充血性心力衰竭患者预后因素探讨

目的：探讨充血性心力衰竭（CHF）患者的预后因素。方法：前瞻性研究163例CHF患者临床、心电图及血流动力学的预后价值，用多因素Cox回归模型分析各因素对预后的影响。结果：平均随访29个月，心脏性死亡59例，其中猝死34例，泵衰竭死亡19例，心肌梗死死亡6例；多因素分析示，平均主动脉压、平均肺动脉压和QTc是心脏性死亡的独立危险因素；生存率分析示，平均主动脉压≤12kPa，平均肺动脉压≥3．33kPa，QTc≥440ms，射血分数≤25％及有束支阻滞者，生存率显著降低。结论：低血压、QTc延长及伴肺动脉高压者预后不良，治疗中应防止过度降压和延长心肌复极。     

快速测定脑利钠肽预测充血性心力衰竭患者预后的价值

目的　探讨快速测定脑利钠肽预测充血性心力衰竭近期预后的价值。方法　 70例充血性心力衰竭住院患者 ,NYHA心功能Ⅲ级 3 7例、Ⅳ级 3 3例。入院时、出院前或临终前 2 4小时内分别测定血浆BNP ,分析住院治疗前后BNP水平变化与心源性死亡、3 0天内再住院事件的关系。结果　 2 3例患者出现终点事件 (因心功能恶化死亡 6例、再住院 17例 ) ,其入院时BNP水平 ( 15 16pg/ml± 872pg/ml)高于未发生临床终点者 ( 10 3 7pg/ml± 65 4pg/ml) ,P <0 .0 1;发生临床终点者住院期间BNP升高 3 18pg/ml ,而未发生终点事件的患者 ,住院期间BNP平均降低 3 5 9pg/ml ,P <0 .0 1;BNP升高组患者发生临床终点 68.2 % ,BNP降低组患者发生临床终点 16.7% ,P <0 .0 0 5。结论　BNP水平可预测失代偿充血性心力衰竭患者的近期预后     

Impact of congestive heart failure treatment on peripheral microvascular tissue oxygenation

The authors evaluated peripheral tissue oxygenation during treatment of acutely decompensated congestive heart failure (CHF) to determine whether differences exist between patients who experienced adverse outcomes (AO), defined as death or readmission within 6 months, and patients who did not (non-AO). This prospective, observational study measured differential absorption spectroscopy-derived tissue hemoglobin oxygenation (S(t) O(2) ) in CHF patients from presentation through hospital discharge to determine whether differences between the AO and non-AO groups exist. Of 52 patients, 6 died and 27 were readmitted. In the non-AO group, S(t) O(2) increased from admission to discharge by 5.2% (?P<.01; 95% confidence interval, 1.7%-8.7%). No S(t) O(2) change occurred in the AO group (2.3%; P=.42; 95% CI, -2.2%-6.8%). Tissue oxygenation increased during inpatient treatment in CHF patients without future adverse outcomes, but was unchanged for those who later died or were readmitted. Lack of improvement may be associated with higher rates of death and readmission.     

Prognosis of congestive heart failure and predictors of mortality

The interaction of physiologic variables that appear to be predictive of prognosis in patients with severe congestive heart failure was examined in a series of 139 patients referred to a heart failure service. Left ventricular ejection fraction, peak oxygen consumption during a progressive maximal exercise test and resting plasma norepinephrine concentration were identified as the strongest univariate predictors of prognosis. Examination of their interaction was accomplished by stratifying each variable into quartiles and then pooling quartiles for bivariate analysis. The data demonstrate that ejection fraction has the most profound effect on survival calculated from maximal oxygen consumption and norepinephrine concentration, but that each of the variables provides additional independent prognostic information when added to survival estimated from any of the other variables. Therefore, ventricular function, exercise tolerance and sympathetic nervous system activation appear to provide independent insight into the prognosis of patients with heart failure.     

Heart rate variability enhances the prognostic value of established parameters in patients with congestive heart failure

This prospective study evaluated whether heart rate variability (HRV) assessed from Holter ECG has prognostic value in addition to established parameters in patients with congestive heart failure (CHF). The study included 222 patients with CHF due to dilated or ischemic cardiomyopathy (left ventricular ejection fraction LVEF 21+/-1%; mean+/-SEM). During a mean follow-up of 15+/-1 months, 38 (17%) patients died and 45 (20%) were hospitalized due to worsening of CHF. The HRV parameter SDNN (standard deviation of all intervals between normal beats) was significantly lower in non-surviving or hospitalized than in event-free patients (118+/-6 vs 142+/-5 ms), as were LVEF (18+/-1 vs 23+/-1%), and peak oxygen uptake during exercise (peak VO(2)) (12.8+/-0.5 vs 15.6+/-0.5 ml/min/kg). While each of these parameters was a risk predictor in univariate analysis, multivariate analysis revealed that HRV provides both independent and additional prognostic information with respect to the risk 'cardiac mortality or deterioration of CHF'. It is concluded that the determination of HRV enhances the prognostic power given by the most widely used parameters LVEF and peak VO(2) in the prediction of mortality or deterioration of CHF and thus enables to improve risk stratification.     

心阻抗血流图在充血性心力衰竭治疗初期的临床价值

目的：探讨应用心阻抗法无创心功能检测仪监测充血性心力衰竭（CHF）时血流动力学变化,指导下一步治疗的应用价值。方法：入选67例CHF患者,应用无创心功能检测仪监测心率、基础阻抗、每搏输出量、心排血量、心缩力指数、收缩功能指数、舒张功能指数、外周血管阻力和血管顺应性指标,统计分析其用药前、用药后3h和用药后3d的患者的症状和以上指标的变化,分析无创心功能检测仪的应用价值。结果：用药前、用药后3h和用药后3d统计学分析显示心率和外周血管阻力下降,基础阻抗、每搏输出量、心排血量、心缩力指数、收缩功能指数、舒张功能指数和血管顺应性升高,有统计学差异（（均P〈0．01）。结论：无创心功能检测仪能反映CHF时血流动力学变化的过程,对CHF的治疗有一定的指导意义。     

QT离散度对老年严重心力衰竭病人无预后价值

目的:探讨QT离散度(QTd)对老年严重心衰(CHF)病人的预后价值。方法:362例老年严重心衰患者入院时记录基础静态12导联同步心电图,计算QT离散度,平均随访(7.2±4.8)个月。结果:随访期间142例(39.2%)病人死亡,QT离散度为(76.3±28.6)ms,存活者220例,QT离散度为(74.8±30.2)ms。两组间比较无明显差异(P>0.05);生存分析显示QT离散度对总死亡率(RR 1.00,95%CI 1.00~1.00),心源性死亡率(RR 1.00,95%CI 1.00~1.01)及心律失常性死亡率(RR 1.00,95%CI 1.00~1.01)均无预后价值(P>0.05).结论:QT离散度(QTd)对老年严重心衰病人的总死亡率,心源性死亡率及心律失常性死亡率均无预后价值。     

Nitrates in the treatment of congestive heart failure

Nitrates have been widely used for the treatment of patients with chronic congestive heart failure. Although the use of these drugs has not been evaluated by large-scale studies traditionally used for evaluation of new therapy, multiple studies over the years have demonstrated their favorable effects. Organic nitrates have been shown to have a beneficial effect on ischemia, hemodynamic profile, magnitude of mitral regurgitation, endothelial function, and cardiac remodeling. These drugs alone or in combination with hydralazine have improved exercise capacity, maximal oxygen consumption, cardiac function, and survival. The use of nitrates in patients with heart failure has been limited by reduced responsiveness (resistance) and early development of tolerance. Nitrate resistance is due to reduced vascular response and results in the need to use a larger dose of any nitrate preparation when used for the treatment of patients with heart failure compared to patients without heart failure. Recent information suggests that nitrate tolerance is caused by increased levels of superoxide at the vascular wall, which leads to reduced nitric oxide level and to increased sensitivity to vasoconstrictive mechanisms, such as endothelin and angiotensin II. Intermittent dosing of nitrates allowing a 12-hour nitrate-free interval is effective in preventing nitrate tolerance and is, therefore, recommended. Recent information suggests that augmentation of nitrate dose by the use of an escalating dose regimen and a concomitant use of hydralazine can prevent or overcome the effect of nitrate tolerance in patients with heart failure.     

Pharmacologic treatment of congestive heart failure

Congestive heart failure is a clinical syndrome producing symptomatic deterioration, functional impairment, and shortened life span. The syndrome is complex in that it includes both peripheral and cardiac effects which contribute to the progression of heart failure. In the periphery, elevations in thesympathetic nervous system and renin-angiotensin system increase afterload and contribute to further salt and water retention. The central cardiac abnormalities include remodeling of the heart and downregulation of beta receptors. Traditional heart failure therapy has included treatment of fluid retention with diuretics, although their effect on mortality has never been addressed. The most proven therapy in heart failure is treatment with vasodilators, particularly angiotensin-converting enzyme (ACE) inhibitors. Improved survival with ACE-inhibitor therapy has been demonstrated in patients with severe heart failure (CONSENSUS), mild to moderate heart failure (SOLVD), and in comparison with vasodilator therapy with hydralazine isosorbide dinitrate (VHeFT II). Improved survival has also been noted in postmyocardial infarction when the ejection fraction is decreased (SAVE). The ACE inhibitors have now become standard therapy for heart failure regardless of severity. Additive vasodilator therapy with calcium-channel antagonists is under investigation. Inotropic therapy is controversial at present because of disappointing mortality results. The clinical mainstay digitalis remains without convincing mortality reduction data. Other inotropic agents, particularly phosphodiesterase inhibitors, have shown uniformly negative survival results. However, the new mixed action agents vesnarinone and pimobenden have shown favorable data, with vesnarinone demonstrating a mortality reduction effect. Beta-blocker therapy in heart failure has also found renewed interest, particularly with the new agents carvedolol and bucindolol which also have vasodilating properties.     

Surgical treatment of congestive heart failure

Cardiac transplantation is the definitive surgical treatment for patients with severe left ventricular dysfunction and congestive heart failure. Unfortunately, however, the supply of donor hearts remains severely limited, so transplantation is an option for only a minority of these patients. Even after being approved for a heart transplant, patients often have a long wait until a suitable donor heart can be found. This waiting period entails a significant mortality rate. Because the supply of donor hearts is not expected to increase, surgeons have introduced several alternatives to heart transplantation, including partial left ventriculectomy, mitral valve repair, myocardial revascularization, and endoventricular circular patch plasty. For maximal benefit, surgeons must refine the selection criteria for determining which patients are the best candidates for each of these procedures.     

The prognostic value of circulating soluble cell adhesion molecules in patients with chronic congestive heart failure

BACKGROUND: Circulating soluble (s) cell adhesion molecules (CAMs) are elevated in patients with congestive heart failure (CHF) and may play an important role in the pathogenesis of CHF by mediating the cell-cell interactions of the immune response. However, clinical data about the prognostic value of sCAMs are sparse. The purpose of this study is to determine whether various sCAMs can provide prognostic information in patients with CHF. METHODS: We measured circulating levels of three sCAMs (vascular cell adhesion molecule-1, intercellular adhesion molecule-1, and sP-selectin) in 74 patients with symptomatic chronic CHF and left ventricular ejection fraction (LVEF) <50%. We compared these levels with those of a group of 19 age-matched control subjects. Major adverse cardiac events (death, heart transplantation or hospitalization with worsening CHF) during a median follow-up period of 240 days were determined. RESULTS: The concentrations of the three sCAMs in the 74 patients with CHF were significantly associated with one another. Their levels were higher than those of the control subjects and increased with the severity of CHF. Significantly higher sCAM levels were noted in those patients who had major adverse cardiac events during the follow-up period. There were significant negative correlations between LVEF and sCAMs. However, only high levels of sP-selectin were found to be an independent significant predictor of CHF by Cox proportional hazards analysis. CONCLUSIONS: These findings indicate that the levels of these three sCAMs increase with the severity of CHF and are related to clinical outcomes. Among them, high levels of sP-selectin can provide prognostic information independently in patients with CHF.     

Reliability and prognostic value of traditional signs and symptoms in outpatients with congestive heart failure.

BACKGROUND: Previous validation studies of congestive heart failure (CHF) signs and symptoms were performed in acute settings. Few data have supported the validity of CHF clinical findings during the chronic stages of the disease. This study was designed to evaluate the reliability and prognostic value of traditional signs and symptoms in stable CHF outpatients. METHODS: Sixty CHF outpatients who underwent 102 simultaneous clinical and echocardiographic evaluations were prospectively examined. A clinical congestion score was built summing all grades of CHF signs and symptoms. Hemodynamic parameters were estimated according to previously validated echocardiography-based protocols. Major cardiac events were evaluated after 180 days. RESULTS: Most CHF patients were male (67%), middle-aged (56+/-15 years) and in Specific Activity Scale functional classes I to II (70%). Isolated clinical findings demonstrated limited sensitivity and specificity to identify hemodynamic parameters. Absence of all signs of congestion, however, had a predictive value of 95% for a left atrial pressure less than 20 mmHg. Patients with no CHF signs or symptoms (score of 0) had significantly lower right (P<0.001) and left (P=0.03) atrial pressures compared with those with higher scores (scores of at least 5). In multivariate analysis, a congestion score of at least 3 (RR 4.8, 95% CI 1.3 to 17.4, P=0.02) and beta-blockers use (P=0.02) remained associated with future cardiac events. CONCLUSIONS: Although CHF signs and symptoms did not accurately identify hemodynamic parameters, combined data from history and physical examination provided meaningful information to guide clinical decisions and for prognostication.     

Brain natriuretic peptide response is heterogeneous during beta-blocker therapy for congestive heart failure

BACKGROUND: Plasma brain natriuretic peptide (BNP) levels are useful marker to guide medical treatment in patients with congestive heart failure (CHF). We tested the hypothesis that the plasma BNP concentration would be a useful marker of beta-blocker therapy for CHF. METHODS AND RESULTS: Eighty-four patients with New York Heart Association class II-IV CHF and a left ventricular ejection fraction (LVEF) <40% were treated with beta-blockers, including metoprolol and carvedilol, for at least 16 weeks. End-diastolic and end-systolic dimensions decreased, and radionuclide LVEF increased 4 weeks after introduction of beta-blockers (early phase). LV end-diastolic and end-systolic dimensions both decreased, and LVEF increased 16 to 48 weeks after the therapy (late phase). However, the BNP concentration did not change during the observation period. Overall LV function improved in all 4 subgroups divided according to the baseline BNP levels. CONCLUSIONS: Plasma BNP concentration is not a sensitive marker of successful beta-blocker therapy for CHF.     

Placebo treatment in congestive heart failure.

In order to evaluate the effect of placebo treatment in congestive heart failure, we retrospectively studied 24 patients with moderately severe congestive heart failure who participated in heart failure treatment trials performed over the past 10 years in the Ohio State University Heart Failure Research Laboratory. Placebo-treated patients from 4 placebo-controlled trials comprised the placebo treatment group (n = 15), while one natural course-controlled trial provided patients for the non-placebo control group (n = 9). Changes in symptoms, left ventricular function and exercise duration were assessed following an 8-week course of therapy. Chronic placebo therapy resulted in an 81-second improvement in exercise duration which was statistically significant when compared to pretreatment baseline and to the duration achieved by the nonplacebo control group. Clinically, functional class improved significantly by 27% above baseline only for the placebo treatment group. Indices of left ventricular function did not change for either group. The salient feature of this study is that the placebo treatment effect, while believed to exist in congestive heart failure, has never been demonstrated in a manner which controlled for the natural course and variability of the disease process. The operative components of the placebo effect remain unknown, and further investigation will be necessary to elucidate the underlying mechanisms involved. However, the importance of this phenomenon lies not only with the response to and effects of placebo therapy but also in the role that the placebo effect plays in what is generally presumed to be the predominant responses, effects and benefits of active drug therapy.