Comment Expert:
Yao Hua
Yao Hua, Guangdong Provincial People's Hospital Chief Physician of the Department of Cardiology, Deputy Director of Guangdong Cardiovascular Research Institute, Currently, Deputy Head of the Pulmonary Vascular Group of the Cardiovascular Branch of the Chinese Medical Association, Deputy Head of the Structural Cardiology Group of the Cardiovascular Branch of the Guangdong Medical Association, Chairman of the Rational Drug Use Committee of the Cardiovascular Disease Management Branch of the Guangdong Medical Industry Association, Deputy Chairman of the Cardiovascular Professional Committee of the Guangdong Health Management Society, Member of the Female Physician Working Committee of the China Medical Association, Vice President of the Guangdong Female Physician Association, and Member of the 10th and 11th CPPCC of Guangdong Province.
new anti-heart failure scheme is online. The treatment of heart failure with decreased ejaculation fraction has entered a new era
chronic heart failure (referred to as heart failure) is a serious problem faced by aging countries in the world. It is called the last battlefield of heart disease. Among them, heart failure with decreased ejaculation fraction (HFrEF) is a disease that can continue to worsen over time. Usually, patients suffering from this disease will face a higher risk of sudden death. The clinical management of
HFrEF has made considerable progress in the past few decades, but some patients in the clinical practice still cannot significantly improve the symptoms of heart failure and ejection fraction (EF) after active drug treatment. Angiotensin converting enzyme inhibitor (ACEI)/angiotensin receptor antagonist (ARB) + beta blocker + aldosterone receptor antagonist is the current "golden triangle" for the treatment of heart failure, and the emergence of a new anti-heart failure drug angiotensin receptor-enerphalin inhibitor (ARNI) will bring a new choice for further treatment or optimized treatment for HFrEF patients.
Noxintu (Sacubarrli Valsartan sodium tablets) is the world's first ARNI drug. It can act on the two major neuroendocrine systems of heart failure at the same time (renin-angiotensin-aldosterone system, natriuretic peptide system). helps improve heart failure symptoms and reduce the incidence and mortality of cardiovascular events.
PARADIGM-HF trial confirmed that compared with enalapril, sacubitril valsartan sodium tablets can reduce cardiovascular mortality by 20% and all-cause mortality by 16%. The updated guide to heart failure jointly released by the American Heart Association
(AHA) and other in 2017 and the heart failure diagnosis and treatment guide issued by the Heart failure group of the Chinese Medical Association Cardiovascular Branch in 2018 both affirmed the efficacy of sakubalivalsartan sodium tablets in the field of HFrEF, and believed that it can further reduce the hospitalization and mortality rate of such patients compared with ACEI/ARB. In the future, sakubalivalsartan sodium tablets are expected to become the cornerstone drug for HFrEF treatment, bringing more hope to the majority of HFrEF patients.comprehensively evaluates the patient's condition,
heart failure treatment with decreased ejaculation fraction is orderly
cases
(This case is provided by Director Hu Hui of Foshan First People's Hospital)
■ case introduction
current medical history : The patient is male, 66 years old, intending to " repeated chest tightness, shortness of breath for 8 years, and 1 day of " as the main complaint. He was admitted to the hospital for treatment on June 11, 2018.
patient developed chest tightness and breathing difficulties on June 11, 2018, so he came to the clinic and received his admission to our department for "chronic heart failure". The patient was diagnosed with " coronary heart disease, three vascular lesions " 8 years ago (2010) due to chest tightness, chest pain and shortness of breath. He was diagnosed with " coronary heart disease, three vascular lesions ". He was stented with coronary artery and was given antiplatelet, anticoagulation, lipid-lowering treatment, etc., and the symptoms could be relieved.
In December 2017, the patient was admitted to the hospital for acute heart failure and had a follow-up coronary angiography, which showed that had severe three vascular and left main lesion , and had percutaneous coronary angioplasty (TPCA) + intravascular ultrasound (IVUS). After the operation, the patient took the medicine regularly, but still had chest tightness and shortness of breath.
Previous history: This patient has had a history of hypertension for more than 15 years, and his blood pressure control is acceptable. He has a history of diabetes for more than 8 years. He is currently using insulin to lower blood sugar, has poor control, and has a history of lower limb artery sclerosis and carotid artery sclerosis. I have had a history of smoking and drinking, and have quit for many years. Denied history of food allergies in medicine.
body examination : This time, the patient was admitted to the hospital. The body temperature was 36.5 ℃, pulse was 85 times/min, breathing 24 times/min, and blood pressure was 115/69 mmHg; clear; the jugular vein was not filled, and the hepatic jugular vein was negative; the lung breathing sound was thick, and there was no dry and wet rales, and there was no abnormal pulsation or bulge in the anterior heart area; the apex pulsation was 0.5 cm outside the fifth intercostal line at the midline of the left clavicle, the heart boundary expanded to the left, the heart rate was 85 times/min, and the rhythm was uneven, the first heart sound was different, and there was no murmur in each valve auscultation area; both lower limbs were mildly swelled.
auxiliary examination :
Laboratory examination shows: Myocardial infarction index + emergency biochemistry: creatine phosphate kinase 230 IU/L, lactate dehydrogenase 220.2 IU/L, myoglobin 42.0 ng/ml, troponin I 0.20 ng/ml. N-terminal brain natriuretic peptide (NT-proBNP) 3490.0 ng/L. Glycoated hemoglobin (HbA1c) 10.8%. Liver function + blood lipids + renal function: albumin 37.2 g/L, high-density lipoprotein cholesterol 0.79 mmol/L, r-glutamyltransferase 64 IU/L, triglyceride 1.85 mmol/L. Digoxin concentration is 1.05 ng/ml, and the stool routine, stool occult blood, urine analysis + quantitative analysis of urine sediment, D-II aggregate, coagulation function, and blood routine are all normal.
Figure 1: Patient's admission cardiac color ultrasound results
■ preliminary diagnosis
The patient's admission was: chronic heart failure, coronary atherosclerotic heart disease (three vascular lesions, left main trunk lesions, coronary stent implantation status, atrial fibrillation, left coronary sinus thrombosis, cardiac function level III), 2 diabetes, hypertension grade 2 (extremely high risk).
■ treatment After
Table 1: Patient admission treatment plan and adjustment (omitted treatment of hypoglycemia)
After treatment, the patient's symptoms of chest tightness and shortness of breath improved, his condition was stable, and his vital signs were stable, and he was discharged from the hospital. Discharged with medication: Sacubalivalsartan sodium tablets 50 mg bid, warfarin 1.875 mg qn, ticagrelor 90 mg bid, metoprolol 23.75 mg qd, spironolactone 20 mg qd, digoxin 0.125 mg qd, furosemide 20 mg qd, atorvastatin 20 mg qn, and the hypoglycemic regimen remained unchanged.
■ follow-up and treatment
Table 2: Patient's follow-up results and drug adjustment after discharge
Figure 2: Patient's re-examination of cardiac color ultrasound in August 2018
■ treatment experience
from Foshan First People's Hospital standardized treatment experience under the guidance of the guide is as follows:This heart failure patient is of the type of decreased ejection fraction (EF ≤40%). During the diagnosis and treatment, the patient's heart function status, severity of heart failure, cardiovascular underlying diseases and severity, and whether there are any complications.Pay attention to the comprehensive and comprehensive treatment plan (appropriate dose, long-term tolerance, regular evaluation and adjustment);
Learning Guide, such as flexible application of new anti-heart failure drugs (Sacubarmitr valsartan sodium tablets, etc.);
Heart failure patients have full recovery management, and actively communicate and follow up on the patient's feedback.
■ case review
After careful analysis of the case, Professor Yao Hua made comments on the following aspects:
) The patient's history description is clear, and the patient's medical history characteristics and treatment process are systematic and organized. Physical examinations and laboratory examinations are highlighted, laying the foundation for the diagnosis of diseases and the analysis of treatment strategies; ) For the diagnosis of diseases, the diagnosis is sufficient and the diagnosis is accurate. However, differential diagnosis is still necessary to pay attention to the diagnosis of diseases to avoid omissions. ) treatment plan is appropriately selected . In the occurrence and development of heart failure, the hyperactivation of RAAS and sympathetic systems plays an important role. Sakubalivalsartan sodium tablets inhibit enkephalinase through the metabolite LBQ657, and at the same time block the AT1 receptor through valsartan. Therefore, the use of sacubalivalsartan sodium tablets is appropriate and the dose titration is sufficient.mentioned that ARB was stopped when hospitalized in August 2017, and the reason for the suspension needs to be supplemented, which is of significance to the decision of subsequent treatment plans;
β receptor blocker has the effect of increasing blood supply and perfusion of the coronary artery and its collaterals by reducing myocardial oxygen consumption and prolonging the diastolic period of the heart, thereby reducing and alleviating myocardial ischemia attacks. Digoxin, in addition to controlling the ventricular rate, has no obvious benefit to the improvement of heart failure. It is recommended to discontinue digoxin and titrate the dose of metoprolol to the maximum tolerated dose.
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