早期超滤对急性失代偿性心力衰竭伴容量超负荷的疗效

doi:10.3969/j.issn.1674-8115.2021.03.010

摘要/Abstract

摘要：

目的·探讨早期超滤治疗急性失代偿性心力衰竭（acute decompensated heart failure，ADHF）伴容量超负荷患者的效果和安全性。方法·选取2018年7月—2019年9月上海交通大学医学院附属同仁医院心脏重症监护室收治的100例ADHF患者，随机分为早期超滤组（n=40）和利尿剂组（n=60）。早期超滤组患者在入院后的前3 d接受间歇超滤治疗，入院后的4~7 d接受利尿剂序贯治疗（托拉塞米20~40 mg/d和托伐普坦7.5~30.0 mg/d）；利尿剂组患者入院后即接受利尿剂治疗（托拉塞米20~40 mg/d和托伐普坦7.5~30.0 mg/d）。治疗第4日和第8日，分别测量2组患者体质量和尿量；第8日测定患者呼吸困难评分、下腔静脉内径（internal diameter of inferior vena cava，ICV）、下腔静脉塌陷指数（inferior vena cava-collapse index，IVC-CI）、颈静脉压力（jugular vein pressure ，JVP）、B型利钠肽（B-type natriuretic peptide，BNP）；比较2组患者随访1个月和3个月时的再入院率和死亡率；分别比较2组患者治疗第8日与治疗前的安全性指标，包括心率、呼吸频率、血压、血清钠、血清钾、血肌酐水平。结果·早期超滤组患者治疗第4日和第8日的体质量减轻量和尿量增加量均大于利尿剂组（均P<0.05）；治疗第8日，早期超滤组患者呼吸困难评分、IVC、IVC-CI、JVP、BNP的变化值与利尿剂组比较，差异有统计学意义（均P<0.05）。2组患者的安全性指标比较、随访1个月和3个月时的再入院率和死亡率比较，差异均无统计学意义。结论·早期超滤可以排除体内多余体液，降低体质量，增加利尿剂敏感性，对血压、电解质、肾功能无明显影响。

关键词: 早期超滤, 心力衰竭, 容量超负荷, 利尿剂, 序贯治疗

Abstract:

Objective·To investigate the efficacy and safety of early ultrafiltration in acute decompensated heart failure (ADHF) patients with volume overload.

Methods·One hundred patients with ADHF admitted to cardiac care unit of Tongren Hospital, Shanghai Jiao Tong University School of Medicine from July 2018 to September 2019 were randomly divided into early ultrafiltration group (n=40) and diuretic group (n=60). In the early ultrafiltration group, blood ultrafiltration was performed within 3 d after admission,and diuretic sequential treatment (Torasemide 20?40 mg/d and Tolvaptan 7.5?30.0 mg/d) was given on day 4 to 7. The diuretic group received intensive treatment (Torasemide 20?40 mg/d and Tolvaptan 7.5?30.0 mg/d) after admission. On the 4th and 8th day of treatment, the body mass and urine volume of the two groups were compared; on the 8th day, dyspnea score, internal diameter of inferior vena cava (ICV), inferior vena cava-collapse index (IVC-CI), jugular vein pressure (JVP) and B-type natriuretic peptide (BNP) were compared between the two groups. The readmission rate and mortality of the two groups at 1-month and 3-month follow-up were compared. The heart rate, respiratory rate, blood pressure, serum sodium, serum potassium and serum creatinine levels of the two group on the 8th day of treatment were compared with those before treatment, respectively.

Results·Compared with the diuretic group, weight loss and urine increase in the early ultrafiltration group on the 4th day and the 8th day showed significant difference (all P<0.05). There were significant differences in the changes of dyspnea score, IVC, IVC-CI, JVP and BNP on the 8th day of treatment between the two groups (all P<0.05). No significant differences were found in the safety indexes in the two groups, and the readmission rate and mortality rate in the two groups at 1-month and 3-month follow-up.

Conclusion·Early ultrafiltration can effectively remove excess body fluids, reduce body weight, increase the sensitivity of patients to diuretics. It has no effect on blood pressure, electrolytes and renal function.

Key words: early ultrafiltration, heart failure, fluid overload, loop diuretics, sequential therapy

中图分类号:

R459.5

万千里, 胡静轶, 周军, 李苗苗, 张悦, 袁方. 早期超滤对急性失代偿性心力衰竭伴容量超负荷的疗效[J]. 上海交通大学学报(医学版), 2021, 41(3): 344-349.

Qian-li WAN, Jing-yi HU, Jun ZHOU, Miao-miao LI, Yue ZHANG, Fang YUAN. Efficacy of early ultrafiltration in acute decompensated heart failure patients with volume overload[J]. JOURNAL OF SHANGHAI JIAOTONG UNIVERSITY (MEDICAL SCIENCE), 2021, 41(3): 344-349.

图/表 5

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Item	Early ultrafiltration group (N=40)	Diuretic group (N=60)	P value
Age/year	70.60±10.44	73.52±9.83	0.159
Male/n (%)	22 (55.0)	33 (55.0)	1.000
Weight/kg	69.45±12.12	65.63±8.541	0.067
Prior heart failure/n (%)	23 (57.5)	38 (63.3)	0.558
JVP/cm	15.00±2.63	16.20±4.24	0.084
Comorbidity/n (%)
Coronary artery disease	28 (70.0)	43 (71.7)	0.857
History of hypertension	32 (80.0)	48 (80.0)	1.000
Diabetes	26 (65.0)	38 (63.3)	1.000
Dilated cardiomyopathy	9 (22.5)	8 (13.3)	0.232
Arrhythmia	21 (52.5)	24 (40.0)	0.218
Pulmonary infection	14 (35.0)	24 (40.0)	0.614
Post-PCI	10 (25.0)	10 (16.7)	0.307
Renal dysfunction	13 (32.5)	16 (26.7)	0.529
Hepatic dysfunction	3 (7.5)	1 (1.7)	0.299
Laboratory measurement
Serum sodium/(mmol·L^-1)	140.41±4.58	141.37±3.85	0.281
Serum potassium/(mmol·L^-1)	4.03±0.72	3.83±0.63	0.156
Serum creatinine/(μmol·L^-1)	155.70±72.05	128.30±82.66	0.091
BNP/(pg·mL^-1)	1 266.21±1 082.59	1 310.50±982.35	0.839
Medication/n (%)
β-adrenoceptor antagonists	40 (100.0)	59 (98.3)	1.000
ACEI/ARB	40 (100.0)	59 (98.3)	1.000
Diuretic	40 (100.0)	60 (100.0)	1.000
Positive inotropic agents	27 (67.5)	40 (66.7)	0.931
Antithrombotic drugs	25 (62.5)	45 (75.0)	0.181
Lipid-lowering drugs	30 (75.0)	35 (58.3)	0.087

Item	Early ultrafiltration group (N=40)	Diuretic group (N=60)	P value
Age/year	70.60±10.44	73.52±9.83	0.159
Male/n (%)	22 (55.0)	33 (55.0)	1.000
Weight/kg	69.45±12.12	65.63±8.541	0.067
Prior heart failure/n (%)	23 (57.5)	38 (63.3)	0.558
JVP/cm	15.00±2.63	16.20±4.24	0.084
Comorbidity/n (%)
Coronary artery disease	28 (70.0)	43 (71.7)	0.857
History of hypertension	32 (80.0)	48 (80.0)	1.000
Diabetes	26 (65.0)	38 (63.3)	1.000
Dilated cardiomyopathy	9 (22.5)	8 (13.3)	0.232
Arrhythmia	21 (52.5)	24 (40.0)	0.218
Pulmonary infection	14 (35.0)	24 (40.0)	0.614
Post-PCI	10 (25.0)	10 (16.7)	0.307
Renal dysfunction	13 (32.5)	16 (26.7)	0.529
Hepatic dysfunction	3 (7.5)	1 (1.7)	0.299
Laboratory measurement
Serum sodium/(mmol·L^-1)	140.41±4.58	141.37±3.85	0.281
Serum potassium/(mmol·L^-1)	4.03±0.72	3.83±0.63	0.156
Serum creatinine/(μmol·L^-1)	155.70±72.05	128.30±82.66	0.091
BNP/(pg·mL^-1)	1 266.21±1 082.59	1 310.50±982.35	0.839
Medication/n (%)
β-adrenoceptor antagonists	40 (100.0)	59 (98.3)	1.000
ACEI/ARB	40 (100.0)	59 (98.3)	1.000
Diuretic	40 (100.0)	60 (100.0)	1.000
Positive inotropic agents	27 (67.5)	40 (66.7)	0.931
Antithrombotic drugs	25 (62.5)	45 (75.0)	0.181
Lipid-lowering drugs	30 (75.0)	35 (58.3)	0.087

Item	Early ultrafiltration group (N=40)	Diuretic group (N=60)	P value
Dyspnea score
Before treatment	12.20±2.50	13.53±2.55	0.011
After treatment	16.28±4.20	16.30±2.45	0.973
△	4.08±3.44	2.77±2.03	0.035
BNP/(pg·mL^-1)
Before treatment	1 733.00±1 608.00	1 310.50±982.35	0.106
After treatment	558.20±581.80	656.47±802.90	0.507
△	-1 144.00±1 435.00	-654.02±889.65	0.037
BNP score
Before treatment	2.60±0.81	2.83±0.46	0.104
After treatment	1.32±0.80	1.97±1.04	0.001
△	-1.27±0.82	-0.87±1.03	0.038
JVP/cm
Before treatment	15.00±2.63	16.20±4.24	0.084
After treatment	8.35±1.89	11.90±3.19	0.000
△	-6.65±2.99	-4.30±2.98	0.000
JVP score
Before treatment	2.38±0.70	2.48±0.79	0.486
After treatment	0.48±1.01	1.70±0.83	0.000
△	-1.90±1.13	-0.78±0.69	0.000
IVC/mm
Before treatment	37.35±10.97	33.98±6.34	0.085
After treatment	22.00±4.52	29.00±5.33	0.000
△	-15.35±11.03	-4.98±6.00	0.000
IVC-CI/%
Before treatment	47.88±11.49	43.87±8.07	0.060
After treatment	35.45±8.14	40.37±10.49	0.014
△	-12.43±9.87	-3.50±3.89	0.000

Item	Early ultrafiltration group (N=40)	Diuretic group (N=60)	P value
Dyspnea score
Before treatment	12.20±2.50	13.53±2.55	0.011
After treatment	16.28±4.20	16.30±2.45	0.973
△	4.08±3.44	2.77±2.03	0.035
BNP/(pg·mL^-1)
Before treatment	1 733.00±1 608.00	1 310.50±982.35	0.106
After treatment	558.20±581.80	656.47±802.90	0.507
△	-1 144.00±1 435.00	-654.02±889.65	0.037
BNP score
Before treatment	2.60±0.81	2.83±0.46	0.104
After treatment	1.32±0.80	1.97±1.04	0.001
△	-1.27±0.82	-0.87±1.03	0.038
JVP/cm
Before treatment	15.00±2.63	16.20±4.24	0.084
After treatment	8.35±1.89	11.90±3.19	0.000
△	-6.65±2.99	-4.30±2.98	0.000
JVP score
Before treatment	2.38±0.70	2.48±0.79	0.486
After treatment	0.48±1.01	1.70±0.83	0.000
△	-1.90±1.13	-0.78±0.69	0.000
IVC/mm
Before treatment	37.35±10.97	33.98±6.34	0.085
After treatment	22.00±4.52	29.00±5.33	0.000
△	-15.35±11.03	-4.98±6.00	0.000
IVC-CI/%
Before treatment	47.88±11.49	43.87±8.07	0.060
After treatment	35.45±8.14	40.37±10.49	0.014
△	-12.43±9.87	-3.50±3.89	0.000

Time	Early ultrafiltration group (N=40)	Diuretic group (N=60)	P value
1-month follow-up/n (%)
Readmission rate	7 (17.5)	12 (20.0)	0.755
Mortality	0 (0)	1 (1.7)	1.000
3-month follow-up/n (%)
Readmission rate	8 (20.0)	22 (36.7)	0.075
Mortality	0 (0)	1 (1.7)	1.000