射血分数正常心力衰竭

1、射血分数正常心力衰竭概 念临床中具有明显心力衰竭表现而左室射血分数(EF)EF45%者，称之为射血分数正常的心力衰竭(HFNEF)。又称为收缩功能保存的心衰（HFPEF）,或舒张性心力衰竭（DHF）.流行病学特点约有20%一60%的慢性心力衰竭病人属于HFPEF，且多发生在老年、女性、肥胖、有高血压、房颤、糖尿病史的人群； HFPEF在老年女性中最常见，女性年龄老化对舒张功能的影响更加敏感。 HFPEF病理生理特点心室主动松弛能力受损 ：影响因素有 Ca2+-ATP酶表达减少或活性降低，肌浆网磷酸受纳蛋白活性增高，心肌缺血、低氧血症导致的能量代谢障碍等；心室壁僵硬度增加（顺应性降低） ：影响心

2、肌僵硬度的因素包括:心肌纤维化、细胞支架蛋白的改变、以及心肌局部病变和某些全身性疾病。扩张储备功能降低，血管顺应性降低。 HFPEF病理生理特点3.年龄老化 ：年龄老化降低心脏和大 血管弹性，结果导致收缩压升高和 心肌僵硬度增加。 HFPEF特征左室腔不大；向心性肥厚；LVEF正常；与HFREF相比，心肌细胞直径较大，肌丝密度较高HFPEF病因 心室松弛受损、室壁僵硬度增加主要病因有高血压、冠心病、心肌病变、糖尿病、房颤及老龄化等因素。HFPEF诊断要点典型心力衰竭症状或体征 ；LVEF正常（45%），心室腔大小正常；超声心动图有左室舒张功能异常的证据，左室充盈压增高； 超声心动图检查无心脏瓣

3、膜疾病，并可排除心包疾病、肥厚性心肌病、限制性（浸润性）心肌病等；BNP升高。 HFREFHFPEFDyspnea,edema,fatigue+LVEDV-LV massLV geometryecentricconcentricESPVR-LVEDPEDPVRvariable (stiffer)BNPHFPEF辅助检查超声心动图 血流多普勒 E-舒张早期血流峰值速度 A-心房收缩血流峰值速度 EDT-E峰减速时间 早期松弛受损 E /A 1 中度松弛受损（“假性正常化” ） E/A EDT 可正常 重度松弛受损 限制性充盈异常 E /A增大 EDT缩短HFPEF辅助检查 超声心动图 组织多普勒

4、 Ea-舒张早期E峰 Aa-舒张晚期A峰 Vp(彩色M型多普勒)-舒张早期传播速度 Ea/Aa=10 Vp2.5提示PCWP15mmHg，两者有很好的相关性 HFPEF辅助检查心电图：房颤及其他心律失常；心肌梗死、缺血；左室肥厚；血浆心房肽和脑钠肽增高 ；胸片：肺淤血、肺水肿，心脏大小正常；核医学检查 ：PFR、 TPFR和1/3FF；心导管：右房压、肺动脉和肺毛细血管楔压(12mmHg)；冠脉造影：有心绞痛或其他缺血证据，药物治疗效果差，需明确诊断并考虑血运重建治疗。 鉴别诊断 原发性瓣膜疾病、限制性（浸润性）心肌病、心肌淀粉样变性、心包缩窄、发作性或可逆转的左室收缩功能不全、高代谢（高输出

5、量状态）的心衰、慢性肺疾病合并右心衰竭、与肺血管疾病有关的肺动脉高压、心房黏液瘤 2007年中国指南（DHF治疗）控制血压160 mm Hg; prior EF 2.5, Hb 11PlaceboForced titrationMaintenanceEnrollmentSingle-blind2 weeksW 2W 4W 8M 6M 10M 14 to endEvery 4 months75 mg150 mg300 mgFollow-up continued until 1,440 primary endpoints occurredN=4,128I-PRESERVE: Study Desig

6、nIrbesartanROnly 1/3 pts could enter on an ACEIRandomized, double-blind, placebo controlled trialI-PRESERVE: OutcomesPrimary endpoint: All cause mortality and protocol-specified CV hospitalizations (for heart failure, MI, unstable angina, stroke, ventricular or atrial arrhythmia).Secondary endpoints

7、:All cause mortalityCV deathHF death or HF hospitalizationCV death, MI or strokeQoL (Minnesota)Change in BNP levelsI-PRESERVE: Primary EndpointDeath or protocol specified CV hospitalizationMonths from RandomizationCumulative Incidence of Primary Events (%)40 -0 -10 -20 -30 -0612182436423048605420671

8、9291812173016401513129115691088497816206119211808171516181466124615391051446776No. at RiskIrbesartanPlaceboHR (95% CI) = 0.95 (0.86-1.05)Log-rank p=0.35PlaceboIrbesartanPrimary Outcome with Component Events* Protocol-specifiedVentricular arrhythmiaAtrial arrhythmiaStrokeUnstable anginaMyocardial inf

9、arctionWorsening heart failureCV hospitalization*DeathPrimary Outcome577682060291521221742Irbesartan (n=2067)368791954314537226763Placebo (n=2061)Secondary OutcomesPatients with Events 1.01 (0.86-1.18)311302CV death0.99 (0.86-1.13)402400CV death MI or stroke0.96 (0.84-1.09)428438HF death or HF hospi

10、talization1.00 (0.88-1.14)445436DeathHR (95% CI)Irbesartan (n=2067)Placebo (n=2061) OutcomeP=NS for all I-PRESERVE: ConclusionsIn I-PRESERVE, HF-PEF patients experienced substantial mortality and cardiovascular morbidity.Irbesartan did not reduce the primary endpoint of death and protocol-specified

11、CV hospitalizations, nor did it significantly benefit prespecified secondary endpoints.Our results are consistent with the two previous trials in patients with HF-PEF that did not demonstrate a positive effect.For this large group of patients constituting half of all heart failure patients, there continues to be no specific evidence-based therapy. In order for this field to move forward, a better understanding of the mechanisms underlying