伊伐布雷定联合艾司洛尔对脓毒症心肌病急性期心率及预后的影响

Effect of Ivabradine Combined with Esmolol on Heart Rate and Prognosis in Acute Stage of Septic Cardiomyopathy

目的探讨伊伐布雷定联合艾司洛尔对脓毒症心肌病急性期心率(HR)及预后的影响。方法选择2021年3月至2023年3月徐州医科大学附属滕州医院重症医学科收治的100例脓毒症心肌病急性期患者为研究对象,均接受标准脓毒症治疗。按照不同治疗方法分为对照组和联合组,每组50例。对照组在标准脓毒症治疗基础上给予艾司洛尔治疗:静脉泵入负荷量0.50 mg/(kg·min),持续输注1 min,而后以0.05 mg/(kg·min)的剂量持续输注4 min,每日1次,连续治疗7 d;联合组在对照组基础上给予伊伐布雷定治疗:起始剂量5 mg/次,每日2次,期间可根据患者HR调整剂量,最大剂量不超过7.5 mg/次,每日2次,连续治疗7 d。观察两组患者治疗前后HR控制情况,比较治疗前后血流动力学指标[血乳酸(Lac)、中心静脉压(CVP)及氧合指数(OI)]、心功能指标[心脏指数(CI)、左心室舒张末期内径(LVEDD)、左心室射血分数(LVEF)]、心肌损伤标志物[脑钠肽(BNP)、心肌肌钙蛋白I(cTnI)、肌酸激酶同工酶MB(CK-MB)]变化及治疗期间不良反应发生情况,记录两组患者入院28 d死亡率。结果治疗前后HR时点间的主效应差异有统计学意义(P<0.01),不考虑测量时间,两组间的主效应差异有统计学意义(P<0.01),两组HR均于治疗后1 h开始下降,其中联合组HR于治疗后6 h趋于平缓,对照组HR于治疗后12 h趋于平缓。联合组治疗后6、12、24 h HR达标率均高于对照组[56.00%(28/50)比32.00%(16/50)、78.00%(39/50)比58.00%(29/50)、94.00%(47/50)比80.00%(40/50)](P<0.05)。联合组ΔHR12、ΔHR24均小于对照组(15.2±2.6比24.5±6.2、18±4比28±6)(P<0.01)。治疗后,两组Lac、BNP、cTnI、CK-MB水平较治疗前均降低(P<0.05),且联合组Lac、BNP、cTnI、CK-MB水平低于对照组(P<0.01);CVP、OI、CI、LVEF较治疗前均升高(P<0.05),且联合组CVP、OI、CI、LVEF高于对照组(P<0.01);LVEDD较治疗前均减小(P<0.05),但两组间比较差异无统计学意义(P>0.05)。治疗期间,两组不良反应发生率比较差异无统计学意义(P>0.05);联合组入院28 d死亡率低于对照组[30.00%(15/50)比52.00%(26/50)](χ^(2)=5.002,P=0.025)。结论伊伐布雷定联合艾司洛尔可更快、更好地控制脓毒症心肌病急性期患者HR,同时改善患者心功能,降低心肌损伤发生风险,提高早期生存率。

Objective To prospectively explore the effect of ivabradine combined with esmolol on heart rate(HR)and prognosis in acute stage of septic cardiomyopathy.Methods A total of 100 patients with acute stage of septic cardiomyopathy admitted to the Department of Intensive Care Medicine of Tengzhou Hospital Affiliated to Xuzhou Medical University from Mar.2021 to Mar.2023 were included,all of whom received standard sepsis treatment.According to different treatment methods,they were divided into a control group and a combination group,with 50 cases in each group.The control group was given esmolol on the basis of standard sepsis treatment:intravenously pumped 0.50 mg/(kg·min)for 1 min,then 0.05 mg/(kg·min)for 4 min,once a day for 7 days continuously;the combination group was given ivabradine on the basis of the control group:the initial dose was 5 mg/time,twice a day,during which the dose could be adjusted according to the patient′s HR and the maximum dose was 7.5 mg/time,twice a day,for 7 days continuously.The control of HR before and after treatment was observed in the two groups,the changes of hemodynamic indexes[blood lactic acid(Lac),central venous pressure(CVP)and oxygenation index(OI)],cardiac function indexes[heart index(CI),left ventricular end-diastolic diameter(LVEDD),left ventricular ejection fraction(LVEF)],markers of myocardial injury[brain natriuretic peptide(BNP),myocardial troponin I(cTnI),creatine kinase isoenzyme-MB(CK-MB)]of the two groups before and after treatment were compared,as well as the occurrence of adverse reactions during treatment.The mortality rate at 28 days after admission of the two groups was recorded.Results The main effect difference between HR time points before and after treatment was statistically significant(P<0.01),regardless of the measurement time,the main effect difference between the two groups was statistically significant(P<0.01).HR in both groups began to decline 1 h after treatment,and HR in the combination group tended to be stable at 6 h after treatment,while HR in the control group tended to be stable at 12 h after treatment.The HR compliance rates at 6 h,12 h and 24 h after treatment of the combination group were higher than those of the control group[56.00%(28/50)vs 32.00%(16/50),78.00%(39/50)vs 58.00%(29/50),94.00%(47/50)vs 80.00%(40/50)](P<0.05).TheΔHR12 andΔHR24 in the combination group were lower than those in the control group(15.2±2.6 vs 24.5±6.2,18±4 vs 28±6)(P<0.01).After treatment,the levels of Lac,BNP,cTnI and CK-MB in both groups were lower than before treatment(P<0.05),and the levels of Lac,BNP,cTnI and CK-MB in the combination group were lower than those in the control group(P<0.01);CVP,OI,CI and LVEF were all increased compared with those before treatment(P<0.05),and CVP,OI,CI and LVEF in the combination group were higher than those in the control group(P<0.01);LVEDD decreased compared with that before treatment,but there was no significant difference between the two groups(P>0.05).During treatment,there was no significant difference in the incidence of adverse reactions between the two groups(P>0.05);the mortality rate at 28 days after admission in the combination group was lower than that in the control group[30.00%(15/50)vs 52.00%(26/50)](χ^(2)=5.002,P=0.025).Conclusion Ivabridine combined with esmolol can control HR faster and better in patients with acute stage of septic cardiomyopathy,improve cardiac function,reduce the risk of myocardial injury,and improve early survival of the patients.