治疗等方面进行总结分析,发现HFmrEF可能是HFrEF及HFpEF的中间和过渡型。目前在HFmrEF诊疗策略的多个方面仍有待进一步验证,比如更积极地抗心肌缺血治疗及射血分数动态监测对心肌细胞的保护价值;心血管和非心血管疾病合并症的筛查协助认识HFmrEF病理生理特征的临床价值;心脏磁共振成像检查对 HFmrEF 病理生理学改变的诊断价值;C端成纤维细胞生长因子23（cFGF23）和冠状窦神经肽Y（NPY）水平在HFmrEF中的风险预测和临床转归上的作用价值。更深入地探索与研究会进一步提高临床医生对HFmrEF发病机制与临床特征的理解,利于制定更有效的诊疗策略。     

红细胞分布宽度对不同射血分数的老年急性心力衰竭的预测价值

目的 探讨红细胞分布宽度（RDW）对不同射血分数的老年急性心力衰竭患者分类的诊断价值。方法选取293例老年急性心力衰竭患者,根据左室射血分数（LVEF）不同,分为射血分数减低性心力衰竭（LVEF＜40%）38例（HFrEF组）、射血分数中间性心力衰竭（40%≤LVEF＜50%）74例（HFmrEF组）、射血分数保留性心力衰竭（LVEF≥50%）131例（HFpEF组）,同时选取年龄、性别相匹配的无心力衰竭老年人51例作为对照组,收集患者的临床资料,分别检测血常规、生化指标、氨基末端B型钠尿肽原（NT-proBNP）及超声心动图。分析RDW与不同射血分数的老年急性心力衰竭的相关性及诊断意义。结果HFrEF组、HFmrEF组、HFpEF组中RDW值（1442±217)％、(1330±200)％、(1339±247)％,与对照组RDW值(1210±057)％差异有统计学意义（P<005)。RDW与LVEF呈显著负相关(r=-014,P<005)。RDW与NT-proBNP呈显著正相关 (r=013,P<005)。RDW鉴别HFpEF、HFmrEF的受试者工作特征（ROC）曲线下面积（AUC）为059,RDW取值1405%作为界值的敏感度为338%,特异度为829%;RDW鉴别HFrEF、HFmrEF的AUC为062,RDW取值1445%作为界值的敏感度为50%,特异度为76%。结论RDW在老年急性心力衰竭患者中显著升高,并且在HFpEF组、HFmrEF组、HFrEF组中表达各不相同。RDW＜1405%时,诊断HFpEF可能性大;1405%≤RDW≤1445%时,诊断HFmrEF可能性大;RDW＞1445%时,诊断HFrEF可能性大。RDW结合NT-proBNP可作为快速区分不同射血分数类型老年急性心力衰竭的有效指标。     

维利西呱在心力衰竭中应用进展

心力衰竭的发生、发展涉及血管内皮功能障碍、炎症和氧化应激,这一病理生理过程会影响一氧化氮（nitric oxide,NO）-可溶性鸟苷酸环化酶（soluble guanylate cyclase,sGC）-环磷酸鸟苷-（cyclic guanosine monophosphate,cGMP）信号通路活性。维利西呱可通过刺激sGC提高cGMP水平,cGMP作为第二信使激活蛋白激酶、磷酸二酯酶和下游的信号通路,不仅舒张血管,改善冠状动脉血流量,而且可抑制炎症、心肌纤维化的进展,从而改善心衰患者的预后。目前维利西呱在射血分数降低的心力衰竭（heart failure with reduced ejection fraction,HFrEF）和射血分数保留的心力衰竭（heart failure with preserved ejection fraction,HFpEF）中均进行数个临床研究,其治疗心衰患者的安全性已被广泛证实,但有效性在不同类型的心衰患者有所差别。本文对心衰发生中的NO-sGC-cGMP通路的改变、维利西呱的作用机制及在心衰中的治疗进展进行综述。     

射血分数改善型心力衰竭的临床特点及预后研究

背景左心室射血分数（LVEF）常被用来对心力衰竭（HF）进行分型,但部分HF患者经治疗后射血分数会发生改善,因此产生了射血分数改善型心力衰竭（HFimpEF）这一概念。然而目前HFimpEF相关研究多集中于欧美国家,我国关于此类人群的临床特点及预后分析鲜有报道。目的分析我国HFimpEF患者临床特点、预后及预后的预测因素。方法纳入于2018年6月至2020年5月在河北省人民医院心内科住院治疗的慢性心力衰竭（CHF）患者,从电子病历中获取患者的人口学数据和基线临床信息,根据基线及复查时的LVEF分为射血分数保留（HFpEF）组、射血分数中间值（HFmrEF）组、射血分数降低（HFrEF）组、射血分数改善（HFimpEF）组。自最后一次复查超声心动图开始,通过电子病历、门诊及电话进行随访,终点事件为全因死亡及全因再住院,随访时间截至2021-06-01。采用二元Logistic回归分析探讨LVEF改善的影响因素,采用Kaplan-Meier法绘制全因死亡和全因住院的生存曲线,采用Cox比例风险回归模型分析全因死亡和全因再入院的危险因素。结果最终纳入患者530例,HFpEF组245例（占46.2%）,HFmrEF组55例（占10.4%）,HFrEF组133例（占25.1%）,HFimpEF组97例（占18.3%）。HFimpEF组死亡率低于HFpEF组（P=0.014）和HFrEF组（P<0.001）。HFimpEF组再住院率低于HFpEF组（P=0.011）和HFmrEF组（P=0.001）。基线时收缩压较高〔OR=1.036,95%CI（1.019,1.053）,P<0.001〕、左心室收缩末内径（LVESD）≤37 mm〔OR=0.245,95%CI（0.118,0.507）,P<0.001〕、应用β-受体阻滞剂〔OR=2.868,95%CI（1.304,6.305）,P=0.009〕和醛固酮受体拮抗剂〔OR=2.691,95%CI（1.316,5.503）,P=0.007〕是LVEF改善的影响因素。HFrEF、年龄较大、合并心脏瓣膜病、慢性肾脏病、贫血、未应用β-受体阻滞剂及口服抗凝药是CHF患者全因死亡的独立风险因素（P<0.05）,HFpEF、HFmrEF、慢性肾脏病是CHF患者全因再入院的独立风险因素（P<0.05）。合并心脏瓣膜病〔HR=6.499,95%CI（1.504,28.089）,P=0.012〕、贫血〔HR=4.884,95%CI（1.242,19.208）,P=0.023〕是HFimpEF患者死亡的风险因素。结论HFimpEF是一组独立的HF表型,此类患者临床表现较轻、心室重构程度较小、预后较好,收缩压较高、LVESD≤37 mm、应用β-受体阻滞剂和醛固酮受体拮抗剂是LVEF改善的独立预测因子,而合并心脏瓣膜疾病、贫血是HFimpEF患者全因死亡的风险因素。     

不同射血分数心力衰竭患者的客观睡眠特征及睡眠呼吸暂停的危险因素

目的 研究不同射血分数心力衰竭患者的客观睡眠特征并探讨影响睡眠呼吸暂停的相关独立危险因素。方法 本研究共纳入2019年4月~2020年10月期间在新乡医学院第一附属医院心血管内科住院治疗的慢性心力衰竭患者共107例。根据心脏 超声左心室射血分数将其分为射血分数减少的心力衰竭患者（HFrEF组,LVEF<40%,35例）、射血分数中间值的心力衰竭患者（HFmrEF组,40%≤LVEF<50%,21例）及射血分数保留的心力衰竭患者（HFpEF组,LVEF≥50%,51例）。收集3组患者入院期间的基线人口学资料,并进行夜间多导睡眠监测,评估其客观睡眠特征,采用Spearman相关分析及多分类Logistic回归模型分析影响心衰患者客观睡眠特征的风险因素。结果 HFpEF组患者的非快速眼动睡眠1期占比及呼吸暂停低通气指数（AHI）水平显著低于HFrEF组患者,且较少表现为中枢性睡眠呼吸暂停（CSA）（P<0.05）。而HFmrEF组患者与其他两组的基线资料及睡眠结构参数方面相比无统计学意义（P>0.05）。Spearman相关分析表明,性别、利尿剂使用、左室射血分数（LVEF）、NT-proBNP及总胆固醇水平与心衰患者的AHI水平及呼吸事件相关（P<0.05）。多分类Logistic回归分析显示年龄、饮酒及LVEF是心衰患者睡眠呼吸暂停发生及严重程度的独立危险因素。结论 3组心衰患者均存在客观睡眠结构的紊乱,以睡眠呼吸暂停为主,但与HFrEF组患者相比,HFpEF组患者发生睡眠呼吸暂停包含CSA的比例较低。高龄、饮酒及低LVEF是心衰患者睡眠呼吸暂停发生及严重程度的独立危险因素。     

射血分数保留的心力衰竭与骨质疏松症的相关性

目的 探讨射血分数保留的心力衰竭(HFpEF)与骨质疏松(OP)的相关性.方法 选取2018年11月～2019年12月贵州医科大学附属医院心血管内科收治的211例心力衰竭(HF)患者为研究对象,分为HFpEF组(n=108),射血分数中间值的心力衰竭(HFmrEF)组(n=52)及射血分数降低的心力衰竭(HFrEF组)...     

射血分数保留心力衰竭患者右心室功能障碍的研究进展

在射血分数减低心力衰竭（HFrEF）中,右心室功能障碍（right ventricular dysfunction,RVD）已被广泛证实和认识,但在射血分数保留心力衰竭（heart failure with preserved ejection fraction,HFpEF）中,RVD还未被广泛关注和描述。近年来,研究表明RVD在HFpEF中所占比例较高,而且与心力衰竭不良预后独立相关。此外,肺动脉高压及心房颤动、2型糖尿病、高血压、冠心病等多个合并症是RVD的致病或促进因素,也与心力衰竭临床预后不良相关。同时,认识右心与左心之间的相互作用关系对RVD的进一步理解至关重要。本文就HFpEF患者,RVD的患病率、RVD与多个合并症及与左心之间的关系等方面进行综述,以期通过对HFpEF患者右心室功能进行评估为临床干预和治疗决策提供指导。     

可溶性ST2和NTproBNP对射血分数中间型心力衰竭患者的预后价值

目的:探讨射血分数中间型心力衰竭(heart failure with mid-range ejection fraction,HFmrEF)患者血浆可溶性生长刺激表达因子(sST2)以及N末端B型脑钠肽前体(NTproBNP)水平与心血管事件发生的相关性.方法:HFmrEF患者126例,根据随访结果分为事件组34例和...     

Value of D-Dimers in patients with acute aortic dissection

Objective: To evaluatel the value of D-dimers in patients with acute aortic dissection (AAD). Methods: This study consisted of 16 patients with AAD and 27 non-AAD patients. Serum D-dimets were measured by Sta-Liatest D-DI immunoturbidimetric assay. Results: D-dimer level was higher (P ＜ 0.001) in patients with AAD(7.91 ± 5.52 μg/ml) than that in non- AAD group(1.57±1.24 μg/ml). D-dimer was positive (＞0.4 μg/ml) in all patients with AAD and in 10 control group patients (37%). Among patients with acute AAD, D-dimers tended to be higher in Stanford A than in Stanford B (8.67 ± 4.31 μg/ml vs. 3.24±1.27 μg/ml, P ＜0.01). D-dimer values tended to be higher in more extended disease(3.84 ± 1.65 μg/ml, 8.57 ± 3.58 μg/ml and 11.87 ± 5.69 μg/ml in thoracic aorta, thoracic and abdominal aorta, thoracic and abdominal aorta and iliacal arteries, respectively, P ＜ 0.05 for both 8.57 ± 3.58 and 11.87 ± 5.69 vs. 3.84 ± 1.65 ). Including the control group into the analysis, we found a sensitivity of 100%, a negative predictive value of 100%, and a specificity of 66% and a positive predictive value of 64% for D-dimer in diagnosis of AAD in our patients with suspected AAD. Conclusion: D-dimer was elevated in patients with AAD. A negative D-dimer test result could be useful in excluding AAD.     

Research of combined liver-kidney transplantation model in rats

Objective： To set up a simple and reliable rat model of combined liver-kidney transplantation. Methods： SD rats served as both donors and recipients. 4℃ sodium lactate Ringer＇s was infused from portal veins to donated livers,and from abdominal aorta to donated kidneys, respectively. Anastomosis of the portal vein and the inferior vena cava （IVC） inferior to the right kidney between the graft and the recipient was performed by a double cuff method, then the superior hepatic vena cava with suture. A patch of donated renal artery was anastomosed to the recipient abdominal aorta. The urethra and bile duct were reconstructed with a simple inside bracket. Results： Among 65 cases of combined liver-kidney transplantation, the success rate in the late 40 cases was 77.5%. The function of the grafted liver and kidney remained normal. Conclusion： This rat model of combined liver-kidney transplantation can be established in common laboratory conditions with high success rate and meet the needs of renal transplantation experiment.     

BLOOD PRESSURE CHANGE WITH AGE IN SALT-SENSITIVE TEENAGERS

Objective To observe blood pressure change with age in salt-sensitive teenagers whose salt sensitivity were determined by repeated testing.Methods Salt sensitivity was determined through intravenous infusion of normal saline combined with volume-depletion by oral diuretic furosemide in 55 teenagers. After five years, salt sensitivity was re-examined and subject blood pressure was followed up. Blood pressure changes in salt-sensitive teenagers were compared to that of non-salt sensitive teenagers over five years.Results After 5 years, the repetition rate of salt sensitivity determined by intravenous saline loading is 92.7%. In teenagers with salt sensitivity on the baseline, both the systolic blood pressure increments and increment rates were much higher than non-salt sensitive teenagers (12.7±12.1 mmHg vs. 2.8±5.2 mmHg, P＜ 0.01; 12.2%± 12.0% vs. 2.5% ±4.4%, P＜ 0.001,respectively). There was a similar trend for diastolic blood pressure (8.4 ± 6.4 mmHg vs. 3.7 ± 6.4 mmHg, P = 0.052; 13.2% ±10.6 % vs. 6.8%± 10.1%, P = 0.053, respectively).Conclusions Salt sensitivity determined by intravenous saline loading showed good reproducibility. Blood pressure increments with age were much higher in salt-sensitive teenagers than non-salt sensitive teenagers, especially in terms of systolic blood pressure.     

安心颗粒对急诊经皮冠状动脉介入术后生活质量影响的研究

目的：评价使用安心颗粒对急诊经皮冠状动脉介入术（PPCI）术后生活质量的影响.方法：将160例接受PPCI的急性ST段抬高型心肌梗死患者随机分为安心颗粒组（术前顿服安心颗粒8.8g,术后安心颗粒4.4 g/次,每日2次）和对照组（仅接受基础药物治疗）.所有患者均服用阿司匹林、氯吡格雷和阿托伐他汀.分别在入院时、出院前1d、出院后180 d时,应用心肌梗死多维度量表（MIDAS）、中文版SF-36评价量表对患者生活质量评分.并观察术后30 d以内的出血并发症、血小板减少症发生情况.结果：入院时和出院前1d,两组患者的心肌梗死MIDAS、SF-36量表评分比较无差异（P＞0.05）;出院后180 d时,与对照组比较,安心颗粒组MIDAS、SF-36评分明显减低（P＜0.05）;组内与入院时比较,两组出院前1d、出院后180 d时,MIDAS、SF-36评分均降低（P＜0.05）.两组患者在随访期间均无大量出血、少量出血、重度和极重度血小板减少症发生,安心颗粒组有4例、对照组有7例发生不明显出血（P＞0.05）.两组发生轻度血小板减少症的患者数比较无差异（P＞0.05）.结论：PPCI使用安心颗粒,能改善急性ST段抬高型心肌梗死患者的生活质量,且不增加出血风险.     

The comparative studies of the influences of Urapidil and Nicardipine on sino-atrial node function, atrio-ventricular node function and hemodynamics

Objective:To investigate the influences of urapidil and nicardipine on rabbit sinus function,atrio-ventricular node function and hemodynamics.Methods:Thirty-two Angora's rabbits were selected and randomly divided into four groups.U1 group:urapidil 0.25 mg/kg;U2 group:urapidil 0.5 mg/kg;N1 group:nicardipine 10 μg/kg;N2 group:nicardipine 20 μg/kg.All these medicine were administrated within 30 seconds.Measurements were taken before and after the administration of urapidil or nicardipine for the following data:mean blood pressure(MAP),heart rate(HR),sino-atrial conduction time(SACT),maximal sinoatrial recovery time(SNRTmax)corrected sinus node recovery time(CSNRT),index of sinus node recovery time(SNRTI),Wenckebach A-V conduction frequency (WB),and P-R interval.Results:Significant MAP and HR changes were identified in all of the four groups before and after administration of both urapidil and nicardipine.No significant changes could be found in the rest of the parameters.Intergroup analysis showed that SACT and CSNRT of N1 and N2 groups were shorter than those of the U2 group(P＜0.01);the MAP decreased(P＜0.01)and the HR increased drastically(P＜0.01).Conclusions:Neither urapidil(0.25 mg/kg,0.5 mg/kg)nor nicardipine(10μg/kg,20μg/kg)has any significant influence on rabbit sinus function or rabbit atrio-ventricular node function.Nicardipine could be a better choice than urapidil for parafunctional sinus node patients.     

Expression of OPGmRNA and ODFmRNA in the patients of hip fracture due to osteoporosis

Objective：To investigate the gene expression of osteoprotegerin（OPG） and osteoclast differentiation factor（ODF） in the bone tissue of patients with hip fracture due to osteoporosis. Methods：OPGmRNA and ODFmRNA in the bone tissue in 50 cases of osteoporosis sufferers（over 50 years old） with hip fracture（Observer Group） and 30 cases of hip facture sufferers with no osteoporosis（Control group） were analyzed with the Semi-Quantitative RT-PCR method. Results：The mRNA expressed of ODF, OPG were both high in the patients with hip fracture. In the control group, the expression of OPG mRNA was observed, while the expression of ODF mRNA was very slight. Conclusion：Aged patients contained all signals including OPG, ODF that are essential for inducing osteoclastogenesis and promoting bone resorption.     

The clinicopathological and immuohistochemical analysis of solid-pseudopapillary tumor of the pancreas： report of 9 cases

Objective：To investigate the clinical features, pathological characteristics and immunophenotype of solid-pseudopapillary tumor of the pancreas（SPTP）. Methods：Nine surgically treated cases of SPTP were retrospectively reviewed. Hematoxylin and Eosin（HE） staining and immunohistochemical staining were used to analyze all cases, and the general clinical data was collected. Results：Six patients were asymptomatic except for a palpable mass. Two patients complained of vague-epigastric pain. One patient appeared jaundice. The tumor was encapsulated and solid tissues alternately with cystic tissues. Histologically, the histological structure of solid portion was pseudopapillary with a fibrovascular core. Tumor cells were uniform and medium-sized which were arranged in sheets ets or nests or pseudopapillary patterns. Immunohistochemical studies demonstrated that SPTP proved positive in vimentin（9/9 cases）, AAT（9/9 cases）, NSE（9/9 cases）, ACT（7/9 cases）, CK20（2/9 cases）, CgA（1/9 cases）, S-100（3/gcases）, PR（4/gcases）, Syn（3/9 cases） and CD56（5/9cases）, negative in CEA and ER. Conclusion：SPTP is a tumor predominantly occurring in young women frequently without special symptoms. This tumor has various characteristical histological patterns with different immunophenotype.     

Dynamic Changes in Serum Estradiol and Progesterone levels in Patients of Premenstrual Syndrome with Adverse Flow of Liver-qi

Objective:To probe into the influence of changes of ovarian hormones on the pathogenesis of the specific sub-type premenstrual syndrome(PMS)and reveal partial microcosmic mechanisms of adverse flow of liver-qi.Methods:Estradiol(E2)and progesterone(P)levels in serum were determined at different phases of menstrual cycle by radioimmunoassay.Results:In the group of PMS with adverse flow of liver-qi.the secretive peak value Of E2 and P at the follicular phase significantly decreased,and the secretive peak value at the luteal phase did not come into being.Conclusions:Low E2 and P secretive peak at the follicular phase and absence of secretive peak at the luteal phase is one of the microcosmic mechanisms of PMS with adverse flow of liver-qi.One of the pathophysiologic mechanisms of specific sub-type PMS is probably the continuous low level of E2and P.     

Real-time Three-dimensional Echocardiography in Assessment of Left Ventricular and Right Ventricular Volumes

Real-time three-dimensional echocardiography (RT3DE)is a new ultrasound technique that enables dynamic threedimensional visualization and quantification of the heart in real time. Investigation of feasibility and methodology of RT3DE in determining left ventricular (LV) and right ventricular (RV) volumes, RT3DE was performed in 35 normal adults using Philips SONOS 7500 system with a 2-4 MHz matrix array transducer. The 60°×60° "pyramid" volume database was obtained and analyzed on a TomTec echo workstation. Both LV and RV volumes were calculated with four 3DE methods (i.e. apical 2, 4, 8, and 16-plane) through manually tracing ventricular endocardial borders in end diastole and end systole. Stroke volumes were then calculated. LV volume was also measured by 2DE Simpson's rule using GE VIVID 7 ultrasound machine.     

SCREENING FOR A 21-CHROMOSOME ABNORMALITY IN PREIMPLANTED EMBRYOS OF ELDERLY WOMEN

Increasing maternal age is the only etiological factor unequivocally linked to Down's syndrome in humans. The occurrence rate of newborns with Down's syndrome is about 1/220 in women over 35 years old. However, the occurrence rate in embryos fertilized in vitro, of the elder woman is unclear. Using FISH we screened the number of chromosome 21 in preimplanted embryos of 5 elderly women (average age, 38.4 years) to study the feasibility and necessity of screening trisomy 21 in embryos in patients over 35 years old at the in vitro fertilization (IVF) center.