慢性心衰规范化治疗的价值

发布时间：2018-01-01 02:28

  本文关键词：慢性心衰规范化治疗的价值　出处：《山东大学》2013年硕士论文　论文类型：学位论文

  更多相关文章： 慢性心力衰竭 规范化治疗 β受体阻滞剂 ACEI 目标剂量 个体化治疗

【摘要】：研究背景： 慢性心力衰竭(Chronic Heart Failure, CHF)是由于不同病因的器质性心血管疾病引起的心肌收缩力减弱,导致心脏泵血功能低下所致的临床综合征。国外最新的流行病学资料表明,发达国家成年人群中CHF发病率为1～2%,在70岁以上的老年人群中可高达10%。我国的流行病学研究显示中国CHF患病率为0.9%,据此估计我国35～74岁成年人中有约400万心衰患者。心衰患者的预后通常较差,轻度患者年死亡率约5～10%,而重度患者可高达40%以上,死亡率超过了某些恶性肿瘤。目前心衰患者数量不断增加,随着冠心病及其他心血管病治疗手段的提高导致其死亡率降低,这些存活的患者因严重的器质性心脏病最终转归为心力衰竭；另一方面心衰治疗理论与实践的日趋成熟也是不可忽略的因素。据研究显示在过去的50年里,心衰患者的生存率不断提高,这主要得益于人们对慢性心衰的发病机理的认识水平不断提高以及循证医学试验的开展,逐步建立起了一套得到各国认可的慢性心衰规范化治疗方案,即以神经内分泌拮抗剂作为基石进行规范化治疗。心衰一旦确诊,排除禁忌后血管紧张素转化酶抑制剂(Angiotensin Converting Enzyme Inhibiter, ACEI)和p受体阻滞剂的联合治疗就应该启动,从极小量开始,逐渐用至目标剂量,当患者不能耐受ACEI时可使用血管紧张素受体拮抗剂(Angiotensin Receptor Blocker, ARB)替代。 尽管世界各国包括我国已认可慢性心衰规范化治疗的疗效,但是由于我国地域广,人口众多,社会医疗资源分布不均,且对慢性心衰规范化治疗缺乏可以参照的实践经验,慢性心衰规范化治疗的推广尚处于起步阶段。根据一项我国基层医院慢性心衰的药物治疗现状调查,慢性心衰患者p受体阻滞剂使用率为40%,达口标剂最者只有1%,ACEI的使用率为80%,达目标剂量者只有2%,通过地域分析发现这一情况在偏远地区尤为严重。另一项回顾性调查显示,在1980到2010年的20年间,洋地黄的使用率由51.7%降至40.3%,β受体阻滞剂、ACEI、ARB的使用率分别由8.5%、14.0%、0.5%升至19.0%、40.4%、4.5%,说明随着慢性心衰规范化治疗的推广,以拮抗神经内分泌治疗的心哀治疗已开始被我国医生所接受,但是仍处于起步阶段,存在着诸如神经内分泌拮抗剂使用率低,使用剂量不足的问题。慢性心衰规范化治疗可以降低患者死亡率和住院率,利于患者的长期预后,也可以逐步降低因心衰住院的巨额医疗花费,因此推广慢性心衰规范化治疗刻不容缓。 研究目的： 验证慢性心衰规范化治疗的疗效与安全性,尝试建立适合我国国情的慢性心衰患者门诊监管体系,改善患者预后。 资料和方法： 1.入选患者及数据采集 收集山东大学齐鲁医院心内科门诊经慢性心衰规范化治疗的患者符合纳入标准,排除禁忌 2.药物规范化治疗 对于符合入选标准切无禁忌的患者,开始加用β受体阻滞剂和ACEI,从极小剂量开始启动,用药期间严格检测静息心率、血压及每日体重变化等情况,如能耐受根据患者具体情况可每2～4,周剂量增加一倍,直至达到目标剂量或最大耐受剂量。结合实际采用个体化治疗,剂量可因人而异,如果患者不能耐受药物剂量的增加,如出现水肿等心衰加重的症状或体征,可考虑加用利尿剂(常为螺内酯联合袢利尿剂)和/或小剂量地高辛等药物以缓解,如果仍不能耐受则维持原剂量,以原剂量作为该患者的目标剂量长期维持。如果患者使用ACEI类药物不能耐受(如严重的干咳),可换用ARB类药物。当患者达目标剂量后按此剂量长期服用。 3.数据采集 记录患者性别、年龄等基本信息,记录各治疗阶段的心率、血压、纽约心脏病协会(New York Heart Association,NYHA)心功能分级等资料。患者在进行慢性规范化治疗前和治疗达目标剂量3个月后各进行-次心脏超声检查,测量患者的左室舒张末内径(Left Ventricular End-diastolic Dimension, LVEDD)及左室射血分数(Left Ventricular Ejection Fraction,LVEF)。 建立数据库并采用SPSS19.0统计分析软件进行分析,指标均以均数±标准差(x±s)的形式表示,采用配对样本t检验、均数样本t检验进行结果比较,多组间的均数比较使用One-way ANOVA方式进行分析，，所有结果以P0.05示有统计学意义。 结果： 入选患者30名,平均年龄52.2±12.0岁,男性患者63.3%,由冠心病导致心衰者50.0%,各种原发性心肌病者13.3%,其他原因导致心肌病变者占36.7%。慢性心衰规范化治疗前患者收缩压137.2±18.8mmHg,舒张压86.9±15.1mmHg,心率80.3±9.2次／分；经规范化治疗后收缩压126.5±17.7mmHg,舒张压79.8±8.7mmHg,心率62.4±6.7次／分,治疗前后患者的收缩压、舒张压及心率均具有统计学差异(P0.05)。治疗前NYHA分级为3.2±0.7,规范化治疗后NYHA分级为1.5±0.6,存在统计学差异(P0.05)。超声结果：治疗前LVEDD65.8±10.8mm, LVEF30.9％±7.0％；治疗后LVEDD61.0±11.6mm,LVEF44.0％±14.2％,规范化治疗前后LVEDD及LVEF均具有统计学差异(JP0.05)。明尼苏达心功能不全生命质量量表：治疗前量表综合得分37.8±17.8,身体领域得分11.7±7.5,情绪领域得分11.0±5.9；治疗后综合得分21.2±11.5,身体领域得分7.8±5.4,情绪领域得分5.7±3.3。规范化治疗前后明尼苏达心功能不全生命质量量表的综合得分、身体领域得分和情绪领域得分均具有统计学差异(P0.05)。 亚组分析：采用回顾性分析的方法,将规范化治疗后左心室收缩功能恢复正常者(LVEF50％)定义为显效组,LVEF有改善但仍低于50%者定义为有效组,左室收缩功能恶化者为无效组,分别占试验患者的43.3%、43.3%、13.3%,经One-way ANOVA方式进行分析,各组年龄、治疗前纽约心功能分级及LVEF无统计学差异(P0.05),但是LVEDD在显效组与其他两组之间存在统计学差异(P0.05)。 结论： 慢性心衰规范化治疗具有较好的疗效,经治疗后可使患者的心率和血压降低,达到或接近合适水平,LVEDD缩小,LVEF得到提升,NYHA分级和明尼苏达心功能不全生命质量量表评分均得到改善；通过亚组分析发现经过规范化治疗后疗效较好的患者,治疗前LVEDD较小,而患者年龄、治疗前NYHA分级、治疗前LVEF未发现有统计学差异。故慢性心衰规范化治疗具有较高的临床应用价值,建议在我国进一步的推广施行。
[Abstract]:Research background:
Chronic heart failure (Chronic Heart Failure, CHF) is weakened due to different causes of myocardial contractility in organic cardiovascular diseases caused by, resulting in clinical cardiac function caused by low syndrome. According to the latest foreign epidemiological data, the adult population in developed countries the incidence rate of CHF was 1 ~ 2%, the elderly population at the age of 70 the epidemiological studies can be as high as 10%. in China showed that the prevalence rate of CHF was 0.9% Chinese, according to estimates in China from 35 to 74 years old adults in about 4 million of patients with heart failure. The prognosis of patients with heart failure are usually poor, patients with mild annual death rate of about 5 ~ 10%, and the patients can be as high as 40%, the mortality rate more than some malignant tumors. The increasing number of patients with heart failure, coronary heart disease and other cardiovascular disease improvement of treatment can reduce the mortality, the survival of patients with organic heart disease is serious The final outcome of heart failure; on the other hand, the treatment of heart failure factors of the theory and practice of maturity can not be ignored. According to the study in the past 50 years, the survival rate of patients with heart failure continues to improve, this is mainly due to the pathogenesis of chronic heart failure and continuously improve the understanding level of evidence-based medicine test carry out, gradually establish a set of standardized national recognition of chronic heart failure treatment, which is based on neuroendocrine antagonists is standard treatment. Once the diagnosis of heart failure, after exclusion of contraindications of angiotensin converting enzyme inhibitors (Angiotensin Converting, Enzyme Inhibiter, ACEI) and P receptor blocker combination therapy should be started. From the beginning of a very small amount, gradually to the target dose, when patients intolerant of ACEI can be used when the angiotensin receptor antagonist (Angiotensin Receptor, Blocker, ARB) substitution.
Although countries in the world including China has recognized the effect of standardized treatment of chronic heart failure, but because of China's vast territory, large population, unbalanced distribution of social medical resources, and the lack of reference to the practical experience of the standardized treatment of chronic heart failure, promote the standardized treatment of chronic heart failure is still in its infancy. According to a drug our hospital treatment of chronic heart failure investigation, heart failure in patients with chronic P receptor blocker use was 40%, up to the export standard agent only 1%, ACEI utilization rate was 80%, reached the target dose of only 2%, the geographical analysis found that this situation is particularly serious in rural areas. According to a retrospective survey 1980, in 2010 of 20 years, the use of digitalis was reduced from 51.7% to 40.3%, beta blockers, ACEI and ARB use rate from 8.5%, 14%, 0.5% to 19%, 40.4%, 4.5%, that with chronic heart failure. Promotion of standardized treatment, in treatment of heart failure of neuroendocrine antagonist treatment has begun to be accepted by doctors in China, but is still in the initial stage, such as the existence of neuroendocrine antagonist use rate is low, the problem of insufficient dosage. The standardized treatment of chronic heart failure can reduce mortality and hospitalization rate, long-term prognosis patients, can gradually reduce cost because of the huge medical hospitalization for heart failure, so it is urgent to promote the standardized treatment of chronic heart failure.
The purpose of the study is:
To verify the efficacy and safety of chronic heart failure standardized treatment, try to establish an outpatient supervision system for patients with chronic heart failure suitable for the national conditions of our country, and improve the prognosis of patients.
Information and methods:
1. selected patients and data collection
In the Department of Cardiology, the Department of Cardiology, Qilu Hospital of Qilu Hospital of Shandong University, the standardized treatment of chronic heart failure in the outpatient department of the Department of Cardiology was accorded with the inclusion criteria, and the taboo was excluded.
2. standardized treatment of drugs
For eligible patients without contraindications cut, beginning with beta blockers and ACEI, starting from the minimal dose of medication during the rigorous testing of resting heart rate, blood pressure and body weight changes daily, as tolerated according to the specific circumstances of patients every 2 to 4, Zhou Jiliang doubled until reaching the target or the maximum dose tolerance dose. Combined with the actual use of individual treatment, the dose can be increased if the patients can not tolerate It differs from man to man., drug dosage, such as the emergence of symptoms or signs of edema and the severity of HF, can consider adding diuretics (often spironolactone combined with loop diuretics) and / or small doses of digoxin and other drugs to alleviate, if you still can not maintain tolerance the original dose to the original dose as the target dose of the patients with long-term maintenance. If the patient cannot tolerate the use of ACEI drugs (such as severe dry cough), can be replaced by ARB drugs. When patients reached After the target dose, take this dose for a long time.
3. data collection
Records of patients with gender, age and other basic information, record the treatment stage of the heart rate, blood pressure, New York Heart Association (New York Heart Association, NYHA). The cardiac functional grading in patients with chronic standardized before treatment and reached the target dose 3 months after each time cardiac ultrasound measurement of left ventricular patients with diastolic diameter (Left Ventricular End-diastolic Dimension, LVEDD) and the left ventricular ejection fraction (Left Ventricular Ejection Fraction, LVEF).
The establishment of database and the SPSS19.0 statistical analysis software to analyze the index are mean standard deviation (x + s) in the form of paired sample t test, mean sample t test results were compared between groups were compared using One-way ANOVA analysis, all results in P0.05 showed statistically meaning.
Result锛

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