不同血压控制目标和用药方案对老年心衰合并高血压患者预后的影响研究

Study on influence of different blood pressure control goals and medication regimens on prognosis of elderly patients with heart failure complicated with hypertension

目的分析不同血压控制目标和用药方案对老年心力衰竭(心衰)合并高血压患者预后的影响。方法选取150例老年心衰合并高血压患者,其中118例获得有效随访,按照入院时血压控制目标将118例患者分别纳入强化降压组[入院1 h内降压目标:收缩压<130 mm Hg(1 mm Hg=0.133 kPa);74例]、非强化降压组(入院1 h内降压目标:收缩压130~150 mm Hg;44例);另外按照出院时口服降压药物不同将其分别纳入A组(22例)、B组(27例)、C组(24例)、D组(25例)、E组(20例)。A组接受钙离子拮抗剂(CCB)联合血管紧张素转化酶抑制剂(ACEI)治疗,B组接受CCB联合血管紧张素Ⅱ受体拮抗剂(ARB)治疗,C组接受ACEI联合利尿剂治疗,D组接受ARB联合利尿剂治疗,E组接受CCB联合β受体阻滞剂(β-B)治疗。分析不同血压控制目标对患者预后的影响,以及不同用药方案对患者预后的影响。结果强化降压组与非强化降压组入组时左室射血分数(LVEF)、左室舒张末期内径(LVEDd)、左室收缩末期内径(LVESd)、氨基末端脑钠肽前体(NT-proBNP)、收缩压、舒张压、日间收缩压标准差(dSSD)、日间舒张压标准差(dDSD)、夜间收缩压标准差(nSSD)及夜间舒张压标准差(nDSD)比较,差异无统计学意义(P>0.05);随访6个月时,两组LVEF均较入组时升高,LVEDd、LVESd、NT-proBNP、收缩压、舒张压、dSSD、dDSD、nSSD、nDSD均较入组时下降,强化降压组LVEF(45.41±2.53)%高于非强化降压组的(42.08±2.96)%,LVEDd(46.51±2.44)mm、LVESd(32.98±1.89)mm、NT-proBNP(360.15±33.14)pg/ml、收缩压(133.28±16.47)mm Hg、舒张压(82.93±6.95)mm Hg、dSSD(8.67±1.62)mm Hg、dDSD(8.14±0.29)mm Hg、nSSD(7.28±2.03)mm Hg、nDSD(8.09±1.46)mm Hg均低于非强化降压组的(51.44±4.07)mm、(38.03±1.49)mm、(577.14±35.60)pg/ml、(145.23±12.39)mm Hg、(87.71±7.16)mm Hg、(10.62±2.45)mm Hg、(8.27±0.33)mm Hg、(9.51±1.37)mm Hg、(8.79±1.35)mm Hg,差异有统计学意义(P<0.05)。强化降压组随访1年内心衰再住院率2.70%低于非强化降压组的18.18%,差异有统计学意义(P<0.05);两组死亡率比较差异无统计学意义(P>0.05)。随访6个月时,A组、B组、C组、D组的LVEF均高于E组,LVEDd、LVESd、NT-proBNP及收缩压、舒张压、dSSD、dDSD、nSSD、nDSD均低于E组,差异有统计学意义(P<0.05);A组、B组、C组、D组随访1年内心衰再住院率分别为0、3.70%、4.17%、4.00%,低于E组的35.00%,差异有统计学意义(P<0.05);五组死亡率比较差异无统计学意义(P>0.05)。结论老年心衰合并高血压患者接受早期强化降压治疗后,其心功能恢复及血压控制效果更为理想;除CCB联合β-B外,根据患者个体情况选择CCB、ACEI、ARB、利尿剂药物联合应用均可实现良好的血压控制效果,降低心衰再住院风险。

Objective To analyze the influence of different blood pressure control goals and medication regimens on prognosis of elderly patients with heart failure complicated with hypertension.Methods A total of 150 elderly patients with heart failure combined with hypertension were selected,of which 118 cases were effectively followed up.According to the blood pressure control goals at the time of admission,the 118 patients were included in the intensive antihypertensive group[antihypertensive goal within 1 h of admission:systolic blood pressure<130 mm Hg(1 mm Hg=0.133 kPa);74 cases]and the non-intensive antihypertensive group(antihypertensive goal within 1 h of admission:systolic blood pressure 130-150 mm Hg;44 cases);in addition,they were included in group A(22 cases),group B(27 cases),group C(24 cases),group D(25 cases),and group E(20 cases)according to the difference of antihypertensive medications taken at the time of discharge.Group A received calcium channel blocker(CCB)combined with angiotensin-converting enzyme inhibitor(ACEI),group B received CCB combined with angiotensinⅡreceptor blockers(ARB),group C received ACEI combined with diuretic,group D received ARB combined with diuretic,and group E received CCB combined withβ-blocker(β-B).The influence of different blood pressure control objectives on the prognosis of patients was analyzed,and the influence of different medication regimens on the prognosis of patients.Results The left ventricular ejection fraction(LVEF),left ventricular end-diastolic diameter(LVEDd),left ventricular end-systolic diameter(LVESd),amino-terminal pro-brain natriuretic peptide(NT-proBNP),systolic blood pressure,day systolic blood pressure standard deviation(dSSD),day diastolic blood pressure standard deviation(dDSD),night systolic blood pressure standard deviation(nSSD)and night diastolic blood pressure standard deviation(nDSD)were compared between the intensive antihypertensive group and the non-intensive antihypertensive group,and there was no significant difference(P>0.05).At 6 months of follow-up,LVEF in both groups was higher than that at the time of enrollment,while LVEDd,LVESd,NT-proBNP,systolic blood pressure,diastolic blood pressure,dSSD,dDSD,nSSD and nDSD were lower than those at the time of enrollment;the intensive antihypertensive group had higher LVEF of(45.41±2.53)% than(42.08±2.96)% in the non-intensive antihypertensive group;the intensive antihypertensive group had LVEDd of(46.51±2.44)mm,LVESd of(32.98±1.89)mm,NT-proBNP of(360.15±33.14)pg/ml,systolic blood pressure of(133.28±16.47)mm Hg,diastolic blood pressure of(82.93±6.95)mm Hg,dSSD of(8.67±1.62)mm Hg,dDSD of(8.14±0.29)mm Hg,nSSD of(7.28±2.03)mm Hg and nDSD of(8.09±1.46)mm Hg,which were lower than(51.44±4.07)mm,(38.03±1.49)mm,(577.14±35.60)pg/ml,(145.23±12.39)mm Hg,(87.71±7.16)mm Hg,(10.62±2.45)mm Hg,(8.27±0.33)mm Hg,(9.51±1.37)mm Hg and(8.79±1.35)mm Hg in the non-intensive antihypertensive group;there was significant difference(P<0.05).The rate of heart failure rehospitalization within 1 year of follow-up was 2.70% in the intensive antihypertensive group,which was lower than 18.18%in the non-intensive antihypertensive group,and there was significant difference(P<0.05).The difference in mortality rate between the two groups was not statistically significant(P>0.05).At 6 months of follow-up,the LVEF of group A,group B,group C,and group D was higher than that of group E;the LVEDd,LVESd,NT-proBNP and systolic blood pressure,diastolic blood pressure,dSSD,dDSD,nSSD,and nDSD were lower than that of group E,and there was significant difference(P<0.05).The rates of heart failure rehospitalization within 1 year of follow-up in group A,group B,group C,and group D were 0,3.70%,4.17%,and 4.00%,which were lower than 35.00% of group E,and the difference was statistically significant(P<0.05).There was no statistically significant difference in mortality rate among the five groups(P>0.05).Conclusion After receiving early intensified antihypertensive treatment,elderly patients with heart failure and hypertension have better cardiac function recovery and blood pressure control effects;in addition to CCB combined with β-B,the combination of CCB,ACEI,ARB and diuretics selected according to the individual situation of patients can also achieve good blood pressure control effect and reduce the risk of rehospitalization of heart failure.