血管紧张素受体-脑啡肽酶抑制剂在心力衰竭治疗中的研究进展

心力衰竭治疗策略的变化与其病理生理机制的演变是统一的。现通过对神经内分泌机制中利钠肽系统的介绍增加对血管紧张素受体-脑啡肽酶抑制剂的认识,同时对其目前在随机对照研究及真实世界研究取得的进展进行汇总,最后对血管紧张素受体-脑啡肽酶抑制剂的临床应用提出一些思考,以供临床借鉴。     

超声心动图监测动脉导管未闭封堵治疗中残余分流及临床意义

目的:探讨二维超声心动图(2DE)及彩色多普勒血流显像(CDFI)实时动态监测动脉导管未闭(PDA)导管法封堵治疗过程中残余分流变化规律及临床意义。方法:选择2002年1月至2006年6月102例应用Amplatz-er封堵器进行封堵治疗并有术中超声心动图监测的连续性PDA患者为观察对象,年龄1~63,平均(9.2±8.2)岁,术前2DE和CDFI测量PDA的最小内径为2.0~14.2,平均(6.1±1.9)mm,长度为2.1~15.8,平均(10.0±2.5)mm。当封堵器到位后,应用2DE及CDFI对残余分流进行实时动态监测,记录即刻、5、10、15、20、25、30min共7个阶段的各项观察指标,包括残余分流类型、比例及分流束宽度的变化。结果:(1)封堵器定位后即刻,102例患者中19例(18.6%)无任何类型残余分流、83例(81.4%)患者仍有残余分流;在有残余分流的患者中,CDFI共检出中央型残余分流束41个、边缘型残余分流束133个(宽度<2mm者102个、宽度≥2mm者31个);(2)CDFI动态监测过程中,所有中央型残余分流束均在15min内、多数10min内可自行迅速消失;95%宽度<2mm的边缘性残余分流束25min时可自行消失,30min时5个尚未消失的残余分流束宽度均<1mm;而宽度≥2mm的边缘残余分流6%在30min时可自行消失,余94%不能自行消失,且其宽度在各阶段无显著变化;宽度<2mm和≥2mm的边缘性残余分流束在30min时尚存的残余分流分别为5%和94%(P<0.001)。结论:超声心动图动态监测PDA导管封堵治疗后残余分流变化简单可行,可替代X线造影;边缘性残余分流宽度≥2mm、持续时间30min而无明显变化者,应予更换封堵器,以免造成长期残余分流。     

Palliation via Hybrid Procedure of a 1.4‐kg Patient with a Hypoplastic Left Heart

Despite improvements in survival of patients with hypoplastic left heart syndrome (HLHS) with various palliative procedures, certain risk factors, such as weight less than 2.5 kg, continue to predict increased mortality. We report the palliation of a patient with HLHS weighing 1.4 kg via a hybrid procedure consisting of banding of the pulmonary arteries bilaterally, stenting the ductus arteriosus, and balloon atrial septostomy. We propose that this may be another alternative for palliation in this high‐risk patient group.     

卡维地洛治疗慢性充血性心力衰竭的临床观察

目的：探讨卡维地洛疗慢性充血性心力衰竭的有效性及安全性。方法：选择40例缺血性心肌病患者，随机分为卡维地洛治疗组和对照组，治疗12个月。治疗前、后分别应用超声心动图测量左室射血分数（LVEF）左室收缩末直经（LVESd）和左室舒张末直径（LVEDd）。结果：所有病例治疗后，LVEF升高，LVESd、LVEDd降低，与治疗前相比差异显著（P〈0．01）。与对照组相比，卡维地洛治疗组治疗后各参数明显改善，差异显著（P〈0．05）。结论：卡维地洛治疗慢性充血性心力衰竭安全有效。     

Nurses' decision making in heart failure management based on heart failure certification status

Background

Research findings on the value of nurse certification were based on subjective perceptions or biased by correlations of certification status and global clinical factors. In heart failure, the value of certification is unknown.

Psychometric characteristics of the mutuality scale in heart failure patients and caregivers

Background

Higher patient-caregiver mutuality is associated with improved patient and caregiver outcomes, but no studies have tested the psychometric characteristics of the mutuality scale (MS) in heart failure (HF) patient and caregiver population.

Incidence and Outcomes of Pneumonia in Patients With Heart Failure

BackgroundThe incidence of pneumonia and subsequent outcomes has not been compared in patients with heart failure and reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF).ObjectivesThis study aimed to examine the rate and impact of pneumonia in the PARADIGM-HF (Prospective Comparison of Angiotensin Receptor-Neprilysin Inhibitor With Angiotensin Converting Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure) and PARAGON-HF (Prospective Comparison of ARNI with ARB Global Outcomes in Heart Failure with Preserved Ejection Fraction) trials.MethodsThe authors analyzed the incidence of investigator-reported pneumonia and the rates of HF hospitalization, cardiovascular death, and all-cause death before and after the occurrence of pneumonia, and estimated risk after the first occurrence of pneumonia in unadjusted and adjusted analyses (the latter including N-terminal pro–B-type natriuretic peptide).ResultsIn PARADIGM-HF, 528 patients (6.3%) developed pneumonia after randomization, giving an incidence rate of 29 (95% CI: 27 to 32) per 1,000 patient-years. In PARAGON-HF, 510 patients (10.6%) developed pneumonia, giving an incidence rate of 39 (95% CI: 36 to 42) per 1,000 patient-years. The subsequent risk of all trial outcomes was elevated after the occurrence of pneumonia. In PARADIGM-HF, the adjusted hazard ratio (HR) for the risk of death from any cause was 4.34 (95% CI: 3.73 to 5.05). The corresponding adjusted HR in PARAGON-HF was 3.76 (95% CI: 3.09 to 4.58).ConclusionsThe incidence of pneumonia was high in patients with HF, especially HFpEF, at around 3 times the expected rate. A first episode of pneumonia was associated with 4-fold higher mortality. (Prospective Comparison of Angiotensin Receptor–Neprilysin Inhibitor With Angiotensin-Converting Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure [PARADIGM-HF], NCT01035255; Prospective Comparison of ARNI [Angiotensin Receptor–Neprilysin Inhibitor] With ARB [Angiotensin Receptor Blocker] Global Outcomes in Heart Failure With Preserved Ejection Fraction [PARAGON-HF], NCT01920711)     

Protocol driven palliative care consultation: Outcomes of the ENABLE CHF-PC pilot study

Background

Little has been reported about protocol-driven outpatient palliative care consultation (OPCC) for advanced heart failure (HF).

硝普钠与乌拉地尔治疗顽固性心力衰竭的临床观察

目的观察硝普钠与乌拉地尔治疗顽固性心力衰竭的疗效。方法对42例顽固性心力衰竭患者在综合治疗的基础上应用硝普钠与乌拉地尔治疗顽固性心衰,疗程7-10d。结果乌拉地尔组总有效率(90．9％)显著高于硝普钠组(80％);两组治疗前后的心功能状况左心室射血分数(LVEF)、左心室短轴缩短率(FS)、舒张早期最大充盈速度(E)与舒张晚期最大充盈速度(A)的比值(E／A)、每搏输出量(SV)、心输出量(CO)心脏指数(CI)、及心率、呼吸频率均可得到明显的改善。但乌拉地尔可以更明显地改善心功能。结论在综合治疗的基础上应用乌拉地尔治疗顽固性心力衰竭可以更明显地改善顽固性心力衰竭心功能,且具有更高的临床有效率而无明显的毒副作用。     

慢性心力衰竭大鼠心肌细胞凋亡与心功能的关系及福辛普利和氯沙坦的干预作用

目的:探讨心力衰竭大鼠心肌细胞凋亡与心功能的关系及福辛普利和氯沙坦的干预作用。方法:雌性SD大鼠行左前降支结扎术致急性心肌梗死,术后4周行多普勒超声心动图检测,成功制作慢性心力衰竭(左心室射血分数≤0．45)大鼠36只,随机分成:福辛普利组(50 mg／kg·d,n=12);氯沙坦组(30 mg／kg·d,n=12);生理盐水组(1 mL／d,n=12)。另设假手术组(n=8)不结扎冠状动脉。治疗8周后,再次行超声心动图检测。原位末端标记法(TUNEL)和脱氧核糖核酸(DNA)梯形谱(DNA ladder)检测心肌细胞凋亡。结果:3组心力衰竭大鼠DNA电泳均显示凋亡特征性DNA ladder。与假手术组比较,生理盐水组各项心功能指标显著下降,凋亡指数显著升高(P<0．05)。与生理盐水组比较,福辛普利组和氯沙坦组各项心功能指标显著改善,福辛普利组(P<0．05)和氯沙坦组(P<0．05)凋亡指数显著降低。左心室射血分数与临近梗塞区心肌凋亡细胞数量之间呈负相关关系(r=-0．754,P<0．001)。结论:心肌细胞凋亡与心力衰竭时心功能不断恶化相关。福辛普利和氯沙坦能抑制心肌细胞凋亡并改善左心室收缩功能。