心力衰竭诊断新技术的临床评价施仲伟-会议课件教学幻灯

心力衰竭诊断新技术的临床评价上海交通大学医学院瑞金医院心脏科施仲伟ESC2021心力衰竭：新的定义心力衰竭是一种临床综合征，患者有以下三类特点：典型病症〔呼吸困难、乏力或疲乏、踝部肿胀〕典型体征〔心动过速、呼吸急促、肺部啰音、胸腔积液、颈静脉压力升高、外周水肿、肝大〕休息时心脏结构或功能异常客观证据〔心脏增大、第三心音、心杂音、超声心动图异常、BNP增高〕上海瑞金医院施仲伟DicksteinK,etal.EurHeartJ2021,29:2388Two-dimensionalechocardiographywithDopplershouldbeperformedduringinitialevaluationofpatientspresentingwithHFtoassessleftventricularejectionfraction(LVEF),leftventriclesize,wallthickness,andvalvefunction.RadionuclideventriculographycanbeperformedtoassessLVEFandvolumes.心力衰竭患者的初次评价应包括二维超声心动图和多普勒检查，评估左室射血分数、左室大小、室壁厚度和瓣膜功能。核素心室造影术可用于估计左室射血分数及容量。InitialClinicalAssessmentofPatientsPresentingWithHeartFailure上海瑞金医院施仲伟ACCHeartFailureGuidelines2021超声心动图异常与心力衰竭〔1〕指标异常临床意义左室射血分数降低（<45~50%）收缩功能异常左室室壁运动消失、减低、反常心肌梗死/心肌缺血；心肌病；心肌炎左室舒张期末内径增加（>55~60mm）容量负荷过重（符合心力衰竭）左室收缩期末内径增加（>45mm）容量负荷过重（符合心力衰竭）左室缩短分数降低（<25%）收缩功能异常左房大小增大（>40mm）左室充盈压增高；二尖瓣功能异常；心房颤动上海瑞金医院施仲伟EchocardiographicTissueDopplerImagingIsaPowerfulIndependentPrognosticatorofMortalityintheGeneralPopulation

RasmusMogelvang,MD,PhD

TheCopenhagenCityHeartStudy

&DepartmentofCardiology,

GentofteUniversityHospital,DenmarkCopenhagenCityHeartStudyResultsfromtheFourthCopenhagenCityHeartStudySurvivorsNon-survivors(n=946)(n=90)Age-years 58 74 P<0.001Hypertension–% 42

72 P<0.001BodyMassIndex–kg/m2 25.6

25.7 P=0.91Heartrate–beatsperminute

69

71 P=0.10Malegender–% 41

44 P=0.58Diabetes-% 7 13 P<0.04Ischemicheartdisease-% 8 21 P<0.001Severediastolicdysfunction–% 0.7

1.2 P=0.47Leftventricularejectionfraction<50%-%0.9

3.5 P<0.05Leftventriculardilatation-% 5.7 5.5 P=1.00Leftventricularhypertrophy-% 15 37 P<0.001P-valueCharacteristicsoftheStudyPopulation1036例社区成人，平均随访5.3年，90例死亡s’e’a’Easindex=e’/(a’s’)Eas-index:AnEstimatorofCombined

SystolicandDiastolicPerformance上海瑞金医院施仲伟Kaplan-MeierSurvivalPlotfortheEas-index12345Follow-upinyears61.tertileSurvival-%1009590852.tertile3.tertileAdjustedforageandsexMultivariateanalysis3.tertilevs.1.tertileRelativeRisk2.5

(1.4~4.7);P<0.005

上海瑞金医院施仲伟MogelvangR,etal.Circulation2021,119:2679PatientswithLVEF35%,sinusrhythm,andNYHAfunctionalclassIIIorambulatoryclassIVsymptomsdespiterecommended,optimalmedicaltherapyandwhohavecardiacdyssynchrony,whichiscurrentlydefinedasaQRSduration0.12seconds,shouldreceivecardiacresynchronizationtherapy,withorwithoutanICD,unlesscontraindicated.接受最正确药物治疗而LVEF35%、窦性心律、心功能Ⅲ~Ⅳ级、心脏不同步〔QRS0.12s〕的患者，应接受CRT治疗〔安装或不装心内除颤器〕，除非有禁忌证。CardiacResynchronizationTherapy(CRT)ACCHeartFailureGuidelines2021上海瑞金医院施仲伟498例有CRT适应证的患者12项左室不同步的超声心动图指标没有一项左室不同步的超声心动图指标能帮助更好地选择CRT患者PROSPECT:ModestSensitivityandSpecificityandGreatVariability上海瑞金医院施仲伟ResynchronizationTherapyinNormalQRS(RethinQ)Study20~30%ofpatientsdonotrespondtoCRTdespiteapplicationofestablishedselectioncriteriaPatientswithnormalconductionoraslightlyprolongedQRSdurationalsoexhibitmechanicalabnormalitiesduetointraventriculardyssynchronyWehypothesizedthatpatientswithNYHAclassIII,LVEF35%,QRS<130ms,andevidenceofmechanicaldyssynchronyonechocardiographymaybenefitfromcardiacresynchronizationtherapyBeshaiJF,fortheRethinQstudyinvestigators上海瑞金医院施仲伟PatientsBaselineCharacterizaticsBaselineCharacteristicsControl(n=85)CRT(n=87)Age(yr),Mean±SD58±1460±12Malesex,n(%)49(58%)62(71%)NYHAIII,n(%)84(99%)87(100%)QRSDuration(ms),Mean±SD106±13107±12IschemicCardiomyopathy,n(%)43(51%)47(54%)Leftventricularejectionfraction(%)26±625±5Medications,n(%)ACEinhibitororsubstitute

Beta-Blocker

Diuretic77(91%)79(93%)74(87%)77(89%)84(97%)73(84%)RethinQStudy上海瑞金医院施仲伟Results:PeakVO2bySub-GroupPeakVO2

(%improvedfrombaseline)020406080100QRS≥120msp=0.02QRS<120msp=0.45Controln=25CRTn=17Controln=55CRTn=59PeakVO2

(%improvedfrombaseline)020406080100Ischemicp=0.82Non-ischemicp=0.25Controln=41Controln=39CRTn=40CRTn=36RethinQStudy超声难以准确评价心脏不同步时的复杂畸变过程

1例扩张性心肌病患者：TDI未见不同步、应变显示不同步SeptumLateralwall上海瑞金医院施仲伟心力衰竭的生物标志物定义：能反映心脏应激、功能异常或心肌损伤状态的酶、激素、生物学物质及其他标志物分类及举例：炎症标志物〔C-反响蛋白、肿瘤坏死因子-〕氧化应激标志物〔氧化型LDL、髓性过氧化物酶〕细胞外基质重构标志物〔基质金属蛋白酶、胶原前肽〕神经激素〔去甲肾上腺素、血管紧张素Ⅱ〕心肌损伤标志物〔肌钙蛋白I和T、心脏型脂肪酸蛋白〕心肌应激标志物〔BNP、NT-proBNP、ST2〕新型生物标志物〔嗜铬素、半乳糖凝集素-3、脂联素〕上海瑞金医院施仲伟786例不同程度的慢性心力衰竭患者心功能Ⅰ~Ⅳ级，LVEF5%~65%〔平均2510%〕BNP3~8536pg/ml〔平均688948pg/ml〕，接受标准抗心力衰竭治疗随访24个月，研究终点为任何原因的死亡评价和肽素的预测价值、并与BNP和NT-proBNP相比