射血分数中间值心力衰竭——究竟该如何认识？

doi:10.12114/j.issn.1007-9572.2021.01.316

摘要/Abstract

摘要： 心力衰竭是各类心血管疾病的最终主战场，其危害巨大，可诱发各类心律失常甚至心源性猝死。2016年欧洲心脏病学会（ESC）指南正式将射血分数中间值心力衰竭（HFmrEF）定义为左心室射血分数（LVEF）在40%~49%的心力衰竭，旨在细化心力衰竭的分类，加强临床工作者对心力衰竭病理生理学的重视，促进更多临床研究的开展，从而更好地指导临床诊疗。目前关于HFmrEF的病理生理学、治疗等方面仍然存在不少争议，本文从流行病学、临床特征、病理生理学、治疗等方面分别阐述HFmrEF患者的特点，发现HFmrEF更像是介于射血分数保留型心力衰竭（HFpEF）和射血分数降低型心力衰竭（HFrEF）的过渡型，而不是一种独特的表型。4种心力衰竭领域新药〔血管紧张素受体-脑啡肽酶抑制剂（ARNI）、钠-葡萄糖协同转运蛋白2抑制剂（SGLT-2i）、可溶性鸟苷酸环化酶激动剂（SGC）、心脏肌球蛋白激动剂（OM）〕以及房间隔分流器均在HFmrEF患者的治疗中展现了不同程度的效果。未来需要开展更多关于HFmrEF的临床研究，如LVEF本身变化趋势的HFmrEF亚组研究，以加深临床医生对于HFmrEF的理解和认识，从而更好地指导临床治疗。

关键词: 心力衰竭, 射血分数中间值心力衰竭, 心血管疾病, 血管紧张素受体-脑啡肽酶抑制剂, 钠-葡萄糖协同转运蛋白2抑制剂, 可溶性鸟苷酸环化酶激动剂, 心脏肌球蛋白激动剂, 综述

Abstract:

Heart failure is the final main battlefield of various cardiovascular diseases with huge harm, which can cause all kinds of arrhythmias and even sudden cardiac death. The 2016 ESC guidelines formally define heart failure with mid-range ejection fraction (LVEF) in the range of 40% to 49%, aiming to refine the classification of heart failure, in order to arouse the attention of clinicians to the pathophysiology of heart failure and carry out more clinical research to better guide diagnosis and treatment. At present, there are still many controversies about the pathophysiology and treatment of HFmrEF. This article explains the characteristics of patients with HFmrEF from the aspects of epidemiology, clinical characteristics, pathophysiology, and treatment. It is found that HFmrEF is more like a transition between HFpEF and HFrEF patients than a unique phenotype. Four new drugs in the field of heart failure (ARNI, SGLT-2i, SGC, OM) and atrial septal shunts have shown different degrees of benefit in the treatment of HFmrEF patients. In the future, more clinical studies on HFmrEF (such as the HFmrEF subgroup study based on the changing trend of LVEF) are needed to deepen clinicians' understanding and understanding of HFmrEF, so as to better guide treatment.

Key words: Heart failure, HFmrEF, Cardiovascular diseases, ARNI, SGLT-2i, SGC, OM, Review

中图分类号:

R541.62

阮征,黄建玉,姜文才,等. 射血分数中间值心力衰竭——究竟该如何认识？[J]. 中国全科医学, 2022, 25(05): 522-529. DOI: 10.12114/j.issn.1007-9572.2021.01.316.

RUAN Zheng, HUANG Jianyu, JIANG Wencai, CHEN Meixiang, QIN Changyu, XU Lin.

Heart Failure with Mid-range Ejection Fraction——a Comprehension of the Disease [J]. Chinese General Practice, 2022, 25(05): 522-529.

图/表 1

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临床特征	CHART-2研究（n=3 480）			OPTIMIZE-HF研究（n=37 511）			GWTG-HF研究（n=39 982）
临床特征	HFrEF （n=730）	HFmrEF （n=596）	HFpEF （n=2 154）	HFrEF （n=20 118）	HFmrEF （n=7 321）	HFpEF （n=10 072）	HFrEF （n=18 398）	HFmrEF （n=3 285）	HFpEF （n=18 299）
年龄（岁）	66.9	69.0	71.7	70.4	74.3	75.6	79.0	81.0	82.0
女性占比（%）	23.3	28.2	39.2	38.0	52.0	68.0	41.0	51.5	67.6
BMI（kg/m²）	22.7	22.8	23.2	-	-	-	25.6	26.8	27.3
收缩压（mm Hg）	118	125	128	135	147	150	132	141	143
舒张压（mm Hg）	70	72	72	77	77	75	73	74	72
冠心病占比（%）	-	-	-	-	-	-	56.8	55.1	43.5
心肌梗死占比（%）	39.3	41.1	26.9	-	-	-	22.2	17.5	11.1
糖尿病占比（%）	38.1	36.1	33.8	39.0	44.0	41.0	38.3	41.6	38.8
心房颤动/心房扑动占比（%）	38.1	43.5	51.8	28.0	33.0	32.0	34.5	37.4	38.9
高血压占比（%）	84.7	89.8	91.2	66.0	74.0	77.0	69.9	75.3	77.9
慢性肾脏病占比（%）	-	-	-	-	-	-	19.4	18.8	17.6
ACEI/ARB使用率（%）	84.4	80.0	76.3	56.0	50.0	48.0	55.0	50.1	48.9
β-受体阻断剂使用率（%）	69.6	63.8	46.4	56.0	54.0	50.0	83.9	78.5	70.0
利尿剂使用率（%）	76.2	63.3	52.2	63.0	59.0	57.0	64.6	60.0	62.1
地高辛使用率（%）	-	-	-	30.0	19.0	15.0	21.3	14.8	13.8
醛固酮受体拮抗剂使用率（%）	43.7	29.3	19.4	10.0	6.0	4.0	10.1	6.5	5.0

临床特征	CHART-2研究（n=3 480）			OPTIMIZE-HF研究（n=37 511）			GWTG-HF研究（n=39 982）
临床特征	HFrEF （n=730）	HFmrEF （n=596）	HFpEF （n=2 154）	HFrEF （n=20 118）	HFmrEF （n=7 321）	HFpEF （n=10 072）	HFrEF （n=18 398）	HFmrEF （n=3 285）	HFpEF （n=18 299）
年龄（岁）	66.9	69.0	71.7	70.4	74.3	75.6	79.0	81.0	82.0
女性占比（%）	23.3	28.2	39.2	38.0	52.0	68.0	41.0	51.5	67.6
BMI（kg/m²）	22.7	22.8	23.2	-	-	-	25.6	26.8	27.3
收缩压（mm Hg）	118	125	128	135	147	150	132	141	143
舒张压（mm Hg）	70	72	72	77	77	75	73	74	72
冠心病占比（%）	-	-	-	-	-	-	56.8	55.1	43.5
心肌梗死占比（%）	39.3	41.1	26.9	-	-	-	22.2	17.5	11.1
糖尿病占比（%）	38.1	36.1	33.8	39.0	44.0	41.0	38.3	41.6	38.8
心房颤动/心房扑动占比（%）	38.1	43.5	51.8	28.0	33.0	32.0	34.5	37.4	38.9
高血压占比（%）	84.7	89.8	91.2	66.0	74.0	77.0	69.9	75.3	77.9
慢性肾脏病占比（%）	-	-	-	-	-	-	19.4	18.8	17.6
ACEI/ARB使用率（%）	84.4	80.0	76.3	56.0	50.0	48.0	55.0	50.1	48.9
β-受体阻断剂使用率（%）	69.6	63.8	46.4	56.0	54.0	50.0	83.9	78.5	70.0
利尿剂使用率（%）	76.2	63.3	52.2	63.0	59.0	57.0	64.6	60.0	62.1
地高辛使用率（%）	-	-	-	30.0	19.0	15.0	21.3	14.8	13.8
醛固酮受体拮抗剂使用率（%）	43.7	29.3	19.4	10.0	6.0	4.0	10.1	6.5	5.0