急性失代偿心力衰竭高龄老年患者发生肾功能恶化及对近期预后的影响

目的 探讨急性失代偿心力衰竭（acute decompensated heart failure,ADHF）高龄老年患者肾功能恶化（worsening renal function,WRF）发病情况及对近期预后的影响.方法 连续入选64例ADHF高龄老年患者,以ADHF发病初期是否发生WRF分为WRF组（n=24）和非WRF（n=40）,采集两组患者病史及尿素氮、肌酐、肾小球滤过率（eGFR）、左室射血分数（LVEF）、血浆NT-proBNP等指标和利尿剂等药物使用数据,随访两组患者6个月时全因死亡率.结果 ADHF高龄老年患者WRF的发生率为37.5%.WRF组前7天应用襻利尿剂（以呋噻米剂量表示）总量显著高于非WRF组患者（P＜0.05）.随访6个月时,WRF组患者中位肌酐水平较基线时水平显著升高,差异有统计学意义（P均＜0.05）;而非WRF组患者肌酐水平与基线时水平比较,差异无统计学意义（P＞0.05）.平均随访6个月时,WRF组死亡率为62.5%,显著高于非WRF组患者的死亡率（35.0%,P＜0.05）.Kaplan-Meier生存分析显示,随访期间非WRF组患者生存率显著高于WRF组患者（P＜0.01）.结论 ADHF高龄老年患者在发病初期WRF发生率高,增加利尿剂剂量可能导致WRF发生风险增加,WRF导致ADHF患者的死亡率增加.     

云南思茅地区10年间心力衰竭住院病死率比较分析

目的 :探讨云南思茅地区近 10年来心力衰竭 (心衰 )的治疗概况。方法 :对我院 1987～ 1989年 136例和 1997～ 1999年 2 0 0例心衰患者的资料作比较 ,以了解云南思茅地区 10年间该病的自然病情和诊治学的改变。结果 :与 1987～ 1989年组比较 ,1997～ 1999年组患者的基本临床资料除高血压心脏病心衰率增加外 (P <0 .0 5 ) ,其他无任何改变。由于血管紧张素转换酶抑制剂 (ACEI)等药物的应用 ,使心衰平均住院病死率由 45 .5 9%降至 18.0 0 % ,有统计学意义 (P<0 .0 5 )。但心衰猝死率居高不下。结论 :近 10年来 ,由于 ACEI,β受体阻滞剂的应用 ,使心衰住院病死率明显下降 ,但猝死率无改变。     

Worsening renal function in heart failure: The need for a consensus definition

Acute decompensated heart failure is a common cause of hospitalisation. This is a period of vulnerability both in altered pathophysiology and also the potential for iatrogenesis due to therapeutic interventions. Renal dysfunction is often associated with heart failure and portends adverse outcomes. Identifying heart failure patients at risk of renal dysfunction is important in preventing progression to chronic kidney disease or worsening renal function, informing adjustment to medication management and potentially preventing adverse events. However, there is no working or consensus definition in international heart failure management guidelines for worsening renal function. In addition, there appears to be no concordance or adaptation of chronic kidney disease guidelines by heart failure guideline development groups for the monitoring of chronic kidney disease in heart failure. Our aim is to encourage the debate for an agreed definition given the prognostic impact of worsening renal function in heart failure.     

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.     

Worsening renal function in patients hospitalised for acute heart failure: clinical implications and prognostic significance

BACKGROUND: Renal function is a powerful prognostic variable in patients with heart failure (HF). Hospitalisations for acute HF (AHF) may be associated with further worsening of renal function (WRF). METHODS AND RESULTS: We analysed the clinical significance of WRF in 318 consecutive patients admitted at our institute for AHF. WRF was defined as the occurrence, at any time during the hospitalisation, of both a > or =25% and a > or =0.3 mg/dL increase in serum creatinine (s-Cr) from admission (WRF-Abs-%). RESULTS: Patients were followed for 480+/-363 days. Fifty-three patients (17%) died and 132 (41%) were rehospitalised for HF. WRF-Abs-% occurred in 107 (34%) patients. At multivariable survival analysis, WRF-Abs-% was an independent predictor of death or HF rehospitalisation (adjusted HR, 1.47; 95%CI, 1.13-1.81; p=0.024). The independent predictors of WRF-Abs-%, evaluated using multivariable logistic regression, were history of chronic kidney disease (p=0.002), LV ejection fraction (p=0.012), furosemide daily dose (p=0.03) and NYHA class (p=0.05) on admission. CONCLUSION: WRF is a frequent finding in patients hospitalised for AHF and is associated with a poor prognosis. Severity of HF and daily furosemide dose are the most important predictors of the occurrence of WRF.     

Efficacy and safety of entecavir treatment in a heterogeneous CHB population from a ‘real‐world’ clinical practice setting in China

Chronic hepatitis B infection is an important cause of liver‐related mortality in China. This study assessed the efficacy and safety of entecavir in a heterogeneous patient population from a ‘real‐world’ clinical practice setting in China. This prospective, observational cohort provides 48‐week data on 2600 patients from 50 sites in China who received entecavir (0.5 or 1.0 mg) and were assessed for virologic, serologic and biochemical responses. Patients were nucleos(t)ide‐naïve or ‐experienced and had compensated or decompensated liver function. At Week 48, 1545/2424 (64%) patients with compensated liver disease and 30/44 (68%) patients with decompensated liver disease achieved HBV DNA <50 IU/mL. Greater proportions of nucleos(t)ide‐naïve than nucleos(t)ide‐experienced (69% vs 53%), and adefovir‐experienced than lamivudine/telbivudine‐experienced (62% vs 52%) patients achieved this endpoint. Most patients with HBV DNA <50 IU/mL also achieved HBV DNA <12 IU/L (60%, 45% and 61% of nucleos(t)ide‐naïve, nucleos(t)ide‐experienced and decompensated patients, respectively). In patients with compensated liver disease, ALT values normalized in 1532/1792 patients (85%), and HBeAg loss and HBeAg seroconversion were observed in 17% and 15% of treatment‐naïve and 15% and 11% of treatment‐experienced patients. Entecavir was generally well tolerated. Adverse event rates were comparable between treatment‐naïve and treatment‐experienced patients with compensated liver disease, but were higher in decompensated than in compensated patients, consistent with previous reports in these patients with more advanced disease. Four patients discontinued treatment due to adverse events. In a ‘real‐world’ setting, entecavir was efficacious and well tolerated throughout 48 weeks in a heterogeneous Chinese CHB population.     

Serelaxin in addition to standard therapy in acute heart failure: rationale and design of the RELAX‐AHF‐2 study

Patients admitted for acute heart failure (AHF) experience high rates of in‐hospital and post‐discharge morbidity and mortality despite current therapies. Serelaxin is recombinant human relaxin‐2, a hormone with vasodilatory and end‐organ protective effects believed to play a central role in the cardiovascular and renal adaptations of human pregnancy. In the phase 3 RELAX‐AHF trial, serelaxin met its primary endpoint of improving dyspnoea through day 5 in patients admitted for AHF. Compared to placebo, serelaxin also reduced worsening heart failure (WHF) by 47% through day 5 and both all‐cause and cardiovascular mortality by 37% through day 180. RELAX‐AHF‐2 ( ClinicalTrials.gov NCT01870778) is designed to confirm serelaxin's effect on these clinical outcomes. RELAX‐AHF‐2 is a multicentre, randomized, double‐blind, placebo‐controlled, event‐driven, phase 3 trial enrolling ～6800 patients hospitalized for AHF with dyspnoea, congestion on chest radiograph, increased natriuretic peptide levels, mild‐to‐moderate renal insufficiency, and systolic blood pressure ≥125 mmHg. Patients are randomized within 16 h of presentation to 48 h intravenous infusions of serelaxin (30 µg/kg/day) or placebo, both in addition to standard of care treatments. The primary objectives are to demonstrate that serelaxin is superior to placebo in reducing: (i) 180 day cardiovascular death, and (ii) occurrence of WHF through day 5. Key secondary endpoints include 180 day all‐cause mortality, composite of 180 day combined cardiovascular mortality or heart failure/renal failure rehospitalization, and in‐hospital length of stay during index AHF. The results from RELAX‐AHF‐2 will provide data on the potential beneficial effect of serelaxin on cardiovascular mortality and WHF in selected patients with AHF.