本文關(guān)鍵詞：慢性心衰規(guī)范化治療的價值　出處：《山東大學(xué)》2013年碩士論文　論文類型：學(xué)位論文

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【摘要】：研究背景： 慢性心力衰竭(Chronic Heart Failure, CHF)是由于不同病因的器質(zhì)性心血管疾病引起的心肌收縮力減弱,導(dǎo)致心臟泵血功能低下所致的臨床綜合征。國外最新的流行病學(xué)資料表明,發(fā)達(dá)國家成年人群中CHF發(fā)病率為1～2%,在70歲以上的老年人群中可高達(dá)10%。我國的流行病學(xué)研究顯示中國CHF患病率為0.9%,據(jù)此估計我國35～74歲成年人中有約400萬心衰患者。心衰患者的預(yù)后通常較差,輕度患者年死亡率約5～10%,而重度患者可高達(dá)40%以上,死亡率超過了某些惡性腫瘤。目前心衰患者數(shù)量不斷增加,隨著冠心病及其他心血管病治療手段的提高導(dǎo)致其死亡率降低,這些存活的患者因嚴(yán)重的器質(zhì)性心臟病最終轉(zhuǎn)歸為心力衰竭；另一方面心衰治療理論與實踐的日趨成熟也是不可忽略的因素。據(jù)研究顯示在過去的50年里,心衰患者的生存率不斷提高,這主要得益于人們對慢性心衰的發(fā)病機理的認(rèn)識水平不斷提高以及循證醫(yī)學(xué)試驗的開展,逐步建立起了一套得到各國認(rèn)可的慢性心衰規(guī)范化治療方案,即以神經(jīng)內(nèi)分泌拮抗劑作為基石進(jìn)行規(guī)范化治療。心衰一旦確診,排除禁忌后血管緊張素轉(zhuǎn)化酶抑制劑(Angiotensin Converting Enzyme Inhibiter, ACEI)和p受體阻滯劑的聯(lián)合治療就應(yīng)該啟動,從極小量開始,逐漸用至目標(biāo)劑量,當(dāng)患者不能耐受ACEI時可使用血管緊張素受體拮抗劑(Angiotensin Receptor Blocker, ARB)替代。 盡管世界各國包括我國已認(rèn)可慢性心衰規(guī)范化治療的療效,但是由于我國地域廣,人口眾多,社會醫(yī)療資源分布不均,且對慢性心衰規(guī)范化治療缺乏可以參照的實踐經(jīng)驗,慢性心衰規(guī)范化治療的推廣尚處于起步階段。根據(jù)一項我國基層醫(yī)院慢性心衰的藥物治療現(xiàn)狀調(diào)查,慢性心衰患者p受體阻滯劑使用率為40%,達(dá)口標(biāo)劑最者只有1%,ACEI的使用率為80%,達(dá)目標(biāo)劑量者只有2%,通過地域分析發(fā)現(xiàn)這一情況在偏遠(yuǎn)地區(qū)尤為嚴(yán)重。另一項回顧性調(diào)查顯示,在1980到2010年的20年間,洋地黃的使用率由51.7%降至40.3%,β受體阻滯劑、ACEI、ARB的使用率分別由8.5%、14.0%、0.5%升至19.0%、40.4%、4.5%,說明隨著慢性心衰規(guī)范化治療的推廣,以拮抗神經(jīng)內(nèi)分泌治療的心哀治療已開始被我國醫(yī)生所接受,但是仍處于起步階段,存在著諸如神經(jīng)內(nèi)分泌拮抗劑使用率低,使用劑量不足的問題。慢性心衰規(guī)范化治療可以降低患者死亡率和住院率,利于患者的長期預(yù)后,也可以逐步降低因心衰住院的巨額醫(yī)療花費,因此推廣慢性心衰規(guī)范化治療刻不容緩。 研究目的： 驗證慢性心衰規(guī)范化治療的療效與安全性,嘗試建立適合我國國情的慢性心衰患者門診監(jiān)管體系,改善患者預(yù)后。 資料和方法： 1.入選患者及數(shù)據(jù)采集 收集山東大學(xué)齊魯醫(yī)院心內(nèi)科門診經(jīng)慢性心衰規(guī)范化治療的患者符合納入標(biāo)準(zhǔn),排除禁忌 2.藥物規(guī)范化治療 對于符合入選標(biāo)準(zhǔn)切無禁忌的患者,開始加用β受體阻滯劑和ACEI,從極小劑量開始啟動,用藥期間嚴(yán)格檢測靜息心率、血壓及每日體重變化等情況,如能耐受根據(jù)患者具體情況可每2～4,周劑量增加一倍,直至達(dá)到目標(biāo)劑量或最大耐受劑量。結(jié)合實際采用個體化治療,劑量可因人而異,如果患者不能耐受藥物劑量的增加,如出現(xiàn)水腫等心衰加重的癥狀或體征,可考慮加用利尿劑(常為螺內(nèi)酯聯(lián)合袢利尿劑)和/或小劑量地高辛等藥物以緩解,如果仍不能耐受則維持原劑量,以原劑量作為該患者的目標(biāo)劑量長期維持。如果患者使用ACEI類藥物不能耐受(如嚴(yán)重的干咳),可換用ARB類藥物。當(dāng)患者達(dá)目標(biāo)劑量后按此劑量長期服用。 3.數(shù)據(jù)采集 記錄患者性別、年齡等基本信息,記錄各治療階段的心率、血壓、紐約心臟病協(xié)會(New York Heart Association,NYHA)心功能分級等資料。患者在進(jìn)行慢性規(guī)范化治療前和治療達(dá)目標(biāo)劑量3個月后各進(jìn)行-次心臟超聲檢查,測量患者的左室舒張末內(nèi)徑(Left Ventricular End-diastolic Dimension, LVEDD)及左室射血分?jǐn)?shù)(Left Ventricular Ejection Fraction,LVEF)。 建立數(shù)據(jù)庫并采用SPSS19.0統(tǒng)計分析軟件進(jìn)行分析,指標(biāo)均以均數(shù)±標(biāo)準(zhǔn)差(x±s)的形式表示,采用配對樣本t檢驗、均數(shù)樣本t檢驗進(jìn)行結(jié)果比較,多組間的均數(shù)比較使用One-way ANOVA方式進(jìn)行分析，，所有結(jié)果以P0.05示有統(tǒng)計學(xué)意義。 結(jié)果： 入選患者30名,平均年齡52.2±12.0歲,男性患者63.3%,由冠心病導(dǎo)致心衰者50.0%,各種原發(fā)性心肌病者13.3%,其他原因?qū)е滦募〔∽冋哒?6.7%。慢性心衰規(guī)范化治療前患者收縮壓137.2±18.8mmHg,舒張壓86.9±15.1mmHg,心率80.3±9.2次／分；經(jīng)規(guī)范化治療后收縮壓126.5±17.7mmHg,舒張壓79.8±8.7mmHg,心率62.4±6.7次／分,治療前后患者的收縮壓、舒張壓及心率均具有統(tǒng)計學(xué)差異(P0.05)。治療前NYHA分級為3.2±0.7,規(guī)范化治療后NYHA分級為1.5±0.6,存在統(tǒng)計學(xué)差異(P0.05)。超聲結(jié)果：治療前LVEDD65.8±10.8mm, LVEF30.9％±7.0％；治療后LVEDD61.0±11.6mm,LVEF44.0％±14.2％,規(guī)范化治療前后LVEDD及LVEF均具有統(tǒng)計學(xué)差異(JP0.05)。明尼蘇達(dá)心功能不全生命質(zhì)量量表：治療前量表綜合得分37.8±17.8,身體領(lǐng)域得分11.7±7.5,情緒領(lǐng)域得分11.0±5.9；治療后綜合得分21.2±11.5,身體領(lǐng)域得分7.8±5.4,情緒領(lǐng)域得分5.7±3.3。規(guī)范化治療前后明尼蘇達(dá)心功能不全生命質(zhì)量量表的綜合得分、身體領(lǐng)域得分和情緒領(lǐng)域得分均具有統(tǒng)計學(xué)差異(P0.05)。 亞組分析：采用回顧性分析的方法,將規(guī)范化治療后左心室收縮功能恢復(fù)正常者(LVEF50％)定義為顯效組,LVEF有改善但仍低于50%者定義為有效組,左室收縮功能惡化者為無效組,分別占試驗患者的43.3%、43.3%、13.3%,經(jīng)One-way ANOVA方式進(jìn)行分析,各組年齡、治療前紐約心功能分級及LVEF無統(tǒng)計學(xué)差異(P0.05),但是LVEDD在顯效組與其他兩組之間存在統(tǒng)計學(xué)差異(P0.05)。 結(jié)論： 慢性心衰規(guī)范化治療具有較好的療效,經(jīng)治療后可使患者的心率和血壓降低,達(dá)到或接近合適水平,LVEDD縮小,LVEF得到提升,NYHA分級和明尼蘇達(dá)心功能不全生命質(zhì)量量表評分均得到改善；通過亞組分析發(fā)現(xiàn)經(jīng)過規(guī)范化治療后療效較好的患者,治療前LVEDD較小,而患者年齡、治療前NYHA分級、治療前LVEF未發(fā)現(xiàn)有統(tǒng)計學(xué)差異。故慢性心衰規(guī)范化治療具有較高的臨床應(yīng)用價值,建議在我國進(jìn)一步的推廣施行。
[Abstract]:Research background:
Chronic heart failure (Chronic Heart Failure, CHF) is weakened due to different causes of myocardial contractility in organic cardiovascular diseases caused by, resulting in clinical cardiac function caused by low syndrome. According to the latest foreign epidemiological data, the adult population in developed countries the incidence rate of CHF was 1 ~ 2%, the elderly population at the age of 70 the epidemiological studies can be as high as 10%. in China showed that the prevalence rate of CHF was 0.9% Chinese, according to estimates in China from 35 to 74 years old adults in about 4 million of patients with heart failure. The prognosis of patients with heart failure are usually poor, patients with mild annual death rate of about 5 ~ 10%, and the patients can be as high as 40%, the mortality rate more than some malignant tumors. The increasing number of patients with heart failure, coronary heart disease and other cardiovascular disease improvement of treatment can reduce the mortality, the survival of patients with organic heart disease is serious The final outcome of heart failure; on the other hand, the treatment of heart failure factors of the theory and practice of maturity can not be ignored. According to the study in the past 50 years, the survival rate of patients with heart failure continues to improve, this is mainly due to the pathogenesis of chronic heart failure and continuously improve the understanding level of evidence-based medicine test carry out, gradually establish a set of standardized national recognition of chronic heart failure treatment, which is based on neuroendocrine antagonists is standard treatment. Once the diagnosis of heart failure, after exclusion of contraindications of angiotensin converting enzyme inhibitors (Angiotensin Converting, Enzyme Inhibiter, ACEI) and P receptor blocker combination therapy should be started. From the beginning of a very small amount, gradually to the target dose, when patients intolerant of ACEI can be used when the angiotensin receptor antagonist (Angiotensin Receptor, Blocker, ARB) substitution.
Although countries in the world including China has recognized the effect of standardized treatment of chronic heart failure, but because of China's vast territory, large population, unbalanced distribution of social medical resources, and the lack of reference to the practical experience of the standardized treatment of chronic heart failure, promote the standardized treatment of chronic heart failure is still in its infancy. According to a drug our hospital treatment of chronic heart failure investigation, heart failure in patients with chronic P receptor blocker use was 40%, up to the export standard agent only 1%, ACEI utilization rate was 80%, reached the target dose of only 2%, the geographical analysis found that this situation is particularly serious in rural areas. According to a retrospective survey 1980, in 2010 of 20 years, the use of digitalis was reduced from 51.7% to 40.3%, beta blockers, ACEI and ARB use rate from 8.5%, 14%, 0.5% to 19%, 40.4%, 4.5%, that with chronic heart failure. Promotion of standardized treatment, in treatment of heart failure of neuroendocrine antagonist treatment has begun to be accepted by doctors in China, but is still in the initial stage, such as the existence of neuroendocrine antagonist use rate is low, the problem of insufficient dosage. The standardized treatment of chronic heart failure can reduce mortality and hospitalization rate, long-term prognosis patients, can gradually reduce cost because of the huge medical hospitalization for heart failure, so it is urgent to promote the standardized treatment of chronic heart failure.
The purpose of the study is:
To verify the efficacy and safety of chronic heart failure standardized treatment, try to establish an outpatient supervision system for patients with chronic heart failure suitable for the national conditions of our country, and improve the prognosis of patients.
Information and methods:
1. selected patients and data collection
In the Department of Cardiology, the Department of Cardiology, Qilu Hospital of Qilu Hospital of Shandong University, the standardized treatment of chronic heart failure in the outpatient department of the Department of Cardiology was accorded with the inclusion criteria, and the taboo was excluded.
2. standardized treatment of drugs
For eligible patients without contraindications cut, beginning with beta blockers and ACEI, starting from the minimal dose of medication during the rigorous testing of resting heart rate, blood pressure and body weight changes daily, as tolerated according to the specific circumstances of patients every 2 to 4, Zhou Jiliang doubled until reaching the target or the maximum dose tolerance dose. Combined with the actual use of individual treatment, the dose can be increased if the patients can not tolerate It differs from man to man., drug dosage, such as the emergence of symptoms or signs of edema and the severity of HF, can consider adding diuretics (often spironolactone combined with loop diuretics) and / or small doses of digoxin and other drugs to alleviate, if you still can not maintain tolerance the original dose to the original dose as the target dose of the patients with long-term maintenance. If the patient cannot tolerate the use of ACEI drugs (such as severe dry cough), can be replaced by ARB drugs. When patients reached After the target dose, take this dose for a long time.
3. data collection
Records of patients with gender, age and other basic information, record the treatment stage of the heart rate, blood pressure, New York Heart Association (New York Heart Association, NYHA). The cardiac functional grading in patients with chronic standardized before treatment and reached the target dose 3 months after each time cardiac ultrasound measurement of left ventricular patients with diastolic diameter (Left Ventricular End-diastolic Dimension, LVEDD) and the left ventricular ejection fraction (Left Ventricular Ejection Fraction, LVEF).
The establishment of database and the SPSS19.0 statistical analysis software to analyze the index are mean standard deviation (x + s) in the form of paired sample t test, mean sample t test results were compared between groups were compared using One-way ANOVA analysis, all results in P0.05 showed statistically meaning.
Result錛

本文編號：1362555