短期应用托伐普坦联合米力农治疗老年难治性心力衰竭的临床疗效及预后观察

Observation of clinical efficacy and prognosis of short-term application of tolvaptan combined with milrinone in the treatment of refractory heart failure in the elderly

目的 探讨短期应用托伐普坦联合米力农治疗老年难治性心力衰竭的临床疗效及预后.方法 选取2018年1月至2019年1月于哈尔滨市第四医院收治的120例老年难治性心力衰竭患者,随机分为基础治疗组和联合用药组,每组各60例.其中基础治疗组给予洋地黄、血管紧张素转换酶抑制剂、螺内酯、呋塞米等综合治疗;联合用药组给予托伐普坦和米力农;所有患者均治疗5 d.比较两组治疗前后患者的临床症状、体征、NYHA心功能分级、24 h尿量、血清钾钠水平、肌酐、N末端脑钠肽前体(NT-proBNP)、血半乳糖凝集素-3(Gal-3)、左室射血分数(LVEF)、心脏指数(CI)以评估疗效;记录两组药物不良反应以评估安全性.出院后随访6个月,记录两组心力衰竭再住院和死亡情况以评估短期预后;采用Logistic多因素回归模型探讨影响老年难治性心力衰竭短期预后的独立危险因素.结果 与基础治疗组比较,联合用药组临床总有效率明显升高(P<0.05);与治疗前比较,治疗后两组24 h尿量、血Na+、LVEF和CI均显著升高,NT-proBNP和Gal-3显著降低,差异均有统计学意义(P<0.05),但血K+和Scr变化不明显(P>0.05);治疗后,与基础治疗组比较,联合用药组24 h尿量、血Na+、LVEF和CI显著升高,NT-proBNP和Gal-3显著降低,差异均有统计学意义(P<0.05).治疗期间两组均无死亡,其药物总不良反应率无明显差异(P>0.05),经剂量调整及对症治疗后均得到控制.随访期间,联合用药组心力衰竭再住院率和死亡率均较基础治疗组明显降低(P<0.05).经单因素分析得知,老年难治性心力衰竭短期死亡者和生存者在病程、心功能分级、治疗方案、血Na+和LVEF上比较,差异有统计学意义(P<0.05);经Logistic多因素回归模型分析得知心功能分级、治疗方案、血Na+和LVEF是影响老年难治性心力衰竭短期预后的独立危险因素(P<0.05).结论 短期应用托伐普坦联合米力农治疗老年难治性心力衰竭治疗有效,安全性良好,且可明显改善短期预后.

Objective To explore the clinical efficacy and prognosis of short-term application of tolvaptan combined with milrinone in the treatment of refractory heart failure in the elderly.Methods A total of 120 elderly patients with refractory heart failure who were admitted to the Fourth Hospital of Harbin from January 2018 to January 2019 were selected and divided into a basic treatment group and a combined medication group with a random number table method,60 cases each.The basic treatment group was given digitalis,angiotensin-converting enzyme inhibitor,spironolactone,furosemide and other comprehensive treatments;the combined treatment group was given tolvaptan and milrinone;all patients were treated for 5 days.The clinical symptoms,signs,NYHA cardiac function grade,24 h urine output,serum potassium and sodium levels,blood creatinine,blood N-terminal brain natriuretic peptide(NT-proBNP),blood galectin-3(Gal-3).Left ventricular ejection fraction(LVEF)and cardiac index(CI)to evaluate the efficacy;adverse drug reactions of the two groups were recorded to evaluate the safety.Followed up for 6 months after discharge,heart failure re-hospitalization and death in both groups were recorded to assess short-term prognosis;Logistic multivariate regression model was used to explore independent risk factors affecting short-term prognosis of refractory heart failure in the elderly.Results Compared with the basic treatment group,the total clinical effective rate of the combined treatment group was significantly higher(P<0.05).Compared with before treatment,24-hour urine volume,blood Na+,LVEF and CI increased significantly,NT-proBNP and Gal-3 decreased significantly in the two groups after treatment(P<0.05),but there was no significant change in blood K+and SCr(P>0.05).After treatment,compared with the basic treatment group,24-hour urine volume,blood Na+,LVEF and CI in the combined treatment group increased significantly,while NT-proBNP and Gal-3 decreased significantly(P<0.05).There was no death in the two groups.There was no significant difference in the total adverse drug reaction rate between the two groups(P>0.05).After dose adjustment and symptomatic treatment,both groups were controlled.Compared with the basic treatment group,the re-hospitalization rate and mortality rate of heart failure in the combined treatment group were significantly lower(P<0.05).The univariate analysis showed that there were significant differences in course of disease,cardiac function classification,treatment plan,serum Na+and LVEF between the elderly patients with refractory heart failure and the survivors(P<0.05).The logistic multivariate regression analysis showed that cardiac function classification,treatment regimen,serum Na+and LVEF were independent risk factors for short-term prognosis of refractory heart failure in the elderly(P<0.05).Conclusion The short-term application of topiramate combined with milrinone in the treatment of elderly patients with refractory heart failure is effective,safe and it can significantly improve short-term prognosis.