Effects of diuretic treatment on cardiac and circulating RAS in chronic heart failure post-myocardial infarction in rats

BACKGROUND: Cardiac angiotensin converting enzyme (ACE) is activated by an increase in wall stress and is involved in remodeling processes. Heart failure is often treated with ACE inhibitors and diuretics although diuretic treatment could activate the renin-angiotensin system (RAS). AIMS: To examine the effects of diuretic treatment on cardiac and circulating RAS in post-infarction chronic heart failure. METHODS: Myocardial infarction was produced by coronary artery ligation in spontaneously hypertensive rats. The rats were randomly assigned to receive either ramipril (1 mg/kg/day), furosemide (4 mg/kg/day), or combination therapy for 6 weeks, commencing 2 weeks after infarction. RESULTS: All three treatment protocols equivalently attenuated reactive hypertrophy of the right ventricle and ventricular septum and improved left ventricular systolic function. Both cardiac ACE mRNA and activity were significantly increased in untreated rats. This increase was attenuated by both ramipril and furosemide and further depressed by the combination. The increase in activity was completely inhibited by either agent alone. Plasma renin activity was upregulated by ramipril or ramipril plus furosemide but not influenced by infarction or furosemide alone. CONCLUSIONS: Furosemide and ramipril significantly reduced cardiac ACE and remodeling. Diuretics work favorably and do not interfere with the effects of ACE inhibitors. Possibly, a reduction in wall stress due to decreased volume overload accounts for the effects of diuretics on cardiac ACE in the treatment of post-infarction remodeling in hypertensive hearts. These data suggest a new mechanism for the frequently observed beneficial effect of diuretics in heart failure.     

80岁以上老年糖尿病患者的营养评估

目的了解≥80岁糖尿病患者的营养状况,探讨营养不良相关的危险因素,为临床早期干预治疗,改善预后提供依据。方法采用微型营养评定（mini nutritional assessment,MNA）方法,全面地收集并评估≥80岁糖尿病患者的营养状况,采用SPSS 17.0软件,综合分析影响老年人营养状况的独立危险因素。结果≥80岁糖尿病患者营养不良发生率为63%,与营养不良相关的主要因素分别为性别、年龄、糖尿病病程、糖化血红蛋白水平以及糖尿病并发症。结论≥80岁糖尿病患者营养状况较差,MNA是一种简单、有效的评估方法,应在高龄患者中推广使用。     

高龄老年冠心病诊治中国专家共识

冠状动脉粥样硬化性心脏病(冠心病)是影响高龄(≥80岁)人群健康的主要原因之一。其患病率随增龄而增加,我国高龄老年冠心病患者亦日益增多 ^{[ 1]} 。根据《2015年中国卫生和计划生育统计年鉴》,我国人群2002—2014年急性心肌梗死(AMI)病死率上升,并随增龄而增加,40岁开始上升,其递增趋势近似于指数关系,80岁及以上人群AMI病死率增加更为显著。75岁～、80岁～和85岁以上年龄组AMI病死率增幅：城市男性分别是84.68/10万、207.26/10万和685.94/10万;城市女性分别是66.36/10万、215.10/10万和616.25/10万;农村男性分别是225.92/10万、347.04/10万和801.04/10万;农村女性分别是177.62/10万、348.69/10万和804.85/10万。因此,高龄人群冠心病的防治任务日趋严峻。     

老老年冠心病患者临床特点及治疗分析

目的研究老老年(≥80岁)冠心病(CHD)患者的冠状动脉病变及介入治疗特点,为老老年患者的治疗提供临床依据。方法选取2013年1月至2015年12月我院收治行冠状动脉造影的48例老老年(≥80岁,老老年组)和260例老年(65~79岁,老年组)CHD患者,对其危险因素、累及血管、Gensini评分及围手术期并发症发生率进行分析。计量资料用均数±标准差(±s表示,两组比较采用t检验。计数资料用百分率表示,组间比较用χ~2检验。结果老老年组男性急性心肌梗死、陈旧性心肌梗死、高血压、糖尿病、高胆固醇血症和脑梗死发生率显著高于老年组(P0.05)。老老年组患者以多支病变为主,左主干病变与慢性闭塞病变发生率显著高于老年组(P0.05);老老年组Gensini评分显著高于老年组(P0.05)。围手术期和术中并发症两组无显著差异,但老老年组围手术期死亡率较老年组有增加的趋势。结论老老年CHD患者临床危险因素和基础疾病多,冠状动脉病变复杂,狭窄程度严重。应综合评估患者的手术获益与风险,实施更安全有效的治疗方案。     

不同剂量阿托伐他汀钙对中重度衰弱高龄患者肌少症的影响

目的观察不同剂量阿托伐他汀钙对中重度衰弱高龄患者肌少症的影响。方法入选2016年4月至2018年4月就诊于江苏省钟山康复医院康疗科高龄伴中重度衰弱患者98例,随机数字表法分为20 mg组34例,10 mg组33例,未服药组31例,分别检测服药前、服药12和24个月的总胆固醇(TC)、低密度脂蛋白胆固醇(LDL-C)、甘油三酯(TG)和高密度脂蛋白胆固醇(HDL-C)、握力、4.5 m步行时间、四肢骨骼肌质量指数(ASMI)和衰弱分级。采用SPSS 19.0软件对数据进行分析。组间比较采用t检验、方差分析或χ~2检验。结果服药24个月时,20 mg组患者相比未服药组患者TC[(3.84±0.96)vs(4.36±0.95)mmol/L]、LDL-C[(2.48±1.33)vs(3.19±1.30)mmol/L]、握力[(15.77±3.71)vs(18.58±3.43)kg]和ASMI[(13.90±2.33)vs(15.27±3.16)kg/m~2]降低,相比10 mg组患者TC[(3.84±0.96)vs(4.26±1.03)mmol/L]和LDL-C[(2.48±1.33)vs(3.47±1.41)mmol/L]降低,10 mg组患者相比未服药组患者握力[(15.31±4.71)vs(18.58±3.43)]降低,差异均具有统计学意义(P0.05)。服药24个月20 mg组患者衰弱分级增加一级的发生率为35.3%(12/34),10 mg组患者为18.2%(6/33),未服药组患者为9.7%(3/31),差异具有统计学意义(P=0.036)。结论他汀类药物可能进一步加剧增龄相关的肌功能下降和衰弱。     

The role of renin-angiotensin-aldosterone system-based therapy in diabetes prevention and cardiovascular and renal protection

Hypertension increases the risk of type 2 diabetes mellitus (T2DM) and cardiovascular disease. In addition to lowering blood pressure, blockade of the renin-angiotensin-aldosterone system (RAAS) reduces the risk of new-onset T2DM and offers renal protection. Using a MEDLINE search, we identified multiple trials that reported the incidence of T2DM in patients taking inhibitors of RAAS. In this review, we will discuss the RAAS as a potential target in diabetes prevention and the mechanisms through which inhibitors of this system achieve such an important effect. We will also shed light on the beneficial cardiovascular and renal effects of RAAS blockade. Although multiple studies have demonstrated that inhibitors of RAAS, especially angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, can reduce the incidence of T2DM, randomized controlled studies are still needed to further elucidate their exact role in diabetes prevention.     

高龄危重患者手术麻醉方法和管理

目的探讨合并多个脏器功能异常、年龄逾90岁患者手术麻醉方法和管理的特点。方法总结近3年年龄超过90岁手术患者16例次,其中开腹手术6例次,人工髋关节置换术10例次,术前依据病史有针对性检查各重要脏器的功能,并作相应的积极准备,依手术种类和病情特点选择麻醉方法,应用Hemosonic TM100食道超声多普勒监测血流动力学、A-Line自动回归指数（AAL）监测麻醉深度以及4个成串刺激（TOF）指导追加肌肉松弛剂。结果全组患者术前均伴有2～4个脏器功能异常,且以循环、呼吸和内分泌系统改变较为常见;控制血压、营养心肌、抗心律失常、降血糖和抗感染是术前准备常用且有效的方法;开腹手术以全麻为主,追加维库溴铵间隔时间（87±16）min;人工髋关节置换术全部选择硬膜外阻滞,首次剂量1％利多卡因（7．6±0．9）ml,追加间隔时间（63±17）min。用6％羟乙基淀粉按10ml／kg静输后15min,患者每搏输出量、心输出量、心脏指数和主动脉内血流量（ABF）均分别较扩容前平均增加17％、11％、14％和15％,外周血管阻力和心率分别下降16％和9．6％。术中维持AAI 50～60,术毕出现咳嗽（吞咽）和清醒应答时AAI分别为73±9．4和81±7．3,随访术后无知晓。结论重视术前准备和术中监测;硬膜外阻滞应选用低浓度、小容量局麻药,6％羟乙基淀粉适合用于人工髋关节置换术;分次、小剂量应用静脉麻醉药,间隔更长时间再加肌松剂和维持相对较高AAI,是开腹手术实施全麻应遵循的原则。     

高龄人群(≥80岁)缺血性卒中的危险因素

高龄人群(≥80岁)缺血性卒中的危险因素与其他人群(＜80岁)不尽相同.与其他年龄人群相比,高龄人群女性缺血性卒中的发病率更高,传统危险因素以心房颤动和高血压更为多见,而糖尿病、高脂血症、吸烟和饮洒则较为少见,心力衰竭、缺血性心脏病和高肌酐水平是否会增高其缺血性卒中风险尚不确定.总体而言,传统危险因素对高龄人群缺血性卒中的作用还有待进一步研究.     

The clinical quandary of left and right ventricular diastolic dysfunction and diastolic heart failure

Summary

Diastolic heart failure is a common clinical entity that is indistinguishable from systolic heart failure without direct evaluation of left ventricular function. Diastolic heart failure is a clinical diagnosis in patients with signs and symptoms of heart failure but with preserved left ventricular function and normal ejection fraction, and is often seen in patients with a long-standing history of hypertension or infiltrative cardiac diseases. In contrast, diastolic dysfunction represents a mechanical malfunction of the relaxation of the left ventricular chamber that is primarily diagnosed by two-dimensional transthoracic echocardiography and usually does not present clinically as heart failure. The abnormal relaxation is usually separated in different degrees, based on the severity of reduction in passive compliance and active myocardial relaxation. The question whether diastolic dysfunction ultimately will lead to diastolic heart failure is critically reviewed, based on data from the literature. Treatment recommendations for diastolic heart failure are primarily targeted at risk reduction and symptom relief. Currently, few data only are reported on diastolic dysfunction and its progression to systolic heart failure.