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nykek5i 发表于 2024-6-1 12:29:26

左心衰尽相关肺动脉高压的科研发展

<span style="color: black;"><strong style="color: blue;"><span style="color: black;">左心<span style="color: black;">衰尽</span><span style="color: black;">关联</span>肺动脉高压的<span style="color: black;">科研</span><span style="color: black;">发展</span></span></strong></span>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_png/ticPd5VoOibePjMBjyTPtZYtUngtMYkhTKIb9YiadJibuJjuYaFagQZAIQte6lbwLKjpTL9w4hxw9buJL8ldspibia5w/640?wx_fmt=png&amp;from=appmsg&amp;tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;"></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">心力<span style="color: black;">衰尽</span><span style="color: black;">病人</span>常常合并肺动脉高压，归类为2型肺动脉高压，左心<span style="color: black;">衰尽</span><span style="color: black;">关联</span>肺动脉高压（pulmonary hypertension associated with left heart failure，PH-LHF）是最<span style="color: black;">平常</span>的一类［1］。PH-LHF在射血分数降低的心力<span style="color: black;">衰尽</span>（HFrEF）<span style="color: black;">病人</span>中<span style="color: black;">常常</span><span style="color: black;">出现</span>在<span style="color: black;">疾患</span>的终末<span style="color: black;">周期</span>［2］，而射血分数<span style="color: black;">保存</span>的心力<span style="color: black;">衰尽</span>（HFpEF）<span style="color: black;">病人</span>肺动脉高压<span style="color: black;">显现</span>更早，且其病理生理机制、肺血流动力学和临床表现<span style="color: black;">拥有</span>特殊性。<span style="color: black;">没</span>论何种类型的心力<span style="color: black;">衰尽</span>，肺动脉高压均是心衰<span style="color: black;">病人</span>预后不良的独立危险<span style="color: black;">原因</span>［3］。理解肺动脉高压的<span style="color: black;">出现</span>机制<span style="color: black;">针对</span>探索HFpEF的治疗<span style="color: black;">拥有</span><span style="color: black;">要紧</span><span style="color: black;">道理</span>。本文对PH-LHF的病理生理机制、临床表型和治疗等进行综述。</span></p><img src="https://mmbiz.qpic.cn/sz_mmbiz_jpg/ticPd5VoOibeMqzIS89vyInBF57YTtlFGIBRibX5lAxnQgK8mu48h0c5mo17bDNm3eSqYMOXA1VUvic3PiaDWIwcJbg/640?wx_fmt=jpeg&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1&amp;tp=webp" style="width: 50%; margin-bottom: 20px;"><a style="color: black;"><span style="color: black;">肺动脉高压合并咯血的病因识别和处理</span></a><a style="color: black;"><span style="color: black;">肺动脉高压合并脓毒症<span style="color: black;">病人</span>的液体管理</span></a><a style="color: black;"><span style="color: black;">中国肺动脉高压诊治临床路径</span></a><a style="color: black;"><span style="color: black;">血流动力学监测：肺动脉漂浮导管</span></a><a style="color: black;"><span style="color: black;">肺高压与肺动脉高压危象</span></a><a style="color: black;"><span style="color: black;">肺动脉高压的发病机制与临床管理（综述译文）</span></a><a style="color: black;"><span style="color: black;">重症系列：肺动脉压监测</span></a><a style="color: black;"><span style="color: black;">与肺动脉高压<span style="color: black;">关联</span>的心力<span style="color: black;">衰尽</span>为</span></a>什么<span style="color: black;">要紧</span>？<a style="color: black;"><span style="color: black;">肺动脉高压指南-诊断（2021年ESC/ERS）</span></a>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">1、</span>左心<span style="color: black;">衰尽</span><span style="color: black;">关联</span>肺动脉高压的血流动力学分型和<span style="color: black;">评定</span></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">按照</span>2022年欧洲心脏病学会（ESC）/欧洲<span style="color: black;">呼气</span>学会（ERS）肺动脉高压诊断和治疗指南的定义，第2大类肺动脉高压<span style="color: black;">包含</span>射血分数降低，轻度降低或<span style="color: black;">保存</span>的心衰，以及左侧瓣膜性心脏病和<span style="color: black;">引起</span>毛细血管后肺动脉高压的先天性/<span style="color: black;">得到</span>性心血管病<span style="color: black;">病人</span>。<span style="color: black;">同期</span>指南<span style="color: black;">亦</span>对基于右心导管的血液动力学标准进行了修订（<span style="color: black;">表1</span>），平均肺动脉压（mPAP）&gt;20 mmHg且肺动脉楔压（PAWP）&gt;15 mmHg时，定义为毛细血管后肺动脉高压。如肺血管阻力（pulmonary vascular resistance，PVR）≤2 Wood单位定义为单纯毛细血管后肺动脉高压（isolated post-capillary PH，IPC-PH）；如PVR&gt;2 Wood单位时定义为混合型毛细血管后肺动脉高压（combined post-and pre-capillary PH，CPC-PH）［4］。该指南采用了与第6届世界肺动脉高压大会相同的肺动脉高压定义，<span style="color: black;">重点</span>依据如下所述。<span style="color: black;">科研</span><span style="color: black;">发掘</span>健康成年人静息状态下mPAP为（14.0±3.3）mmHg，mPAP在21~24 mmHg为边缘<span style="color: black;">上升</span>状态，且mPAP在21~24 mmHg与较差的心肺功能和死亡<span style="color: black;">危害</span><span style="color: black;">增多</span><span style="color: black;">关联</span>［5］。Kovacs等［6］对141例肺动脉压力边缘<span style="color: black;">上升</span>的<span style="color: black;">病人</span>行静息和运动右心导管<span style="color: black;">检测</span><span style="color: black;">发掘</span>，此类<span style="color: black;">病人</span>的PVR［（2.7±0.7）Wood单位］<span style="color: black;">显著</span>较高，峰值摄氧量和6分钟步行距离较差，且远期病死率高。美国退伍军人健康系统对21 727例右心导管数据的分析提示，mPAP超过19 mmHg时死亡<span style="color: black;">危害</span>即<span style="color: black;">增多</span>，mPAP在19~24 mmHg的<span style="color: black;">病人</span>死亡<span style="color: black;">危害</span><span style="color: black;">增多</span>24%，住院<span style="color: black;">危害</span><span style="color: black;">增多</span>7%［7］。PH-LHF并非都表现为IPC-PH，大约1/4的<span style="color: black;">病人</span>为CPC-PH，需<span style="color: black;">经过</span>右心导管鉴别［4］。右心导管技术在国内已开展<span style="color: black;">数年</span>，<span style="color: black;">然则</span>针对心力<span style="color: black;">衰尽</span><span style="color: black;">病人</span>的<span style="color: black;">关联</span><span style="color: black;">科研</span>很少。尤其是在不明<span style="color: black;">原由</span><span style="color: black;">呼气</span>困难以及HFpEF<span style="color: black;">病人</span>中<span style="color: black;">经过</span>右心导管<span style="color: black;">评估</span>肺循环的血流动力学<span style="color: black;">针对</span><span style="color: black;">知道</span>病因和治疗决策<span style="color: black;">拥有</span><span style="color: black;">要紧</span><span style="color: black;">道理</span>。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_jpg/ticPd5VoOibeMs3BtMdAKb2kTmh97zzX7xBe4u2LZqym6oVzAkVgeIichT7aUC8rxF4ibDQpj4C7R9GZvpVR65icnibA/640?wx_fmt=jpeg&amp;from=appmsg&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1&amp;tp=webp" style="width: 50%; margin-bottom: 20px;"></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_png/ticPd5VoOibePjMBjyTPtZYtUngtMYkhTKC6MKMOkz7tzM6FsggHssDYVzvH3eRxCZPAIxdc7Fc8QndRaEpNmFNg/640?wx_fmt=png&amp;from=appmsg&amp;tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;"></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">2、</span>左心<span style="color: black;">衰尽</span><span style="color: black;">关联</span>肺动脉高压的流行病学</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">心力<span style="color: black;">衰尽</span><span style="color: black;">病人</span>中肺动脉高压的患病率因<span style="color: black;">疾患</span><span style="color: black;">周期</span>、入选人群和<span style="color: black;">评定</span><span style="color: black;">办法</span>而不同，即超声与右心导管的测定的差异<span style="color: black;">很强</span>。<span style="color: black;">另外</span>，<span style="color: black;">关联</span>临床<span style="color: black;">科研</span><span style="color: black;">常常</span>除外了严重肾功能不全及合并肺部<span style="color: black;">疾患</span>的<span style="color: black;">病人</span>，可能<span style="color: black;">引起</span>肺动脉高压患病率较低。<span style="color: black;">初期</span><span style="color: black;">科研</span>多采用心脏超声测定的肺动脉收缩压（pulmonary arterial systolic pressure，PASP），HFrEF<span style="color: black;">病人</span>肺动脉高压的患病率为45%~75%［8］。HFpEF <span style="color: black;">病人</span>肺动脉高压的患病率为36%~83%［9］，如PARAGON-HF<span style="color: black;">科研</span>［10］<span style="color: black;">报道</span>的患病率约为31%，TOPCAT<span style="color: black;">科研</span>［11］约为36%。超声心动图鉴别IPC-PH和CPC-PH<span style="color: black;">重点</span><span style="color: black;">经过</span>三尖瓣环收缩期位移（tricuspid annular plane systolic excursion，TAPSE）与PASP的比值（TAPSE/PASP）［12］，但采用此标准的<span style="color: black;">科研</span>规模较小。一项采用右心导管测定的PVR<span style="color: black;">做为</span>肺动脉高压标准的<span style="color: black;">科研</span><span style="color: black;">发掘</span>，HFrEF合并CPC-PH 占到55%［2］。HFpEF<span style="color: black;">病人</span>合并CPC-PH的比例更高［8］，在一组美国纽约心脏病学会（New York Heart Association，NYHA）心功能分级Ⅲ~Ⅳ级为主的HFpEF<span style="color: black;">病人</span>中，合并肺动脉高压（mPAP&gt;25 mmHg）的比例<span style="color: black;">达到</span>81%［13］。尽管PAWP水平<span style="color: black;">类似</span>，HFpEF <span style="color: black;">病人</span>合并CPC-PH的比例高于HFrEF <span style="color: black;">病人</span>（38%比17%）［14］。一项纳入2 587例PH-HFpEF<span style="color: black;">病人</span>的回顾性<span style="color: black;">科研</span>中，采用肺动脉舒张压差（diastolic pressure gradient，DPG）&gt;7 mm Hg 或PVR&gt;3 Wood单位定义的肺动脉高压患病率分别为8.8%和3.5%［15］。<span style="color: black;">因此呢</span>，超声心动图难以鉴别单纯毛细血管后肺动脉高压和混合型肺动脉高压，应进行右心导管<span style="color: black;">检测</span>对<span style="color: black;">病人</span>进行血流动力学分型［16］。美国国立卫生<span style="color: black;">科研</span>院<span style="color: black;">起步</span>了PVDOMICS（Redefining Pulmonary Hypertension through Pulmonary Vascular Disease Phenomics）<span style="color: black;">科研</span>计划倡导进行肺动脉高压的表型<span style="color: black;">科研</span>和多组学<span style="color: black;">科研</span>，其采用的<span style="color: black;">评定</span><span style="color: black;">办法</span>即<span style="color: black;">包含</span>右心导管和心肺运动<span style="color: black;">实验</span>等［17］。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_jpg/ticPd5VoOibePnGdIwiaGo7gWzhibYhxfiagKSQTG89Yt6IH8ib2Yjv8m8aYxT8fvft6M7Ine4akqGBLUGia7sica1bNcw/640?wx_fmt=jpeg&amp;from=appmsg&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1&amp;tp=webp" style="width: 50%; margin-bottom: 20px;"></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">3、</span>左心<span style="color: black;">衰尽</span><span style="color: black;">关联</span>肺动脉高压的病理机制</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">传统观点认为PH-LHF的机制是<span style="color: black;">因为</span>左心充盈压<span style="color: black;">上升</span>，即左心房压力被动<span style="color: black;">增多</span>向后传导至肺静脉系统，并<span style="color: black;">最后</span><span style="color: black;">引起</span>右心功能不全。在不同类型心力<span style="color: black;">衰尽</span><span style="color: black;">病人</span>，左、右心房和心室以及肺循环的病理改变和结构<span style="color: black;">反常</span>存在<span style="color: black;">很强</span>差异，<span style="color: black;">因此呢</span>其肺动脉高压的特点有所不同。<span style="color: black;">科研</span>提示PH-LHF<span style="color: black;">病人</span>可存在广泛的肺血管结构和功能的改变，<span style="color: black;">包含</span>肺小静脉和肺小动脉的重构等［3］。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">1. 心房结构和功能的改变：左心房对容量和压力比较<span style="color: black;">敏锐</span>，<span style="color: black;">长时间</span>压力和容量负荷过重，<span style="color: black;">引起</span>心房失代偿，左心房扩大和功能下降，表现为心房心室失偶联，心输出量下降。心房顺应性下降使得<span style="color: black;">贮存</span>功能受损［18］。左心房僵硬度<span style="color: black;">增多</span>，其为左心室和肺动脉之间<span style="color: black;">供给</span>容量和压力缓冲的功能（心室收缩时左房接受肺静脉的回流）受损，<span style="color: black;">引起</span>肺动脉顺应性下降和肺血管阻力<span style="color: black;">增多</span>。肺动脉僵硬度取决于肺血管阻力和肺动脉波动性负荷，<span style="color: black;">引起</span>右心功能不全。但<span style="color: black;">亦</span>有<span style="color: black;">科研</span><span style="color: black;">发掘</span>，与IPC-PH<span style="color: black;">病人</span>比较，CPC-PH<span style="color: black;">病人</span>的心脏结构改变较轻，不除外某些<span style="color: black;">病人</span>肺血管阻力<span style="color: black;">上升</span>在前。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">2. 肺血管的病理生理改变：左心房顺应性下降<span style="color: black;">引起</span>的肺血管结构和功能变化最初是可逆的，但左心房压力<span style="color: black;">连续</span>性<span style="color: black;">增多</span>会<span style="color: black;">引起</span>肺血管<span style="color: black;">出现</span>不可逆的病理改变。不论是HFrEF还是HFpEF均<span style="color: black;">引起</span>肺泡气体弥散功能受损［19］，肺水肿<span style="color: black;">引起</span>肺泡-毛细血管膜<span style="color: black;">损害</span>，激活基质蛋白酶<span style="color: black;">引起</span>血管内皮通透性<span style="color: black;">增多</span>。急性肺水肿<span style="color: black;">病人</span>的肺表面蛋白<span style="color: black;">经过</span><span style="color: black;">损害</span>的肺泡毛细血管膜漏出，外周循环水平<span style="color: black;">增多</span>。肺水肿减轻后，肺表面蛋白<span style="color: black;">连续</span><span style="color: black;">上升</span>达2周，说明肺泡毛细血管膜的<span style="color: black;">连续</span><span style="color: black;">损害</span>［15，20］。<span style="color: black;">另外</span>，急性肺水肿时<span style="color: black;">血液</span>中肿瘤坏死因子α（TNF-α）<span style="color: black;">上升</span>。<span style="color: black;">长时间</span>液体负荷过重<span style="color: black;">引起</span>毛细血管和小动脉血管重构，血管弹力纤维丢失和细胞外基质扩张［21］；炎症激活，一氧化氮（nitric oxide，NO）和利钠肽的活性受到<span style="color: black;">控制</span>，内皮素-1表达<span style="color: black;">增多</span>，促进肺血管纤维化和增殖，<span style="color: black;">引起</span>血管腔闭塞和肺泡间隙增厚。<span style="color: black;">另外</span>，<span style="color: black;">科研</span>还<span style="color: black;">发掘</span>胰岛素代谢<span style="color: black;">反常</span>参与了HFpEF<span style="color: black;">病人</span>的肺血管结构<span style="color: black;">反常</span>。在糖尿病小鼠中，观察到毛细血管中巨噬细胞活化和白细胞粘附以及内皮素-1通路的激活。在代谢<span style="color: black;">综合症</span>合并肺动脉高压的模型中，白细胞介素-6（IL-6）的过度表达<span style="color: black;">经过</span>信号转导和转录激活因子3诱导肺血管平滑肌细胞的增殖和重构［22,&nbsp;23,&nbsp;24］。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_jpg/ticPd5VoOibePnGdIwiaGo7gWzhibYhxfiagK9x9KvSGc8QzJumLntTj9KryKEWkrrVwMvDSPZonBgBWMKP4Ej4r8Kg/640?wx_fmt=jpeg&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1&amp;retryload=1&amp;tp=webp" style="width: 50%; margin-bottom: 20px;"></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">肺血管病理<span style="color: black;">科研</span><span style="color: black;">发掘</span>PH-LHF的严重程度与肺静脉和肺小动脉内膜增厚<span style="color: black;">关联</span>。梅奥诊所的肺组织病理库<span style="color: black;">科研</span>比较了108例心力<span style="color: black;">衰尽</span>且伴PASP&gt;40 mmHg、17例肺静脉闭塞症和12例正常对照<span style="color: black;">病人</span>的肺血管组织标本，<span style="color: black;">发掘</span>PH-LHF<span style="color: black;">病人</span>存在广泛的肺血管重构，且肺动脉高压的严重程度与肺静脉和小血管的内膜厚度最<span style="color: black;">关联</span>，但<span style="color: black;">无</span><span style="color: black;">发掘</span>肺小动脉重构［25］。接受左心室辅助<span style="color: black;">安装</span>的终末期心力<span style="color: black;">衰尽</span><span style="color: black;">病人</span>的肺活检标本提示，肺动脉和肺静脉的内膜、中膜和外膜的体积<span style="color: black;">显著</span><span style="color: black;">增多</span>，<span style="color: black;">乃至</span>管腔闭塞。综上可见，心力<span style="color: black;">衰尽</span><span style="color: black;">初期</span>肺静脉的结构<span style="color: black;">出现</span>改变最<span style="color: black;">显著</span>，而在终末期<span style="color: black;">显现</span>更广泛的肺血管重构，<span style="color: black;">包含</span>肺小动脉［25］。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">3. 血管内皮<span style="color: black;">损害</span>和功能<span style="color: black;">反常</span>：<span style="color: black;">没</span>论是肺动脉高压还是心力<span style="color: black;">衰尽</span><span style="color: black;">病人</span>均存在广泛的血管内皮功能<span style="color: black;">反常</span>，肺动脉压力<span style="color: black;">上升</span>的分子机制<span style="color: black;">包含</span>小窝和小窝蛋白调节细胞内钙信号、NO及肺动脉平滑肌细胞的增殖；β肾上腺素受体的慢性<span style="color: black;">长时间</span>刺激减少小窝的表达［26］；caveolin-1与内皮型一氧化氮合酶结合后使其失活，<span style="color: black;">引起</span>NO途径受损。<span style="color: black;">另外</span>，多种缩血管物质和炎症因子，如内皮素-1、前列环素/血栓素A-2、血小板衍生因子、TNF-α和IL-6均参与在血管功能<span style="color: black;">阻碍</span>的机制中［27］。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">总之，心力<span style="color: black;">衰尽</span><span style="color: black;">病人</span><span style="color: black;">出现</span>肺动脉高压的机制较为<span style="color: black;">繁杂</span>，<span style="color: black;">包含</span>心脏功能<span style="color: black;">反常</span>的血流动力学<span style="color: black;">原因</span>和系统性<span style="color: black;">原因</span>，如炎症和代谢<span style="color: black;">反常</span><span style="color: black;">一起</span>参与，在不同临床表型的<span style="color: black;">病人</span>可能侧重点不同，<span style="color: black;">亦</span>是<span style="color: black;">将来</span><span style="color: black;">科研</span>的重点。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_jpg/ticPd5VoOibePnGdIwiaGo7gWzhibYhxfiagKeDa9FNuwA5OwjlVedviamq9uypFWepVzQUNaianb29fTnFy4zykBMQuw/640?wx_fmt=jpeg&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1&amp;tp=webp" style="width: 50%; margin-bottom: 20px;"></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">4、</span>左心<span style="color: black;">衰尽</span><span style="color: black;">关联</span>肺动脉高压的治疗<span style="color: black;">发展</span></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">日前</span>，PH-LHF的治疗原则<span style="color: black;">重点</span>是针对心脏<span style="color: black;">基本</span><span style="color: black;">疾患</span>和心力<span style="color: black;">衰尽</span>的治疗，如利尿剂可降低肺小动脉楔压。肺血管靶向<span style="color: black;">药品</span>的<span style="color: black;">科研</span>证据较少，且<span style="color: black;">都数</span><span style="color: black;">科研</span>未区别心力<span style="color: black;">衰尽</span>的类型；<span style="color: black;">科研</span>中对肺动脉高压的定义差异<span style="color: black;">很强</span>，未进行血流动力学分型。<span style="color: black;">初期</span><span style="color: black;">科研</span><span style="color: black;">大都是</span>在HFrEF<span style="color: black;">病人</span>中进行的，结果令人失望［28,&nbsp;29］。<span style="color: black;">因此呢</span>，<span style="color: black;">日前</span>指南不<span style="color: black;">举荐</span>肺血管靶向<span style="color: black;">药品</span>常规用于PH-LHF的治疗。<span style="color: black;">然则</span>不同血液动力学类型的<span style="color: black;">病人</span><span style="color: black;">针对</span>靶向<span style="color: black;">药品</span>的治疗反应可能不同，尤其是HFpEF合并CPC-PH的<span style="color: black;">病人</span>可能获益（<span style="color: black;">表2</span>）。<span style="color: black;">另外</span>，<span style="color: black;">科研</span><span style="color: black;">发掘</span><span style="color: black;">经过</span><span style="color: black;">移植</span>压力传感器远程监测肺动脉压，并<span style="color: black;">调节</span>心力<span style="color: black;">衰尽</span>治疗<span style="color: black;">明显</span>降低了心力<span style="color: black;">衰尽</span><span style="color: black;">病人</span>的住院率并改善了预后［30,&nbsp;31］。这些<span style="color: black;">科研</span>提示减少肺充血对心力<span style="color: black;">衰尽</span>的治疗是有益的，区分IPC-PH和 CPC-PH<span style="color: black;">非常</span><span style="color: black;">要紧</span>。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_png/ticPd5VoOibePjMBjyTPtZYtUngtMYkhTK11icmglAKlgxXe8uTUic1h2NUu6zMbBZQDGIWplsj2RYTW118GNst14Q/640?wx_fmt=png&amp;from=appmsg&amp;tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;"></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_png/ticPd5VoOibePjMBjyTPtZYtUngtMYkhTKUPdTgang3Wm8KbeqYEpiaP8qzOmym1yeGlf4jONT0EeXUodK6apEfEg/640?wx_fmt=png&amp;from=appmsg&amp;tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;"></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_jpg/ticPd5VoOibePnGdIwiaGo7gWzhibYhxfiagKmLFr2LEIJj2yDnt03oggiclZV4WUFhr4AWvAO10ce4RygarbvGCXAeA/640?wx_fmt=jpeg&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1&amp;tp=webp" style="width: 50%; margin-bottom: 20px;"></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">（一）肺血管靶向<span style="color: black;">药品</span></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">1. 5型磷酸二酯酶（PEG5）<span style="color: black;">控制</span>剂：PEG5<span style="color: black;">控制</span>剂<span style="color: black;">经过</span><span style="color: black;">选取</span>性<span style="color: black;">控制</span>磷酸二酯酶减少环磷酸鸟苷（cyclic guanosine monophosphate，cGMP）的降解，促进NO介导的血管舒张<span style="color: black;">功效</span>［32］。PEG5<span style="color: black;">控制</span>剂用于治疗PH-LHF的<span style="color: black;">科研</span>因纳入人群不同而结果不同。SIOVAC<span style="color: black;">科研</span>入选<span style="color: black;">最少</span>1年内成功进行瓣膜置换或修复手术的<span style="color: black;">病人</span>，随机分为西地那非40 mg，每日3次组（n=104）和安慰剂组（n=96）治疗6个月。<span style="color: black;">重点</span>终点是综合临床评分，<span style="color: black;">包含</span>死亡、心力<span style="color: black;">衰尽</span>入院、NYHA 心功能的变化和<span style="color: black;">病人</span>自我<span style="color: black;">评定</span>。结果安慰剂组的临床评分改善更<span style="color: black;">显著</span>（44比 27），两组心力<span style="color: black;">衰尽</span>入院事件差异<span style="color: black;">亦</span><span style="color: black;">没</span>统计学<span style="color: black;">道理</span>［33］。RELAX<span style="color: black;">科研</span>随机213例NYHA分级Ⅱ~Ⅳ级的心力<span style="color: black;">衰尽</span>且左室射血分数（LVEF）≥50%的<span style="color: black;">病人</span>，西地那非未能改善<span style="color: black;">重点</span>终点24周时的峰值摄氧量，两组间死亡和再住院差异<span style="color: black;">亦</span><span style="color: black;">没</span>统计学<span style="color: black;">道理</span>［34］。该<span style="color: black;">科研</span>的后续分析<span style="color: black;">选取</span>了合并右心功能<span style="color: black;">阻碍</span>（TAPSE/PASP 比值）的亚组，<span style="color: black;">亦</span>未<span style="color: black;">发掘</span>西地那非能改善血流动力学指标［35］。一项<span style="color: black;">科研</span>纳入52例HFpEF合并肺动脉高压（mPAP≥25 mmHg）且PAWP&gt;15 mmHg的<span style="color: black;">病人</span>，其结果<span style="color: black;">表示</span>随机接受西地那非60 mg，每日3次治疗12周后，西地那非未能降低肺动脉压力，<span style="color: black;">亦</span>未能改变其他血流动力学指标，<span style="color: black;">包含</span>PAWP、心输出量和峰值摄氧量［36］。<span style="color: black;">因此呢</span>，<span style="color: black;">以上</span><span style="color: black;">科研</span>提示在未进行血流动力学分型的PH-LHF<span style="color: black;">病人</span>PEG5<span style="color: black;">控制</span>剂<span style="color: black;">不可</span>获益。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">然则</span>，两项小规模的<span style="color: black;">科研</span>提示合并CPC-PH的HFpEF<span style="color: black;">病人</span>可能获益。Guazzi等［37］的一项44例HFpEF伴PASP&gt;40 mmHg<span style="color: black;">病人</span>的安慰剂对照<span style="color: black;">科研</span>提示，西地那非50 mg，每日3次组mPAP和右心功能<span style="color: black;">显著</span>改善。6个月时，mPAP下降42.0%±13.0%，TAPSE<span style="color: black;">增多</span>69.0%±19.0%，右心房压力下降54.0%±7.2%。一项40例HFpEF<span style="color: black;">病人</span>合并CPC-PH的观察性<span style="color: black;">科研</span>中，他达拉非<span style="color: black;">或</span>西地那非治疗12个月后，6分钟步行距离从（277±17）米增加到（340±18）米，WHO功能分级Ⅰ/Ⅱ级的比例从5%<span style="color: black;">增多</span>37.5%。N-末端脑钠肽前体（NT-proBNP）下降了33%，TAPSE从（16.8±0.7）mm <span style="color: black;">增多</span>到（18.2±0.6）mm（P=0.01）［38］。这两项<span style="color: black;">科研</span>提示，在合并CPC-PH的心力<span style="color: black;">衰尽</span><span style="color: black;">病人</span>肺血管靶向<span style="color: black;">药品</span>可能有益。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="data:image/svg+xml,%3C%3Fxml version=1.0 encoding=UTF-8%3F%3E%3Csvg width=1px height=1px viewBox=0 0 1 1 version=1.1 xmlns=http://www.w3.org/2000/svg xmlns:xlink=http://www.w3.org/1999/xlink%3E%3Ctitle%3E%3C/title%3E%3Cg stroke=none stroke-width=1 fill=none fill-rule=evenodd fill-opacity=0%3E%3Cg transform=translate(-249.000000, -126.000000) fill=%23FFFFFF%3E%3Crect x=249 y=126 width=1 height=1%3E%3C/rect%3E%3C/g%3E%3C/g%3E%3C/svg%3E" style="width: 50%; margin-bottom: 20px;"></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">2. 可溶性鸟苷酸环化酶激动剂：可溶性鸟苷酸环化酶激动剂<span style="color: black;">经过</span>调节NO/cGMP途径扩张肺血管并<span style="color: black;">控制</span>重构。SOCRATES系列2期临床<span style="color: black;">科研</span><span style="color: black;">评定</span>了维利西呱在HFrEF 和HFpEF <span style="color: black;">病人</span>的疗效。在SOCRATES-Reduced<span style="color: black;">科研</span>入组了LVEF&lt;45%的心衰<span style="color: black;">病人</span>，与安慰剂相比，维利西呱治疗12周时<span style="color: black;">无</span>降低NT-proBNP水平［39］。<span style="color: black;">一样</span>，在SOCRATES-Preserved<span style="color: black;">科研</span>入选了HFpEF <span style="color: black;">病人</span>，与安慰剂组<span style="color: black;">重点</span><span style="color: black;">科研</span>终点NT-proBNP和左心房容积指数<span style="color: black;">没</span><span style="color: black;">显著</span>差异［40］。这两项<span style="color: black;">科研</span>并<span style="color: black;">无</span>进行右心导管<span style="color: black;">评定</span>。<span style="color: black;">然则</span>，在入选合并肺动脉高压（mPAP≥25 mmHg）的HFrEF<span style="color: black;">病人</span>的LEPHT<span style="color: black;">科研</span>中，尽管治疗16周后利奥西呱未能<span style="color: black;">显著</span>降低肺动脉压力，<span style="color: black;">然则</span>心输出量和肺血管阻力均<span style="color: black;">显著</span><span style="color: black;">增多</span>［41］。<span style="color: black;">另一</span>一项Ⅱb期双盲安慰剂对照<span style="color: black;">科研</span>，入选了合并肺动脉高压（mPAP≥25 mmHg）的HFpEF<span style="color: black;">病人</span>，结果与安慰剂比较，利奥西呱治疗26周后，右心导管测定的心输出量<span style="color: black;">增多</span>（0.37±1.263）L/min，对照组下降（0.11±0.921）L/min［42］。该项<span style="color: black;">科研</span>提示，可溶性鸟苷酸环化酶激动剂<span style="color: black;">针对</span>右心导管确诊的肺动脉高压<span style="color: black;">病人</span>可能有益。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">3. 内皮素受体拮抗剂：内皮素致血管收缩和水钠潴留，促进心肌肥厚和重构，内皮素受体拮抗剂可<span style="color: black;">显著</span>降低肺动脉压力，<span style="color: black;">然则</span>在PH-LHF<span style="color: black;">病人</span>的疗效不<span style="color: black;">知道</span>。ENABLE系列<span style="color: black;">科研</span>共入选了1 613 例LVEF&lt;35%且NYHA分级Ⅲ~Ⅳ级的<span style="color: black;">病人</span>，结果内皮素-1拮抗剂波生坦（<span style="color: black;">目的</span>剂量150 mg）未能改善HFrEF<span style="color: black;">病人</span>的临床状态，对预后<span style="color: black;">无</span>影响［29］，该<span style="color: black;">科研</span><span style="color: black;">亦</span><span style="color: black;">无</span>进行肺动脉血流动力学的<span style="color: black;">评估</span>。MELODY-1<span style="color: black;">科研</span><span style="color: black;">经过</span>右心导管筛选合并CPC-PH的心衰<span style="color: black;">病人</span>，LVEF≥50%的<span style="color: black;">病人</span>占<span style="color: black;">都数</span>，随机分为安慰剂组或马昔腾坦10 mg组。在第1个月内，<span style="color: black;">运用</span>马昔腾坦治疗与安慰剂相比，液体潴留<span style="color: black;">危害</span><span style="color: black;">增多</span>10.1%。在第12周，马昔腾坦组<span style="color: black;">病人</span>的PVR、平均右心房压力或PAWP较安慰剂组<span style="color: black;">无</span>变化［43］。<span style="color: black;">以上</span><span style="color: black;">科研</span>结果提示内皮素-1拮抗剂<span style="color: black;">针对</span>PH-LHF<span style="color: black;">没</span>效。调节NO/cGMP途径的<span style="color: black;">科研</span>中纳入<span style="color: black;">病人</span>的典型特征为老年、女性占<span style="color: black;">优良</span>，基线时合并心房颤动的比例高（半数<span style="color: black;">上下</span>），射血分数正常的<span style="color: black;">病人</span>占在一半以上。MELODY<span style="color: black;">实验</span>中招募的<span style="color: black;">病人</span><span style="color: black;">拥有</span>典型的CPC-PH特征，其与较高的基线NT-proBNP<span style="color: black;">关联</span>，提示右心室功能更差。可见，PH-LHF<span style="color: black;">病人</span>的异质性<span style="color: black;">很强</span>，其有效治疗<span style="color: black;">办法</span>应该基于<span style="color: black;">病人</span>特征。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="data:image/svg+xml,%3C%3Fxml version=1.0 encoding=UTF-8%3F%3E%3Csvg width=1px height=1px viewBox=0 0 1 1 version=1.1 xmlns=http://www.w3.org/2000/svg xmlns:xlink=http://www.w3.org/1999/xlink%3E%3Ctitle%3E%3C/title%3E%3Cg stroke=none stroke-width=1 fill=none fill-rule=evenodd fill-opacity=0%3E%3Cg transform=translate(-249.000000, -126.000000) fill=%23FFFFFF%3E%3Crect x=249 y=126 width=1 height=1%3E%3C/rect%3E%3C/g%3E%3C/g%3E%3C/svg%3E" style="width: 50%; margin-bottom: 20px;"></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">（二）改善慢性心衰预后的<span style="color: black;">药品</span></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">SGLT-2<span style="color: black;">控制</span>剂是葡萄糖-钠转运体<span style="color: black;">控制</span>剂，可用于不同射血分数的心力<span style="color: black;">衰尽</span><span style="color: black;">病人</span>，其<span style="color: black;">功效</span>机制较为<span style="color: black;">繁杂</span>，<span style="color: black;">包含</span>利尿、改善心肌代谢和<span style="color: black;">控制</span>重构等等。EMBRACE-HF<span style="color: black;">科研</span>入选65例心力<span style="color: black;">衰尽</span>（射血分数<span style="color: black;">没</span>关）<span style="color: black;">病人</span>，<span style="color: black;">经过</span><span style="color: black;">移植</span>式肺动脉压力感受器监测肺动脉压力，结果恩格列净<span style="color: black;">显著</span>降低了肺动脉舒张压，从第1周<span style="color: black;">起始</span><span style="color: black;">功效</span><span style="color: black;">逐步</span><span style="color: black;">增多</span>，肺动脉收缩压和平均压<span style="color: black;">亦</span><span style="color: black;">一样</span>下降［44］。<span style="color: black;">另一</span>一项小样本荟萃分析<span style="color: black;">评估</span>了沙库巴曲/缬沙坦在HFrEF<span style="color: black;">病人</span>对肺循环的影响，共纳入10项观察性<span style="color: black;">科研</span>共875例<span style="color: black;">病人</span>，结果沙库巴曲/缬沙坦治疗后较基线肺动脉收缩压下降，其中仅有两项<span style="color: black;">科研</span>测定了mPAP，沙库巴曲/缬沙坦治疗后平均下降2.92 mm Hg。<span style="color: black;">日前</span>，尚<span style="color: black;">没</span>前瞻性随机对照<span style="color: black;">科研</span><span style="color: black;">评估</span>沙库巴曲/缬沙坦对肺血管的影响［45］。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">（三）左西孟旦</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">左西孟旦<span style="color: black;">经过</span><span style="color: black;">增多</span>心肌肌钙蛋白C对钙离子的<span style="color: black;">敏锐</span>性、激活钾通道和<span style="color: black;">控制</span>3型磷酸二酯酶等改善心脏功能。在急性失代偿心力<span style="color: black;">衰尽</span><span style="color: black;">病人</span>，左西孟旦剂量依赖性<span style="color: black;">增多</span>心输出量，降低肺毛细血管楔压（PCWP）和中心静脉压以及肺血管阻力和全身血管阻力。一项随机对照<span style="color: black;">科研</span>入选了mPAP≥35 mmHg且PCWP≥20 mmHg的LVEF≥40%的<span style="color: black;">病人</span>37例，随机接受左西孟旦治疗共6周，结果与安慰剂比较，<span style="color: black;">重点</span>终点运动负荷下的PCWP组间<span style="color: black;">无</span>差异，<span style="color: black;">然则</span>左西孟旦组改善了6分钟步行距离［46］。<span style="color: black;">日前</span>尚缺少左西孟旦改善<span style="color: black;">长时间</span>预后的证据，但可改善症状。间断<span style="color: black;">长时间</span>用药的<span style="color: black;">科研</span>正在进行中。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="data:image/svg+xml,%3C%3Fxml version=1.0 encoding=UTF-8%3F%3E%3Csvg width=1px height=1px viewBox=0 0 1 1 version=1.1 xmlns=http://www.w3.org/2000/svg xmlns:xlink=http://www.w3.org/1999/xlink%3E%3Ctitle%3E%3C/title%3E%3Cg stroke=none stroke-width=1 fill=none fill-rule=evenodd fill-opacity=0%3E%3Cg transform=translate(-249.000000, -126.000000) fill=%23FFFFFF%3E%3Crect x=249 y=126 width=1 height=1%3E%3C/rect%3E%3C/g%3E%3C/g%3E%3C/svg%3E" style="width: 50%; margin-bottom: 20px;"></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">（四）其他<span style="color: black;">药品</span></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">NO途径在心力<span style="color: black;">衰尽</span>和肺动脉高压<span style="color: black;">病人</span>均<span style="color: black;">显著</span>受损，吸入NO可减少静息时左心充盈压和肺动脉压。INDIE-HFpEF<span style="color: black;">科研</span>是一项随机安慰剂交叉设计的<span style="color: black;">科研</span>，纳入105例HFpEF<span style="color: black;">病人</span>，结果雾化吸入<span style="color: black;">没</span>机亚硝酸盐组的<span style="color: black;">重点</span>终点峰值耗氧量<span style="color: black;">无</span><span style="color: black;">显著</span>改善［47］。<span style="color: black;">另一</span>一项采用运动负荷右心导管的<span style="color: black;">科研</span><span style="color: black;">发掘</span>，HFpEF<span style="color: black;">病人</span>在运动负荷后PCWP<span style="color: black;">显著</span><span style="color: black;">增多</span>，而雾化吸入亚硝酸盐<span style="color: black;">显著</span>降低了运动负荷下的PCWP以及静息和运动状态下的肺动脉压［48］。一项小规模的<span style="color: black;">科研</span><span style="color: black;">表示</span>，β2-受体激动剂沙丁胺醇吸入后，PVR<span style="color: black;">显著</span>下降［49］。<span style="color: black;">选取</span>性β-3受体激动剂米拉贝隆<span style="color: black;">拥有</span>减轻右心室重构和肺血管重构的作用，正在进行一项<span style="color: black;">科研</span><span style="color: black;">评估</span>该<span style="color: black;">药品</span>在合并CPC-PH的心力<span style="color: black;">衰尽</span><span style="color: black;">病人</span>中对肺血管阻力的影响。Sotatercept是一种新型融合蛋白，可与激活素和生长分化因子结合，恢复骨形成蛋白Ⅱ型受体（BMPR2）生长促进和生长<span style="color: black;">控制</span>信号通路之间的平衡，是降低肺动脉压力新机制<span style="color: black;">药品</span>，其临床<span style="color: black;">科研</span><span style="color: black;">亦</span>正在进行中。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">（五）非<span style="color: black;">药品</span>治疗</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">手术或介入治疗是左侧瓣膜性心脏病<span style="color: black;">关联</span>肺动脉高压<span style="color: black;">病人</span>的<span style="color: black;">要紧</span>治疗手段，手术纠正瓣膜狭窄或关闭不全<span style="color: black;">能够</span>改善肺血液动力学，但术后肺动脉高压仍可能残存。在心力<span style="color: black;">衰尽</span>伴功能性二尖瓣反流<span style="color: black;">病人</span>中，介入瓣膜修复术<span style="color: black;">明显</span>降低了mPAP和肺动脉峰压力，改善了心输出量。然而，部分<span style="color: black;">病人</span>肺动脉压力仍然<span style="color: black;">上升</span>，<span style="color: black;">原由</span>可能是残余反流和/或狭窄组分。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">交感神经过度激活参与肺动脉高压的<span style="color: black;">出现</span>和发展，肺血管肺动脉去神经术（PADN）能降低1型和4型肺动脉高压<span style="color: black;">病人</span>的NT-proBNP并改善6分钟步行距离。PADN-5<span style="color: black;">科研</span>入选了伴CPC-PH的心衰<span style="color: black;">病人</span>，结果<span style="color: black;">发掘</span>肺动脉去神经术与西地那非+假手术组比较，6个月随访时，<span style="color: black;">重点</span>终点6分钟步行距离平均<span style="color: black;">增多</span>83米，对照组<span style="color: black;">增多</span>15米（P&lt;0.001）；PADN组PVR<span style="color: black;">明显</span><span style="color: black;">小于</span>对照组（4.2 Wood单位 比 6.1 Wood单位，P=0.001）［50］。<span style="color: black;">另外</span>，PADN组临床恶化<span style="color: black;">出现</span>率较低。PADN-5<span style="color: black;">科研</span>的3年随访结果证明了PADN可使伴CPC-PH的心力<span style="color: black;">衰尽</span><span style="color: black;">病人</span><span style="color: black;">长时间</span>获益。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="data:image/svg+xml,%3C%3Fxml version=1.0 encoding=UTF-8%3F%3E%3Csvg width=1px height=1px viewBox=0 0 1 1 version=1.1 xmlns=http://www.w3.org/2000/svg xmlns:xlink=http://www.w3.org/1999/xlink%3E%3Ctitle%3E%3C/title%3E%3Cg stroke=none stroke-width=1 fill=none fill-rule=evenodd fill-opacity=0%3E%3Cg transform=translate(-249.000000, -126.000000) fill=%23FFFFFF%3E%3Crect x=249 y=126 width=1 height=1%3E%3C/rect%3E%3C/g%3E%3C/g%3E%3C/svg%3E" style="width: 50%; margin-bottom: 20px;"></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">心房分流器<span style="color: black;">经过</span>缓解左心房压力而改善心力<span style="color: black;">衰尽</span><span style="color: black;">病人</span>的症状，<span style="color: black;">然则</span>REDUCE-LAP-HF Ⅱ期临床<span style="color: black;">实验</span><span style="color: black;">表示</span>，在一组LVEF≥40%的<span style="color: black;">病人</span><span style="color: black;">安置</span>心房分流<span style="color: black;">安装</span>后，并未观察到心力<span style="color: black;">衰尽</span>事件的减少［51］。亚组分析<span style="color: black;">发掘</span>，基线PVR高于中位数（&gt;1.74 Wood单位）的<span style="color: black;">病人</span>，心房分流器可能有害，推测肺动脉血流的<span style="color: black;">连续</span><span style="color: black;">增多</span>可能会加重肺血管重塑［52］。该<span style="color: black;">科研</span>再次提示对LDH-PH<span style="color: black;">病人</span>进行血流动力学分型的<span style="color: black;">要紧</span>性。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="data:image/svg+xml,%3C%3Fxml version=1.0 encoding=UTF-8%3F%3E%3Csvg width=1px height=1px viewBox=0 0 1 1 version=1.1 xmlns=http://www.w3.org/2000/svg xmlns:xlink=http://www.w3.org/1999/xlink%3E%3Ctitle%3E%3C/title%3E%3Cg stroke=none stroke-width=1 fill=none fill-rule=evenodd fill-opacity=0%3E%3Cg transform=translate(-249.000000, -126.000000) fill=%23FFFFFF%3E%3Crect x=249 y=126 width=1 height=1%3E%3C/rect%3E%3C/g%3E%3C/g%3E%3C/svg%3E" style="width: 50%; margin-bottom: 20px;"></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">总之，LDH-PH的机制<span style="color: black;">繁杂</span>，临床<span style="color: black;">干涉</span><span style="color: black;">科研</span>总体规模较小且多采用替代终点，但仍然为<span style="color: black;">咱们</span><span style="color: black;">供给</span>了两个<span style="color: black;">要紧</span>提示。<span style="color: black;">首要</span>，采用右心导管对LDH-PH<span style="color: black;">病人</span>进行血流动力学<span style="color: black;">评估</span>有助于<span style="color: black;">指点</span>治疗，尤其是HFpEF<span style="color: black;">病人</span>，还应该<span style="color: black;">思虑</span>采用运动负荷右心导管；其次，尽管靶向<span style="color: black;">药品</span>未能改善心力<span style="color: black;">衰尽</span><span style="color: black;">病人</span>的血流动力学指标，但其中合并CPC-PH表型的<span style="color: black;">病人</span>仍然是靶向<span style="color: black;">药品</span><span style="color: black;">科研</span>的<span style="color: black;">要紧</span>方向。肺动脉高压可能仅为左心<span style="color: black;">疾患</span>严重程度的指标，但<span style="color: black;">亦</span>有可能是有效的<span style="color: black;">干涉</span>靶点；在PH-LHF<span style="color: black;">关联</span>临床<span style="color: black;">实验</span>中，对<span style="color: black;">科研</span>人群进行血流动力学分型的必要性仍有待探讨。治疗决策方面，<span style="color: black;">可否</span>应对此类<span style="color: black;">病人</span>进行右心功能干预尚<span style="color: black;">没</span>结论，这些是<span style="color: black;">将来</span><span style="color: black;">基本</span>和临床<span style="color: black;">科研</span>的<span style="color: black;">要紧</span>方向。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">引用：</span><span style="color: black;">郑舒文, 王喆, 翟振国, 等. 左心<span style="color: black;">衰尽</span><span style="color: black;">关联</span>肺动脉高压的<span style="color: black;">科研</span><span style="color: black;">发展</span>. 中华内科杂志, 2024, 63(1): 113-120.</span></p><span style="color: black;"><a style="color: black;">集锦：肺功能，共计13篇</a></span>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><a style="color: black;"><span style="color: black;">集锦：心力<span style="color: black;">衰尽</span> 2.0版，新增32篇，共108篇</span></a></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><a style="color: black;"><span style="color: black;">集锦：流感病毒/流行性感冒，共计35篇</span></a></p><a style="color: black;"><span style="color: black;">集</span></a>锦：支原体肺炎，共计30篇<span style="color: black;"><a style="color: black;">集锦：噬血细胞<span style="color: black;">综合症</span>、传染性单核细胞<span style="color: black;">增加</span>症，共计12篇</a></span><a style="color: black;"><span style="color: black;">集锦：脓毒症、脓毒性休克，共计170篇</span></a><a style="color: black;"><span style="color: black;">集锦：关于【钾】的40篇<span style="color: black;">文案</span>合集</span></a><a style="color: black;"><span style="color: black;">集锦：关于【钠】的27篇<span style="color: black;">文案</span>合集</span></a><a style="color: black;"><span style="color: black;">集锦：胸部CT阅读，共计51篇</span></a><a style="color: black;"><span style="color: black;">集锦：降钙素原，共计18篇</span></a><a style="color: black;"><span style="color: black;">集锦：<span style="color: black;">呼气</span><span 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black;">集锦：横纹肌溶解症（</span></a>7篇）<a style="color: black;"><span style="color: black;">集锦：咳嗽，共计22篇</span></a><a style="color: black;"><span style="color: black;">集锦：血流动力学，共计28篇</span></a><a style="color: black;"><span style="color: black;">集锦：血栓、血栓栓塞</span></a><a style="color: black;"><span style="color: black;">集锦：重症的<span style="color: black;">止疼</span>+镇静</span></a><a style="color: black;"><span style="color: black;">集锦：休克</span></a><a style="color: black;"><span style="color: black;">集锦：心电图学习</span></a><a style="color: black;"><span style="color: black;">集锦：碳酸氢钠、酸/碱中毒、酸碱失衡</span></a><a style="color: black;"><span style="color: black;">集锦：肺栓塞</span></a><a style="color: black;"><span style="color: black;">集锦：微量泵、血管活性物质等</span></a><a style="color: black;"><span style="color: black;">集锦：抗生素，共40篇</span></a><a style="color: black;"><span style="color: black;">集锦：细菌耐药</span></a><a style="color: black;"><span style="color: black;">集锦：关于“血压”的37文献</span></a><a style="color: black;"><span style="color: black;">集锦：抗结核治疗<span style="color: black;">方法</span>、不良反应及处理</span></a>，共计35篇<a style="color: black;"><span style="color: black;">集锦：结缔组织病，肺动脉高压，间质性肺病，<span style="color: black;">自己</span>抗体</span></a><a style="color: black;"><span style="color: black;">集锦：临床营养治疗，共计27篇</span></a><a style="color: black;"><span style="color: black;">集锦：深静脉置管、管理；中心静脉压（共计27篇）</span></a><a style="color: black;"><span style="color: black;">集锦：<span style="color: black;">综合症</span>、综合症、危象，共计70篇</span></a><a style="color: black;"><span style="color: black;">集锦：阑尾，共计7篇</span></a><a style="color: black;"><span style="color: black;">集锦：糖皮质激素、皮质醇功能不全，共计19篇</span></a><a style="color: black;"><span style="color: black;">集锦：高血压，共计22篇</span></a><a style="color: black;"><span style="color: black;">集锦：心肌梗死、ST段，共计20篇</span></a><a style="color: black;"><span style="color: black;">集锦：胸腔积液，共计38篇</span></a><a style="color: black;"><span style="color: black;">集锦：高钾血症</span></a><a style="color: black;"><span style="color: black;">集锦：肝<span style="color: black;">衰尽</span>、肝性脑病、肝肾<span style="color: black;">综合症</span></span></a><a style="color: black;"><span style="color: black;">集锦：血糖、糖尿病、胰岛素、糖尿病酮症酸中毒等</span></a><a style="color: black;"><span style="color: black;">集锦：临床<span style="color: black;">各样</span><span style="color: black;">评定</span>、评分、管理策略</span></a><a style="color: black;"><span style="color: black;">避免落坑：<span style="color: black;">平常</span>的危急重症影像实例集锦</span></a><a style="color: black;"><span style="color: black;">肺间质改变为表现的不典型肺结核（CT集锦）</span></a><a style="color: black;"><span style="color: black;">集锦：腹腔结核的CT影像——TB or not TB？</span></a><a style="color: black;"><span style="color: black;">指南集锦：乙肝</span></a>病毒与母婴（2017-2021年国内7部）<a style="color: black;"><span style="color: black;">临床各科危急值集锦 | 危急值报告，关<span style="color: black;">咱们</span>什么事?</span></a><a style="color: black;"><span style="color: black;">硬货<span style="color: black;">归类</span>：蛛网膜下腔<span style="color: black;">流血</span>，共计8篇</span></a><a style="color: black;"><span style="color: black;">硬货<span style="color: black;">归类</span>：脉搏指示连续心输出量PiCCO，11篇<span style="color: black;">文案</span>合集</span></a><a style="color: black;"><span style="color: black;">硬货<span style="color: black;">归类</span>：老年科指南，共计30篇</span></a><a style="color: black;"><span style="color: black;">硬货<span style="color: black;">归类</span>：肾脏病</span></a><a style="color: black;"><span style="color: black;">硬货<span style="color: black;">归类</span>：重症超声、心脏超声、肺部超声、超声引导</span></a><a style="color: black;"><span style="color: black;">硬货<span style="color: black;">归类</span>：腹泻，共计1</span></a>2篇<a style="color: black;"><span style="color: black;">硬货<span style="color: black;">归类</span>：<span style="color: black;">心率</span>失常，共计17篇</span></a><a style="color: black;"><span style="color: black;">硬货<span style="color: black;">归类</span>：脑卒中、脑梗死、脑<span style="color: black;">流血</span>、脑血管、脑水肿，共计26篇</span></a><a style="color: black;"><span 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情迷布拉格 发表于 2024-8-28 15:49:12

你的留言真是温暖如春，让我感受到了无尽的支持与鼓励。

b1gc8v 发表于 2024-11-8 13:42:29

感谢楼主的分享！我学到了很多。

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