终末期心衰的治疗
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">终末期心衰又<span style="color: black;">叫作</span>顽固性心衰，<span style="color: black;">指的是</span>经过<span style="color: black;">各样</span>常规治疗（利尿、血管扩张剂、正性肌力药）1~2周后，病情仍然不见好转，<span style="color: black;">乃至</span>还有<span style="color: black;">发展</span>的<span style="color: black;">病人</span>。难治性心衰是心脏<span style="color: black;">疾患</span>发展至终末期的结果，但心衰症状并非完全不可改善。在第29届长城国际心脏病学会议上，大连医科大学<span style="color: black;">附庸</span>第二医院曲鹏教授向与会者分享了终末期心衰治疗的策略<span style="color: black;">选取</span>。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">一. 心衰诊断标准与原则</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">1. 四个"<span style="color: black;">知道</span>"</p><span style="color: black;">知道</span><span style="color: black;">病人</span><span style="color: black;">可否</span><span style="color: black;">身患</span>心衰；<span style="color: black;">知道</span>心衰的病因；<span style="color: black;">知道</span>心衰的诱因；<span style="color: black;">知道</span>心衰的治疗<span style="color: black;">方法</span>。<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">2. 十四个"有<span style="color: black;">没</span>"</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">病人</span>有<span style="color: black;">没</span>手术<span style="color: black;">能够</span>纠正的心脏<span style="color: black;">疾患</span>；<span style="color: black;">病人</span>有<span style="color: black;">没</span>过度利尿；<span style="color: black;">病人</span>有<span style="color: black;">没</span>洋地黄中毒；<span style="color: black;">病人</span>有<span style="color: black;">没</span><span style="color: black;">运用</span>负性肌力药；<span style="color: black;">病人</span>有<span style="color: black;">没</span>饮酒或饮茶；<span style="color: black;">病人</span>有<span style="color: black;">没</span>甲亢或甲低；<span style="color: black;">病人</span>有<span style="color: black;">没</span>风湿活动；<span style="color: black;">病人</span>有<span style="color: black;">没</span>肺梗死；<span style="color: black;">病人</span>有<span style="color: black;">没</span>肺感染、亚急性细菌性心内膜炎（SBE）；<span style="color: black;">病人</span>有<span style="color: black;">没</span><span style="color: black;">很难</span><span style="color: black;">掌控</span>的<span style="color: black;">心率</span>失常；<span style="color: black;">病人</span>有<span style="color: black;">没</span>贫血；<span style="color: black;">病人</span>有<span style="color: black;">没</span>肝肾功能<span style="color: black;">衰退</span>；<span style="color: black;">病人</span>有<span style="color: black;">没</span>冠状动脉供血不足；<span style="color: black;">病人</span>有<span style="color: black;">没</span>酸碱中毒或电解质<span style="color: black;">错乱</span>。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">3. 六个"<span style="color: black;">可否</span>"</p>利尿剂<span style="color: black;">可否</span>充分发挥<span style="color: black;">功效</span>；<span style="color: black;">病人</span><span style="color: black;">可否</span>得到充分<span style="color: black;">休憩</span>；血管扩张剂应用<span style="color: black;">可否</span><span style="color: black;">稳妥</span>；<span style="color: black;">身体</span>液体潴留<span style="color: black;">可否</span><span style="color: black;">太多</span>；神经体液失衡<span style="color: black;">可否</span>纠正。<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">二. 临床<span style="color: black;">评定</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">临床<span style="color: black;">必须</span>从三个方面<span style="color: black;">评定</span>难治性心衰，<span style="color: black;">包含</span>①判断心衰程度；②<span style="color: black;">评定</span><span style="color: black;">病人</span>血流动力学；③<span style="color: black;">评定</span>预后。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">1. 心功能级别判定</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">（1）NYHA分级</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">NYHA分级适用于收缩性心衰（SHF）、左心衰，不适用于失代偿性心衰（DHF）、右心衰。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">表1. NYHA分级</p>
<div style="color: black; text-align: left; margin-bottom: 10px;"><img src="https://pic4.zhimg.com/80/v2-6109da84e783dfb6f5bc62f6ee94f15b_720w.webp" style="width: 50%; margin-bottom: 20px;"></div>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">（2）WEBER运动耐量分级</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">WEBER运动耐量分级观察指标<span style="color: black;">重点</span><span style="color: black;">包含</span>运动时最大氧摄入量（VO2 max）和<span style="color: black;">没</span>氧代谢阈（AT）。其中VO2 max正常值为＞20 ml/min/<span style="color: black;">公斤</span>、AT＞14 ml/min/<span style="color: black;">公斤</span>。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">学者Weber<span style="color: black;">按照</span>VO2 max及AT数值将心功能分为A、B、C、D四级（表3），<span style="color: black;">能够</span>客观地反映心脏<span style="color: black;">贮存</span>功能，又可定量分级。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">表2. Weber运动耐量分级</p>
<div style="color: black; text-align: left; margin-bottom: 10px;"><img src="https://pic2.zhimg.com/80/v2-5f62d16a08f608f06c0541694a156275_720w.webp" style="width: 50%; margin-bottom: 20px;"></div>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">（3）6分钟步行<span style="color: black;">实验</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">六分钟步行<span style="color: black;">实验</span>是一项简单易行、安全、简便的<span style="color: black;">实验</span>，不仅<span style="color: black;">能够</span>评定心衰<span style="color: black;">病人</span>的运动耐力，<span style="color: black;">同期</span><span style="color: black;">能够</span>预测预后。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">（4）Forresfer泵衰竭分型</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">Forrester分级<span style="color: black;">重点</span>依据临床表现及血流动力学指标。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">表3. Forresfer泵衰竭分型</p>
<div style="color: black; text-align: left; margin-bottom: 10px;"><img src="https://pic3.zhimg.com/80/v2-a4883b2306d65d3dda5ce33e9bbebb5a_720w.webp" style="width: 50%; margin-bottom: 20px;"></div>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">（5）Killp分级</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">Killip分级仅适用于急性心梗<span style="color: black;">病人</span>，<span style="color: black;">重点</span>依据临床表现和胸部X片结果进行分级。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">表4. Killip分级</p>
<div style="color: black; text-align: left; margin-bottom: 10px;"><img src="https://pic2.zhimg.com/80/v2-6b2e333d10f7d8bfbc9708c51cddd615_720w.webp" style="width: 50%; margin-bottom: 20px;"></div>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">2. 心衰的分期</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">表5. 心衰<span style="color: black;">病人</span>的分期</p>
<div style="color: black; text-align: left; margin-bottom: 10px;"><img src="https://pic2.zhimg.com/80/v2-a118ca25a65adebddb803add11488b9d_720w.webp" style="width: 50%; margin-bottom: 20px;"></div>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">三. 心衰的治疗</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">图1. 慢性心衰的治疗原则</p>
<div style="color: black; text-align: left; margin-bottom: 10px;"><img src="https://pic2.zhimg.com/80/v2-d566fe9e5c44cf1f0dd46c625856b14d_720w.webp" style="width: 50%; margin-bottom: 20px;"></div>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">图2. 终末期心衰治疗的流程</p>
<div style="color: black; text-align: left; margin-bottom: 10px;"><img src="https://pic2.zhimg.com/80/v2-76a8a45a63754299190ab000a6472239_720w.webp" style="width: 50%; margin-bottom: 20px;"></div>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">1. <span style="color: black;">药品</span>治疗</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">心衰<span style="color: black;">病人</span>的<span style="color: black;">药品</span>治疗<span style="color: black;">包含</span>①利尿剂；②ACEI/ ARB；③β受体阻滞剂；④醛固酮受体拮抗剂；⑤地高辛；⑥伊伐布雷定；⑦神经内分泌<span style="color: black;">控制</span>剂联合应用；⑧有争议、正在<span style="color: black;">科研</span>或疗效尚<span style="color: black;">不愿</span>定的<span style="color: black;">药品</span>。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">（1）终末期心衰的治疗</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">按照</span>血流动力学特点将顽固性心衰分为有<span style="color: black;">没</span>液体潴留（干/湿）和有<span style="color: black;">没</span>低灌注征象（暖/冷）。</p>湿暖型<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">联合应用泮利尿剂，静脉滴注硝酸甘油，且不<span style="color: black;">必须</span>应用正性肌力药。</p>湿冷型<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">采用血管扩张药改善临床症状。静脉应用硝普钠时，在有创血流动力学的监测下效果较好，稳定后改用ACEI或肼苯哒嗪+硝酸酯。</p>干冷型<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">干冷型<span style="color: black;">病人</span>临床较为稳定，但症状加重时，口服<span style="color: black;">药品</span><span style="color: black;">一般</span><span style="color: black;">没</span>效。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">（2）顽固性水肿的治疗</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">顽固性水肿的治疗<span style="color: black;">重要</span>在于识别和<span style="color: black;">掌控</span>液体潴留。</p>稀释性低钠血症<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">该类<span style="color: black;">病人</span>对利尿剂反应差，<span style="color: black;">血液</span>渗透压低，<span style="color: black;">因此呢</span><span style="color: black;">选取</span>渗透性利尿剂，且甘露醇优于其他利尿剂。值得<span style="color: black;">重视</span>的是，脑水肿时需快速输注，心衰时需缓慢静滴，静滴的速度为100~200 ml/2~3小时，在输注一半时应用强心药西地兰，10~20分钟后<span style="color: black;">按照</span><span style="color: black;">状况</span>静脉注射呋塞100~200 mg，加用小剂量多巴胺2~3 µg/min/<span style="color: black;">公斤</span>，会使利尿效果更好。</p>真性低钠血症<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">运用</span>大剂量泮利尿剂或输注小剂量高渗盐水治疗顽固性心衰的效果较好。用药<span style="color: black;">方法</span>为呋塞米500~1000 mg，<span style="color: black;">同期</span>在30分钟内快速输入1.4%~4.6%高渗盐水100 ml，一日两次。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">若<span style="color: black;">病人</span>的血钠浓度<125 mmol/L时，<span style="color: black;">运用</span>4.6%的高渗盐水；若<span style="color: black;">病人</span>的血钠浓度在126~135 mmol/L时，<span style="color: black;">运用</span>3.5%的高渗盐水；若<span style="color: black;">病人</span>的血钠浓度>135 mmol/L时，<span style="color: black;">运用</span>1.4%~2.4%的高渗盐水。且所有<span style="color: black;">病人</span>都应静脉给予氯化钾20~40 mg/d，以预防低钾血症，<span style="color: black;">同期</span><span style="color: black;">病人</span><span style="color: black;">每日</span>钠的摄入量为120 mmol，入液量为1000 ml。原则是大利小补，先利后补。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">（3）心梗后的心衰治疗</p>肺充血型<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">心排血指数>2.2 L/min/m2、肺毛细血管楔压>18 mmHg且<span style="color: black;">没</span>组织灌注不足的<span style="color: black;">病人</span>应<span style="color: black;">选择</span>硝酸盐制剂，如硝酸甘油、单硝酸异山梨酯加利尿剂。</p>低排高阻型<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">心排血指数<2.2 L/min/m2、肺毛细血管楔压<18 mmHg且血压<span style="color: black;">上升</span>的<span style="color: black;">病人</span>应<span style="color: black;">选取</span>酚妥拉明、乌拉地尔联合多巴酚丁胺或米力农。</p>肺充血型伴低排高阻型（混合型）<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">心排血指数≤2.2 L/min/m2、肺毛细血管楔压>18 mmHg的<span style="color: black;">病人</span>应<span style="color: black;">选取</span>米力农或多巴酚丁胺联合硝普钠治疗。</p>低排低阻型<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">心排血指数<2.2 L/min/m2、血压降低的<span style="color: black;">病人</span>应<span style="color: black;">选取</span>多巴酚丁胺联合多巴胺治疗。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">2. 机械辅助循环<span style="color: black;">安装</span>及其他治疗</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">机械辅助循环<span style="color: black;">安装</span>及其他治疗<span style="color: black;">包含</span>①体外膜式氧合器；②心脏再同步化治疗；③左心循环辅助<span style="color: black;">安装</span>；④运动性心肌成形术；⑤左心室减容术；⑥基因和细胞治疗；⑦心脏移植术；⑧全人工心脏。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">最后，曲鹏教授总结<span style="color: black;">叫作</span>，临床<span style="color: black;">大夫</span>应<span style="color: black;">注意</span>终末期心衰的诊断、功能及预后<span style="color: black;">评定</span>；治疗终末期心衰的<span style="color: black;">重要</span>在于改善原发<span style="color: black;">疾患</span>、去除诱因。<span style="color: black;">另外</span>，心衰<span style="color: black;">发展</span>和恶化时常会<span style="color: black;">显现</span>利尿剂抵抗，可<span style="color: black;">经过</span>改变用药途径、剂量或联合小剂量多巴胺改善肾血流，<span style="color: black;">加强</span>利尿效果；<span style="color: black;">重视</span>洋地黄和非洋地黄类正性肌力药的<span style="color: black;">运用</span>。<span style="color: black;">另一</span>，非<span style="color: black;">药品</span>治疗是难治性心衰的<span style="color: black;">要紧</span>治疗<span style="color: black;">办法</span>，加强心肺运动功能<span style="color: black;">评定</span>和综合的<span style="color: black;">恢复</span>心理关怀<span style="color: black;">干涉</span>。</p>
感谢你的精彩评论，为我的思绪打开了新的窗口。 我完全同意你的观点，说得太对了。
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