CHF患者血清TNF-α、可溶性Fas和sFasL联检的临床意义

目的:探讨慢性心力衰竭(CHF)患者治疗前后血清TNF-α、sFas和sFasL水平的变化及意义.方法:应用放免法对36例CHF患者进行了治疗前后血清TNF-α、sFas和sFasL的检测,并与35例正常健康人作比较.结果:在CHF治疗前,患者血清TNF-α、sFas和sFasL水平非常显著地高于正常人组(P<0.01...     

Lung Fluid Movements in Hypoxia

Pulmonary edema is a problem of major clinical importance resulting from a persistent imbalance between forces that drive water into the airspace of the lung and the biological mechanisms for its removal. Here, we will first review the fundamental mechanisms implicated in the regulation of lung fluid homeostasis, namely, the Starling forces and the respiratory transepithelial sodium transport. Second, we will discuss the contribution of hypoxia to the perturbation of this fine balance and the role of such perturbations in the development of high-altitude pulmonary edema, a disease characterized by a very high morbidity and mortality. Finally, we will review possible interventions aimed to maintain/restore lung fluid homeostasis and their importance for the prevention/treatment of pulmonary edema.     

Cardiac Toxicity From Systemic Cancer Therapy: A Comprehensive Review

Cardiovascular toxicity is a potential short- or long-term complication of anticancer therapy. Exposure to chemotherapy medications, primarily the anthracycline class, can lead to potentially irreversible clinically significant cardiac dysfunction. The advent of novel biologic agents, including monoclonal antibodies and tyrosine kinase inhibitors, has revolutionized the treatment of several types of malignancies. Although targeted therapies are considered less toxic and better tolerated by patients compared with classic chemotherapy agents, rare serious complications have been observed; and longer-term follow-up is needed to determine the exact profile of related cardiac adverse effects. Cardiac toxicity associated with cancer therapies can range from asymptomatic subclinical abnormalities, including electrocardiographic changes and temporary left ventricular ejection fraction decline, to life-threatening events such as congestive heart failure or acute coronary syndromes. Assessment of the prevalence, type, and severity of cardiac toxicity caused by various cancer treatments is a critical topic for patient management and specifically for new drug development. Guidelines for monitoring cardiac adverse effects have been formulated; however, appropriate supportive evidence remains limited. Given the rate of new drug development designed to fulfill unmet oncologic needs, efforts are needed to promote strategies for cardiac risk detection and management and to avoid unintended consequences potentially impeding development of, regulatory approval for, and patient access to novel therapies. These advances require ongoing research to assess and manage the cardiovascular safety of patients treated with anticancer agents, as well as a well-organized collaboration between oncologists and cardiologists. The aim of this review is to summarize potential cardiovascular toxicities for a range of cancer chemotherapeutics and to review general mechanisms of cardiovascular toxicity for each agent.     

个性化容量管理对慢性心力衰竭患者的影响

目的 探讨个性化容量管理在慢性心力衰竭（chronic heart failure,CHF）患者延续性护理中的应用效果,评价其对心功能状况、再入院和预后的影响。方法 选择2019年2—12月在上海市浦东医院心内科住院的211例心功能分级Ⅱ~Ⅳ级的CHF患者,随机分为干预组和对照组。对照组采用CHF常规治疗和护理;干预组在对照组的基础上进行个性化的容量管理干预,分别观察两组患者随访6个月后体重、血清肌酐（SCr）、钾（K⁺）、钠（Na⁺）、氯（Cl^-）、血浆脑钠肽（brain natriuretic peptide,BNP）水平、NYHA心功能分级、6分钟步行试验（6-MWT）、左室射血分数（left ventricular ejection fraction,LVEF）、明尼苏达心力衰竭生活问卷（Minnesota living with heart failure questionnaire,MLHFQ）及再入院情况。结果 随访6个月后干预组患者体重、SCr、BNP及MLHFQ显著低于对照组,LVEF和6-MWT高于对照组（P<0.05）,两组间NYHA分级存在显著差异（P<0.05）,K⁺、Na⁺和CL^-水平差异无统计学意义。随访6个月后干预组和对照组患者因心衰加重住院人数和全因再入院次数存在显著差异（P<0.05）。结论 个性化容量管理有助于改善CHF患者的心功能状况和生活质量,改善患者预后,减少再入院,具有一定临床实用价值。     

心力衰竭病人生活质量的影响因素分析

目的 :研究慢性心力衰竭 (CHF)病人生活质量 (QOL)的影响因素 ,提出延长生存期、提高QOL的措施和建议。方法 :采用现况调查方法 ,应用心衰QOL、家庭支持和综合自护能力评估量表 ,对心内科住院治疗的 2 0 4例CHF者进行问卷调查 ,所得有效数据应用SPSS软件包进行统计描述和Logistic回归分析。结果 :80 .9%的CHF者QOL处于中低水平。差异有显著性意义 (P <0 .0 5 ) ,使QOL呈下降趋势的因素有 :年龄、体力劳动者 ,心功能分级增高和心衰年限长伴CHD者 ,住院前不合理用药未及时应用非药物治疗方法行血流重建者 ,不做运动训练者 ,由配偶以外的子女等提供帮助者 ,家庭成员的行为和态度处于中低水平者 ,家庭人均月收入 <6 0 0元和医疗费自费者 ,综合自护能力处于中低水平者。结论 :影响CHF病人QOL的因素很多 ,4项对策可提高其QOL。     

Examining Risk: A Systematic Review of Perioperative Cardiac Risk Prediction Indices

ObjectiveTo conduct a systematic review of published cardiac risk indices relevant to patients undergoing noncardiac surgery and to provide clinically meaningful recommendations to physicians regarding the use of these indices.MethodsA literature search of articles published from January 1, 1999, through December 28, 2018, was conducted in Ovid (MEDLINE), PubMed, Embase, CINAHL, and Web of Science. Publications describing models predicting risk of cardiac complications after noncardiac surgery were included and citation chaining was used to identify additional studies for inclusion.ResultsEleven risk indices involving 2,910,297 adult patients were included in this analysis. Studies varied in size, population, quality, risk of bias, outcome event definitions, risk factors identified, index outputs, accuracy, and clinical usefulness. Studies considered 6 to 83 variables to develop their models. Among the identified models, the factors with the highest predictiveness for adverse cardiac outcomes included congestive heart failure, type of surgery, creatinine, diabetes, history of stroke or transient ischemic attack, and emergency surgery. Substantial data from the large studies also supports advancing age, American Society of Anesthesiology physical status classification, functional status, and hypertension as additional risks.ConclusionThe risk indices identified generally fell into two groups — those with higher accuracy for predicting a narrow range of cardiac outcomes and those with lower accuracy for predicting a broader range of cardiac outcomes. Using one index from each group may be the most clinically useful approach. Risk factors identified varied widely among studies. In addition to judicious use of predictive indices, reasoned clinical judgment remains indispensable in assessing perioperative cardiac risk.     

Clinical and echocardiographic characteristics of left atrial spontaneous echo contrast in sinus rhythm

OBJECTIVES

In this study we attempt to define the clinical and echocardiographic characteristics of patients with left atrial spontaneous echo contrast (LASEC) in sinus rhythm (NSR).

BACKGROUND

Left atrial spontaneous echo contrast in atrial fibrillation (AF) is associated with increased risk of thromboembolism. Little is known about its significance in NSR.

METHODS

We reviewed reports of 1,288 transesophageal echocardiogram (TEE) studies done with a 5 MHz probe. Patients with swirling LASEC who were in NSR during TEE were analyzed. We compared them with a control group of 45 age matched patients selected to have NSR, left atrium (LA) >4.0 cm but no SEC.

RESULTS

Spontaneous echo contrast in NSR was noted in 24 patients (2%) and formed our study group. All patients with SEC had enlarged LA, mean 5.6 cm ± 0.6 cm. There was a higher prevalence of cerebrovascular accident (CVA) in patients with SEC when compared with controls with no SEC, 83% versus 56%, p = 0.02. Patients with SEC had larger LA, 5.6 versus 4.9 cm, p < 0.0001 and lower mean peak left atrial appendage emptying velocity (LAAEV), 38 versus 56 cm/s, p = 0.001. Thirteen percent of patients with SEC had LA thrombus as compared with none in the control group, p = 0.02. By multivariate analysis, SEC in NSR was found to be associated with CVA, larger LA size and decreased mean LAAEV. Even after adjusting for LA size, patients with SEC had a higher prevalence of CVA than controls, p = 0.03.

CONCLUSIONS

Spontaneous echo contrast in NSR occurs in patients with significantly dilated LA and depressed atrial function. Left atrial thrombus is noted in 13% of such patients despite NSR. Spontaneous echo contrast in NSR is associated with a higher prevalence of CVA. Further, SEC is found to be an independent and more powerful correlate of CVA than reduced LAAEV or atrial size. These data indicate that LASEC in NSR is a prothombotic condition.     

Risk factors for ARDS in patients receiving mechanical ventilation for > 48 h

BACKGROUND: Low tidal volume (Vt) ventilation for ARDS is a well-accepted concept. However, controversy persists regarding the optimal ventilator settings for patients without ARDS receiving mechanical ventilation. This study tested the hypothesis that ventilator settings influence the development of new ARDS. METHODS: Retrospective analysis of patients from the Multi Parameter Intelligent Monitoring of Intensive Care-II project database who received mechanical ventilation for > or = 48 h between 2001 and 2005. RESULTS: A total of 2,583 patients required > 48 h of ventilation. Of 789 patients who did not have ARDS at hospital admission, ARDS developed in 152 patients (19%). Univariate analysis revealed high peak inspiratory pressure (odds ratio [OR], 1.53 per SD; 95% confidence interval [CI], 1.28 to 1.84), increasing positive end-expiratory pressure (OR, 1.35 per SD; 95% CI, 1.15 to 1.58), and Vt (OR, 1.36 per SD; 95% CI, 1.12 to 1.64) to be significant risk factors. Major nonventilator risk factors for ARDS included sepsis, low pH, elevated lactate, low albumin, transfusion of packed RBCs, transfusion of plasma, high net fluid balance, and low respiratory compliance. Multivariable logistic regression showed that peak pressure (OR, 1.31 per SD; 95% CI, 1.08 to 1.59), high net fluid balance (OR, 1.3 per SD; 95% CI, 1.09 to 1.56), transfusion of plasma (OR, 1.26 per SD; 95% CI, 1.07 to 1.49), sepsis (OR, 1.57; 95% CI, 1.00 to 2.45), and Vt (OR, 1.29 per SD; 95% CI, 1.02 to 1.52) were significantly associated with the development of ARDS. CONCLUSIONS: The associations between the development of ARDS and clinical interventions, including high airway pressures, high Vt, positive fluid balance, and transfusion of blood products, suggests that ARDS may be a preventable complication in some cases.     

Increased myocardial NADPH oxidase activity in human heart failure

OBJECTIVES: This study was designed to investigate whether nicotinamide adenine dinucleotide 3-phosphate (reduced form) (NADPH) oxidase is expressed in the human heart and whether it contributes to reactive oxygen species (ROS) production in heart failure. BACKGROUND: A phagocyte-type NADPH oxidase complex is a major source of ROS in the vasculature and is implicated in the pathophysiology of hypertension and atherosclerosis. An increase in myocardial oxidative stress due to excessive production of ROS may be involved in the pathophysiology of congestive heart failure. Recent studies have suggested an important role for myocardial NADPH oxidase in experimental models of cardiac disease. However, it is unknown whether NADPH oxidase is expressed in the human myocardium or if it has any role in human heart failure. METHODS: Myocardium of explanted nonfailing (n = 9) and end-stage failing (n = 13) hearts was studied for the expression of NADPH oxidase subunits and oxidase activity. RESULTS: The NADPH oxidase subunits p22(phox), gp91(phox), p67(phox), and p47(phox) were all expressed at messenger ribonucleic acid and protein level in cardiomyocytes of both nonfailing and failing hearts. NADPH oxidase activity was significantly increased in end-stage failing versus nonfailing myocardium (5.86 +/- 0.41 vs. 3.72 +/- 0.39 arbitrary units; p < 0.01). The overall level of oxidase subunit expression was unaltered in failing compared with nonfailing hearts. However, there was increased translocation of the regulatory subunit, p47(phox), to myocyte membranes in failing myocardium. CONCLUSIONS: This is the first report of the presence of NADPH oxidase in human myocardium. The increase in NADPH oxidase activity in the failing heart may be important in the pathophysiology of cardiac dysfunction by contributing to increased oxidative stress.