發(fā)布時(shí)間：2019-01-18 17:53

【摘要】：心臟瓣膜病是我國(guó)的常見(jiàn)病,其對(duì)患者的勞動(dòng)能力有很大影響,極大縮短了患者的預(yù)期壽命。據(jù)來(lái)自中國(guó)心臟外科數(shù)據(jù)庫(kù)的統(tǒng)計(jì)表示,我國(guó)每年大約有10余萬(wàn)例患者接受心臟瓣膜置換術(shù),而需要手術(shù)或有手術(shù)指征的病人遠(yuǎn)遠(yuǎn)高于這個(gè)數(shù)據(jù)。心臟瓣膜置換術(shù)由于改善了心臟的血流動(dòng)力學(xué)紊亂,從而在一定程度上為心功能改善奠定了基礎(chǔ)。但是當(dāng)前我國(guó)接受心臟瓣膜置換術(shù)的大部分病人其手術(shù)時(shí)機(jī)均在發(fā)生心功能失代償?shù)那闆r下才進(jìn)行,即病人在手術(shù)前已經(jīng)發(fā)生了嚴(yán)重程度不同的心力衰竭。大量的循證醫(yī)學(xué)證據(jù)也揭示了心力衰竭一旦發(fā)生將呈不可逆轉(zhuǎn)趨勢(shì)。因此心臟瓣膜置換術(shù)后仍然不可能從根本上消除心力衰竭,甚至心力衰竭仍有進(jìn)展之可能。所以,對(duì)于心臟瓣膜置換術(shù)后病人心功能的進(jìn)一步改善,我們不能輕視。目前大量臨床證據(jù)表明,β-受體阻滯劑作為一種通過(guò)神經(jīng)內(nèi)分泌機(jī)制治療心衰的藥物,長(zhǎng)期應(yīng)用有著減緩心率、降低心肌氧耗量、延緩或抑制心室重塑,降低病死率及再住院率的作用。然而β-受體阻滯劑的短期應(yīng)用主要呈現(xiàn)負(fù)性傳導(dǎo)、負(fù)性變時(shí)、負(fù)性變力的“三負(fù)”作用,這也導(dǎo)致了低血壓、心臟傳導(dǎo)阻滯、心動(dòng)過(guò)緩和液體潴等副作用的產(chǎn)生。盡管如此,β-受體阻滯劑對(duì)心力衰竭的治療作用仍無(wú)法替代,許多專(zhuān)家學(xué)者以及治療指南都將其作為心力衰竭標(biāo)準(zhǔn)治療的一個(gè)部分。但國(guó)內(nèi)外大量通過(guò)神經(jīng)內(nèi)分泌機(jī)制治療慢性心力衰竭的長(zhǎng)期臨床試驗(yàn),主要以冠心病、高血壓導(dǎo)致的心力衰竭為主,瓣膜性心臟病心力衰竭則較少,而有關(guān)術(shù)后如何進(jìn)一步改善患者心功能的研究則涉獵甚少。本研究通過(guò)比較術(shù)前、術(shù)后病人在傳統(tǒng)的強(qiáng)心、利尿治療基礎(chǔ)上,加用美托洛爾治療后患者心功能的改善情況,分析藥物實(shí)驗(yàn)組的療效,為臨床醫(yī)師應(yīng)用美托洛爾改善患者瓣膜術(shù)后的心功能提供參照,提高患者術(shù)后生存質(zhì)量。研究目的觀察美托洛爾的使用對(duì)心臟瓣膜置換術(shù)后病人進(jìn)一步改善心功能的狀況。研究方法收集2013年2月至2014年6月于本院行心臟瓣膜置換術(shù)且術(shù)后按期隨訪的病例共96例,隨機(jī)分成實(shí)驗(yàn)組與對(duì)照組。經(jīng)比較兩組患者在年齡、性別、心功能方面的差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.05),說(shuō)明兩組患者具有可比性。對(duì)照組給予強(qiáng)心、利尿等傳統(tǒng)藥物治療,實(shí)驗(yàn)組在對(duì)照組的基礎(chǔ)上加用美托洛爾片,小劑量開(kāi)始逐漸加量,根據(jù)心功能情況調(diào)整劑量。觀察患者臨床癥狀和體征、實(shí)驗(yàn)室檢查,術(shù)后3個(gè)月行動(dòng)態(tài)超聲心動(dòng)圖檢查,測(cè)量左室收縮末期內(nèi)徑(LVES),左室舒張末期內(nèi)徑(LVED),左室射血分?jǐn)?shù)(LVEF),E/A數(shù)值,評(píng)價(jià)心功能。治療3個(gè)月后比較兩組患者治療效果。將所有數(shù)據(jù)進(jìn)行統(tǒng)計(jì)學(xué)分析。結(jié)果3個(gè)月后結(jié)果統(tǒng)計(jì),實(shí)驗(yàn)組顯效15例,有效29例,無(wú)效4例,總有效率91.7%;對(duì)照組顯效6例,有效28例,無(wú)效14例,總有效率70.8%;根據(jù)結(jié)果可知,實(shí)驗(yàn)組治療效果明顯優(yōu)于對(duì)照組(P0.05)。兩組手術(shù)前及術(shù)后3個(gè)月時(shí)左室舒張功能指標(biāo)比較,實(shí)驗(yàn)組的各項(xiàng)指標(biāo)改善顯著高于對(duì)照組(P0.05)。與術(shù)前相比較,兩組患者手術(shù)后心功能都有所改善,術(shù)后3個(gè)月改善明顯,術(shù)后心功能達(dá)NYHA I級(jí)者19例(19.8%),NYHA II級(jí)者65例(67.7%),NYHA III級(jí)者12例(12.5%),提示大部分患者在術(shù)后3個(gè)月心功能都有改善,但距離我們明顯改善患者生存質(zhì)量的要求仍有差距,觀察組治療效果明顯優(yōu)于對(duì)照組。該課題未能揭示心力衰竭的嚴(yán)重程度與藥物劑量之間的關(guān)系。研究結(jié)論與傳統(tǒng)的抗心衰治療方法相比,加用美托洛爾可以有效的改善術(shù)后患者心功能,顯著降低再住院率,改善患者生活質(zhì)量,提高預(yù)期壽命。心臟瓣膜置換術(shù)雖然解除了心臟結(jié)構(gòu)異常性所致的血流動(dòng)力學(xué)異常,為進(jìn)一步改善心功能奠定了基礎(chǔ),但并不能全面阻止心衰的發(fā)展。只有在手術(shù)的基礎(chǔ)上采用神經(jīng)內(nèi)分泌治療,穩(wěn)定和促進(jìn)術(shù)后患者的心功能才更有意義。所以,在心臟瓣膜置換術(shù)后,我們應(yīng)當(dāng)在長(zhǎng)期使用β-受體阻滯劑,并根據(jù)患者自身病情,逐步調(diào)整到最大劑量,充分發(fā)揮其生物學(xué)效應(yīng),延緩心衰的進(jìn)一步發(fā)展。
[Abstract]:Valvular heart disease is a common disease in our country, it has a great influence on the patient's working ability, and greatly shortens the life expectancy of the patient. According to the statistics from the Chinese heart surgery database, about 100,000 patients in China receive heart valve replacement each year, and the patients who need surgery or surgical finger sign are far higher than this data. Cardiac valve replacement provides a basis for improving cardiac function by improving the hemodynamic disorder of the heart. However, most of the patients undergoing cardiac valve replacement in our country are in the condition of decompensation of heart function, that is, the patient has undergone a different degree of heart failure before the operation. A large number of evidence-based medical evidence also reveals that the occurrence of heart failure will be irreversible. Therefore, it is still not possible to fundamentally eliminate the heart failure after the heart valve replacement, and even the heart failure can still be made possible. Therefore, for the further improvement of the heart function of the patient after the heart valve replacement, we can not despise. At present, a large number of clinical evidence has shown that as a drug for the treatment of heart failure via a neuroendocrine mechanism, a long-term application has the effects of slowing the heart rate, reducing the amount of myocardial oxygen consumption, delaying or inhibiting the ventricular remodeling, reducing the case-fatality rate and the re-hospitalization rate. However, the short-term application of the antigen-receptor blocker mainly presents the 鈥淚II. Negative鈥，

本文編號(hào)：2410960