充血性心衰ACEI治疗后醛固酮逃逸与螺内脂治疗的预后

The aldosterone escape in patients with congestive heart failure after ACEI treatment and the prognostic meaning after adding spironolactone treatment

目的 观察充血性心衰常规血管紧张素转化酶抑制剂 (ACEI)治疗后 ,血浆血管紧张素Ⅱ (AngⅡ )、醛固酮(Ald)活性变化及醛固酮逃逸程度 ,探讨加用螺内脂治疗对心衰患者预后的影响。方法 93例慢性充血性心衰患者随机分为两组 ,ACEI加螺内脂 (观察组 )和不加螺内脂 (对照组 ) ,采用放射免疫法测定ACEI治疗前、治疗 1个月及 6个月时血浆肾素 (PRA)、AngⅡ、Ald的活性 ,观察治疗前后AngⅡ与Ald的变化及比较两组醛固酮逃逸程度 ;以 6min步行距离为客观指标 ,比较两组治疗后 1,6个月步行距离的改变 ,借以评价心功能改善的程度。结果 ①观察组治疗 1个月后血浆AngⅡ活性明显下降与治疗前比较 ( 14 3± 5 9vs 15 8± 5 8,P <0 0 5 ) ,与对照组比较 ( 14 3± 5 9vs 14 1± 5 7,P >0 0 5 ) ,治疗 6个月后与治疗前比较差异无显著性 ( 166± 5 6vs 15 8± 5 8,P >0 0 5 ) ,与治疗 1个月时比较差异有显著性 ( 166± 5 6vs 14 3± 5 9,P<0 .0 5 ) ,6个月时AngⅡ与对照组比较差异无显著性 ( 166± 5 6vs 167± 5 7)。②观察组治疗 1个月后血浆Ald显著下降( 12 0± 63vs 14 9± 62 ,P <0 0 1) ,继续治疗 6个月时又明显升高。与治疗前比较 ( 2 0 3± 72vs 14 9± 62 ,P <0 0 1) ,与治疗 1个月比较 (P <0 0 1) 。

Objective To observe the changes of plasma angiotensin Ⅱ(Ang Ⅱ) and aldosterone (Ald) activity and the extend of aldosterone escape in patients with congestive heart failure after treatment of angiotensin converting enzyme inhibitor(ACEI)and to explore the effective role after adding spironolactone treatment. Methods Ninety-three consecutive patients with congestive heart failure were divide into two groups randomly: Group one, standard treatment with ACEI, together with spironolactone treatment. Group two, standard treatment with ACEI without spironolactone. The activities of plasma rennin, angiotensin Ⅱ and aldosterone were measured in the two groups before and 1 month and 6 months after ACEI treatment by the method of radioimmunoassay test. The activities of AngⅡ and Ald and the degree of aldosterone escape were compared between the two groups. For identification of improvement of heart function, the distance after 6 minutes walk test was compared between the two groups before and after treatment. Results ①After 1 month treatment there was significantly lower AngⅡ after treatment (143±59 vs 158±58, P <0 05) in spironolactone group but it was not significantly different from the control group (143±59 vs 141±57, P <0 05). After 6 months treatment in pironolactone group there was not significant difference comparing to baseline level (166±56 vs 158±58, P <0 05), but it was significantly higher than 1 month treatment (166±56 vs 143±59, P <0 05). Comparing to control group there was no significant difference in AngⅡ after 6 months treatment (166±56 vs 167±57, P <0 05). ②After one month treatment there was significantly lower Ald than the basline level (120±63 vs 149±62, P <0 01)and continuing treatment to 6 months the plasma Ald dramatically increased in the group one when comparing with the baseline( P <0 01), and comparing with 1 month treatment( P <0 01). There was significant high aldosterone in group one after 6 months treatment compared to control group( P <0 01). ③The distance of 6 minuets walk test was prolonged in group one after 6 months treatment(430±165 vs 348±118, P <0 01). There was significant improvement in walk efficiency in control group after 6 months treatment(388±105 vs 350±120, P <0 05). There was significant difference in 6 minutes walk test after 6 months treatment in two groups (439±165 vs 388±105, P <0 01). Conclusion ①The aldosterone escape appears in congestive heart failure patients with ACEI treatment irrespective of spironolactone use. In terms of aldosterone escape, the effect of spironolactone treatment group seems more apparent comparing with the control group. The spironolactone, an aldosterone receptor antagonist, may combine to the receptor and increase concentration of freed aldosterone in plasma. ②Patients treated with spironlactone has good movement endurance by 6 minutes walking after 6 months treatment. It indicates that spironolactone contribute to improve the prognosis of patients with congestive heart failure by improving heart function and it may infer the major role of aldosterone receptor antagonist in improving the heart and the vessel remolding.