本文選題：心力衰竭 + 治療�。� 參考：《北京協(xié)和醫(yī)學(xué)院》2017年碩士論文

【摘要】：目的:我國(guó)心力衰竭(心衰)住院患者的治療和預(yù)后情況以往有所報(bào)道,但門診心衰患者的情況尚不了解,本研究旨在了解真實(shí)世界中我國(guó)心衰患者的臨床特征,治療情況及預(yù)后。方法:采用前瞻性、多中心注冊(cè)研究,連續(xù)入選2012年12月至2014年11月在我國(guó)不同地區(qū)、不同級(jí)別的24家醫(yī)院門診或住院的972例心衰患者,收集患者的人口學(xué)和臨床資料以及治療情況。在1年時(shí)進(jìn)行隨訪,采用配對(duì)卡方分析比較患者的藥物治療情況。觀察的終點(diǎn)事件為全因死亡、因心衰再住院以及全因死亡/因心衰再住院的聯(lián)合終點(diǎn),分別應(yīng)用單變量和多變量Cox和logistic回歸模型分析評(píng)價(jià)終點(diǎn)事件的影響因素。結(jié)果:患者平均年齡65.6±13.0歲,男性557例(57.3%),門診患者610例(62.8%)。合并高血壓、糖尿病、心肌梗死或行血運(yùn)重建術(shù)、卒中史的患者分別占59.1%、21.7%、25.2%和16.9%,紐約心臟病協(xié)會(huì)(NYHA)Ⅲ/Ⅳ級(jí)者占58%,其中住院患者明顯高于門診患者(70.4%vs 50.8%,P0.001)。無(wú)論住院或門診就診以及左室射血分?jǐn)?shù)(LVEF)50%或≥50%,走坡路時(shí)呼吸困難的心衰患者均占90%以上,而走平路時(shí)呼吸困難、夜間陣發(fā)性呼吸困難和休息時(shí)呼吸困難在住院的心衰患者(72.1%vs 56.9%,49.3%vs 31.3%,29.6%vs 15.1%,均 P0.001)和 LVEF50%的患者(67.5%vs 56.6,P0.005,;43.3%vs 35.1%,P0.05;27.9%vs 15.0%,P0.001)更多。入選時(shí)心電圖顯示房顫或房撲者227例(25.7%),53.4%的患者超聲心動(dòng)圖LVEF50%。缺血性心臟病是心衰的首要病因(52.2%),其次是高血壓性心臟病(16.9%)、擴(kuò)張型心肌病(14.1%)和瓣膜性心臟病(9.5%)。入選時(shí)心衰的藥物治療中血管緊張素阻滯劑(ABs)(血管緊張素轉(zhuǎn)換酶抑制劑(ACEI)或血管緊張素受體阻滯劑(ARB))的使用率為65.7%(ACEI 34.3%,ARB 32.0%),其次為阿司匹林、利尿劑和β-受體阻滯劑,分別為62.6%、60.5%和60.0%。超過(guò)一半的患者使用了醛固酮受體拮抗劑,硝酸酯類藥和地高辛的使用分別為36.2%和26.1%。門診患者中β-受體阻滯劑的應(yīng)用多于住院患者(63.1%vs 54.7%,P0.05),LVEF50%的患者β 受體阻滯劑(66.5%vs 60.5%,P0.05)、ACEI(45.4%vs 29.7%,P0.001)和醛固酮受體拮抗劑(70.5%vs 47.0%,P0.001)的使用均明顯多于LVEF≥500%的患者。隨著入選時(shí)NYHA心功能級(jí)別增加,ACEI和醛固酮受體拮抗劑的使用逐漸增多。入選時(shí)β-受體阻滯劑、ACEI、ARB劑量達(dá)標(biāo)率分別為5.2%、29.9%、10.6%,其中門診患者β-受體阻滯劑(6.5%vs 2.5%,P0.05)、ACEI(34.0%vs 25.1%)的劑量達(dá)標(biāo)率高于住院患者(P0.05)。與入選時(shí)相比,一年隨訪時(shí)除抗凝劑的應(yīng)用率有所增加外(11.6%vs9.9%,P0.05),β-受體阻滯劑和ACEI使用率無(wú)變化,而ARB(30.2%vs32.7%,P0.05)和醛固酮受體拮抗劑(47.5%vs 53.6%,P0.001)的使用率有所減少。ARB使用率降低主要見(jiàn)于門診患者,而醛固酮受體拮抗劑使用率降低主要見(jiàn)于住院患者。一年隨訪時(shí)僅ACEI的劑量達(dá)標(biāo)率高于入選時(shí)(36.6%vs29.9%,P0.05)。一年隨訪時(shí),NHYAⅢ/Ⅳ級(jí)的患者比例明顯低于入選時(shí)(29.1%vs 56.5%,P0.001),患者的全因死亡率為7.9%,因心衰再住院率和聯(lián)合終點(diǎn)發(fā)生率分別為30.2%,和33.9%,其中住院患者因心衰再住院率(37.2%vs 26.00%,P0.001)以及聯(lián)合終點(diǎn)發(fā)生率(42.0%vs 29.1%,P0.001)均明顯高于門診患者。多因素Cox回歸分析顯示糖尿病、吸煙,雙側(cè)胸腔積液和硝酸酯類藥物應(yīng)用是心衰患者一年全因死亡的獨(dú)立危險(xiǎn)因素;多因素Logistic回歸分析顯示一年隨訪時(shí)因心衰再住院和聯(lián)合終點(diǎn)的獨(dú)立危險(xiǎn)因素均為NYHA心功能Ⅲ/Ⅳ級(jí)、糖尿病,X線心/胸比0.5和慢性阻塞性肺疾病(COPD)。結(jié)論:首先,缺血性心臟病是我國(guó)心衰患者的主要病因,擴(kuò)張型心肌病導(dǎo)致的心衰已明顯超過(guò)風(fēng)濕性心臟瓣膜病。其次,心衰患者的規(guī)范化藥物治療有待于提高,不僅體現(xiàn)在有改善預(yù)后意義的抗心衰藥物使用率低,依從性差,更體現(xiàn)在β-受體阻滯劑、ACEI和ARB的劑量達(dá)標(biāo)率低。第三,無(wú)論從心衰患者的癥狀,NYHA心功能分級(jí),藥物治療和預(yù)后方面,住院和門診的心衰患者均存在差異,因此,未來(lái)應(yīng)更加重視對(duì)全部心衰患者的評(píng)估,更全面地了解我國(guó)心衰患者的真實(shí)情況。
[Abstract]:Objective: the treatment and prognosis of patients with heart failure (heart failure) in our country have been reported in the past, but the situation of patients with heart failure is not yet understood. The purpose of this study is to understand the clinical characteristics, treatment and prognosis of heart failure patients in the real world. Methods: a forward-looking, multi center registration study and continuous selection from December 2012 to 2014. The demographic and clinical data and treatment of 972 patients with heart failure in 24 hospitals of different levels and in 24 hospitals of different levels were collected and compared with the patient's drug treatment at 1 years. The end point of the observation was all cause death, heart failure hospitalization and all causes. The combined endpoints of death / heart failure and rehospitalization were analyzed with univariate and multivariate Cox and logistic regression models respectively. Results: the average age of the patients was 65.6 + 13 years, 557 men (57.3%), 610 outpatients (62.8%). Combined with high blood pressure, diabetes, myocardial infarction, or revascularization, stroke history The patients accounted for 59.1%, 21.7%, 25.2% and 16.9% respectively, and the New York Heart Association (NYHA) class III / IV was 58%, and the hospitalized patients were significantly higher than the outpatients (70.4%vs 50.8%, P0.001). No matter the hospitalization or outpatient clinic and the left ventricular ejection fraction (LVEF) 50% or more 50%, the patients with dyspnea were more than 90% in the walk road, while the breathing was on the flat road. Difficulties, nocturnal paroxysmal dyspnea, and breathing difficulties during rest in hospitalized heart failure patients (72.1%vs 56.9%, 49.3%vs 31.3%, 29.6%vs 15.1%, P0.001) and LVEF50% patients (67.5%vs 56.6, P0.005, 43.3%vs 35.1%, P0.05; 27.9%vs 15%, P0.001). 227 cases (25.7%), 53.4% of patients with atrial fibrillation or atrial flutter (25.7%) were selected at the time of entry. Acoustic cardiogram LVEF50%. ischemic heart disease is the primary cause of heart failure (52.2%), followed by hypertensive heart disease (16.9%), dilated cardiomyopathy (14.1%) and valvular heart disease (9.5%). Angiotensin blocker (ABs) (angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (AR) in the drug treatment of heart failure at the time of selection (AR) B)) use of 65.7% (ACEI 34.3%, ARB 32%), followed by aspirin, diuretics and beta blockers, 62.6%, 60.5%, and more than half of the patients with aldosterone receptor antagonists, nitrate and digoxin used in 36.2% and 26.1%. outpatients for beta blockers more than hospitalized patients. Patients (63.1%vs 54.7%, P0.05), LVEF50% patients with beta blockers (66.5%vs 60.5%, P0.05), ACEI (45.4%vs 29.7%, P0.001) and aldosterone receptor antagonists (70.5%vs 47%, P0.001) were significantly more used in patients with LVEF than 500%. With the increase in the grade of NYHA cardiac power, the use of the antagonists and aldosterone receptor antagonists increased gradually. The dose rate of beta blocker, ACEI, and ARB was 5.2%, 29.9%, 10.6%, respectively. The rate of beta blocker (6.5%vs 2.5%, P0.05), ACEI (34.0%vs 25.1%) was higher than that of hospitalized patients (P0.05). The rate of anticoagulant application was increased (11.6%vs9.9%, P0.05) and beta receptor resistance at one year follow-up. The use of hysteresis and ACEI was not changed, while the use of ARB (30.2%vs32.7%, P0.05) and aldosterone receptor antagonists (47.5%vs 53.6%, P0.001) decreased the.ARB use rate and decreased mainly in outpatients, while the reduction of aldosterone receptor antagonists was mainly in hospitalized patients. The rate of only ACEI at one year follow-up was higher than that of the admission (3 6.6%vs29.9%, P0.05). At a one-year follow-up, the proportion of patients with NHYA III / IV was significantly lower than that of the admission (29.1%vs 56.5%, P0.001). The total cause mortality was 7.9%, the rate of rehospitalization and the joint endpoint of heart failure were 30.2%, and 33.9% respectively, and the rate of hospitalization for heart failure (37.2%vs 26%, P0.001) and the incidence of joint endpoints were in the hospital. 42.0%vs 29.1%, P0.001) were significantly higher than outpatients. Multifactor Cox regression analysis showed that diabetes, smoking, bilateral pleural effusion, and nitroester use were independent risk factors for one year all cause death in patients with heart failure; multiple factor Logistic regression analysis showed an independent risk of heart failure rehospitalization and joint endpoint at one year's follow-up. NYHA cardiac function was grade III / IV, diabetes, X-ray cardiac / thoracic ratio 0.5 and chronic obstructive pulmonary disease (COPD). Conclusion: first, ischemic heart disease is the main cause of heart failure in China. Dilated cardiomyopathy is obviously more than rheumatic valvular heart failure. The drug use rate is low, the compliance is poor, and the dose rate of ACEI and ARB is low. Third, there are differences in the symptoms of heart failure, the classification of NYHA heart function, the drug treatment and the prognosis in both hospitalized and outpatient heart failure patients, therefore, the future should be more aggravated. All patients with heart failure can be assessed for a more comprehensive understanding of the real situation of patients with heart failure in China.
【學(xué)位授予單位】：北京協(xié)和醫(yī)學(xué)院
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R541.6

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