不同左心室射血分数老年充血性心力衰竭患者药物治疗的临床研究

Comparative study on characteristics of congestive heart failure patients with preserved versus abnormal left ventricular systolic function and evaluation effects of therapy

目的探讨充血性心力衰竭(心衰)患者的临床特征和药物治疗情况以及不同左心室射血分数(LVEF)心衰患者的并发症与药物治疗情况。方法连续调查2001年1月—2002年1月香港大学玛丽医院收住60岁以上的老年充血性心衰患者,符合ICD9CM诊断标准,并用弗明翰研究标准确诊,共计1074例次,收集入院时及入院3d内的超声心动图、心电图、X线胸片等检查结果以及患者出院时转归、出院带药情况。结果1女性充血性心衰患者几乎为男性患者的2倍,年龄≥65岁者占95.5%,≥80岁者占50.6%,按美国纽约心脏协会(NYHA)心功能分级,和级占70.2%,521例(占48.5%)入院治疗1次。2充血性心衰的主要并发症为糖尿病和高血压。3399例次行超声心动图检查者中,208例次(占52.1%)LVEF<0.50,191例次(占47.9%)LVEF≥0.50的患者更倾向于女性,年龄≥80岁,而冠心病及糖尿病较少发生,心房颤动84例次(占44.0%)占多数(P<0.05)。糖尿病、完全性左束支传导阻滞及心肌梗死病史常伴随LVEF<0.50的患者(P<0.05)。4大部分患者均接受利尿剂治疗,LVEF<0.50的患者中使用血管紧张素转换酶抑制剂(ACEI)131例次(占63.0%),地高辛47例次(占22.6%),β受体阻滞剂25例次(占12.0%),钙阻滞剂29例次(占13.9%),而LVEF≥0.50的患者分别有119例次(62.3%)、67例次(35.1%)、18例次(占9.4%)和35例次(占18.3%)使用上述药物,地高辛多用在LVEF≥0.50的患者(P<0.05)。结论1LVEF<0.50与≥0.50的充血性心衰患者单从临床症状和体征上较难区别,目前强调对每个心衰患者尽可能进行早期超声心动图检查,这是区别两类心衰的重要手段。2ACEI、β受体阻滞剂的使用与治疗指南还有一定距离。3尽早地区分LVEF<0.50与≥0.50充血性心衰患者将有利于抗心衰治疗。

Objective To compare clinical characteristics and effects of therapy for hospitalized patients with congestive heart failure （CHF） and different left ventricular ejection fraction （LVEF） during hospitalization. Methods The medical records of 1 074 unselected consecutive patients with CHF who were admitted to Queen Mary Hospital from January, 2001 to January, 2002 were retrospectively reviewed. Three hundred and ninety-nine patients were categorized as having either normal left ventricular systolic function or systolic dysfunction based on the results of echocardiography. Clinical features with a slightly modified version of the Framingham criteria, laboratory results and drug therapies at discharge were compared. Results Among patients, the majority were women, 95.5% were ≥65 years and 50. 6 %≥80 years of age. Classification of the severity of heart failure showed that 70. 2% were New York Heart Association （NYHA）Ⅲand Ⅳ. Only 399 patients had borderline LVEF at the time of hospitalization, of these patients 191 （47.9%） had preserved systolic function （LVEF≥0. 50）, and 208 （52.1%） with LVEF〈0. 50. Patients with LVEF≥0. 50, who tended to be elderly and more often female, exhibited a lower incidence of coronary artery disease and diabetes than patients with LVEF〈0. 50 （all P〈0.05）. Patients with preserved systolic function had a significantly higher prevalence of auricular fibrillation （P〈0. 05）, accounting for up to 84 patients （44.0%） with it, and number of hospitalization for CHF increased. Among patients with systolic dysfunction, 22. 6% were discharged on a therapeutic regimen of digoxin, 63.0% on an angiotensin-converting enzyme inhibitor （ACEI）, and 12.0% on a β- blocker, 13.9% on a calcium channel blocker. These accounted for 62.3%, 35.1%, 9.4% and 18.3% in patients with preserved systolic function, respectively. There was a higher incidence of use of digoxin （P〈0. 05）. Conclusion In hospitalized patients with heart failure, the clinical signs and symptoms of chronic heart failure are similar to those of patients with CHF, LVEF is a powerful prognostic predictor to distinguish CHF patients with normal systolic function from those with systolic dysfunction. Criteria for use of ACEI and β-blocker are still not clear cut. It is important to differentiate CHF patients with LVEF 〈 0. 50 from that with LVEF≥0. 50 in order to achieve a better therapeutic result in the treatment of CHF.