Efficacy and safety of Sacubitril/valsartan combined with exercise therapy to improve cardiac functions in patients with chronic heart failure complicated with reduced ejection fraction and hypotension
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摘要:
目的 探讨合并低血压的射血分数降低的慢性心力衰竭患者在沙库巴曲缬沙坦药物治疗的基础上联合运动疗法改善心功能的疗效观察。 方法 选取60例门诊治疗的心衰症状缓解的慢性心衰患者，血压90/50 mmHg～100/60 mmHg，左室射血分数（LVEF）≤40%，分为运动疗法组：沙库巴曲缬沙坦+运动疗法，对照组：单纯沙库巴曲缬沙坦组。两组患者在原发病治疗的基础上，根据血压情况逐渐滴定沙库巴曲缬沙坦致最大耐受剂量，运动疗法组加用运动训练。 结果 与本组治疗前比较，对照组与运动疗法组治疗3个月后6-MWT数值增加，治疗6个月后数值增加量更多（均P<0.01）；与本组治疗前比较，对照组收缩压无统计学差异性变化，运动疗法组治疗3个月后收缩压数值增加，治疗6个月后数值增加量更多，（均P<0.01）；与本组治疗前比较，对照组舒张压治疗6个月后数值增加（P<0.01），运动疗法组舒张压治疗6个月后数值增加（P<0.01）。与本组治疗3个月后比较，对照组与运动疗法组治疗6个月后6-MWT数值增加（均P<0.01）。与对照组同时间点比较，运动疗法组治疗3个月后6-MWT与收缩压数值增加，治疗6个月后数值增加量更多（均P<0.01）；与本组治疗前相比，对照组与运动疗法组治疗3个月后LVEF增加，治疗6个月后增加更多，治疗3个月后LVESD、LVEDD、LVESV、LVEDV下降，治疗6个月后下降更多（均P<0.01）。与本组治疗3个月后相比，对照组与运动疗法组治疗6个月后LVEF增加，治疗6个月后LVESD、LVEDD、LVESV、LVEDV下降（均P<0.01）。运动疗法组与对照组同时间段比较， 运动疗法组治疗3个月后LVEF增加，治疗6个月后LVEF增加更多，治疗3个月后LVESD、LVEDD、LVESV、LVEDV下降，治疗6个月下降更多（均P<0.01）。运动疗法组再住院率低于对照组（P<0.05）。 结论 合并有低血压的射血分数降低的慢性心衰患者，沙库巴曲缬沙坦加用运动疗法后，患者心功能改善明显且安全。 Abstract:AIM To investigate the efficacy and safety of Sacubitril/valsartan combined with exercise therapy on improvement of cardiac functions in patients with chronic heart failure complicated with hypotension and reduced ejection fraction. METHODS Sixty chronic heart failure patients with controlled symptoms, blood pressure ranging from 90/50mmHg to 100/60mmHg and LVEF<40% were selected and they were divided into exercise therapy group (Sacubitril/valsartan + exercise) and control group (Sacubitril/valsartan alone). On the basis of their previous treatment, Sacubitril/valsartan was gradually prescribed to the maximum tolerated dose for the patients in the two groups according to their blood pressure, and exercise therapy was added in exercise group. RESULTS Compared with the control group after 3 months of treatment, the amount of exercise in this group increased more than that in the control group after 3 months of treatment (P<0.01); Compared with that before treatment, there was no significant difference in systolic blood pressure in the control group. The value of systolic blood pressure in the exercise therapy group increased after 3 months of treatment and more after 6 months of treatment (all P<0.01); Compared with that before treatment, the diastolic blood pressure in the control group increased after 6 months of treatment (P<0.05), and the diastolic blood pressure in the exercise therapy group increased after 6 months of treatment (P<0.01). Compared with this group after 3 months of treatment, the value of 6-MWT in the control group and exercise therapy group increased after 6 months of treatment, all P<0.01. Compared with the control group at the same time point, the values of 6-MWT and systolic blood pressure in the exercise therapy group increased after 3 months of treatment, and increased more after 6 months of treatment (all P<0.01); Compared with that before treatment, LVEF in the control group and exercise therapy group increased after 3 months of treatment, increased more after 6 months of treatment, LVESD, LVESV and LVEDV decreased after 3 months of treatment, and decreased more after 6 months of treatment (all P<0.01). Compared with this group after 3 months of treatment, LVEF in the control group and exercise therapy group increased after 6 months of treatment, and LVESD, LVESD, LVESV and LVEDV decreased after 6 months of treatment (all P<0.01). Compared with the control group in the same time period, LVEF in the exercise therapy group increased after 3 months of treatment, increased more after 6 months of treatment, decreased LVESD, LVESD, LVESV and LVEDV after 3 months of treatment, and decreased more after 6 months of treatment (all P<0.01). The rehospitalization rate in the exercise therapy group was lower than that in the control group (P<0.05). CONCLUSION In patients with heart failure complicated with hypotension and reduced ejection fraction, Sacubitril/valsartan plus exercise therapy is safe and markedly improves patients’ cardiac functions. -
Key words:
- chronic heart failure /
- low blood pressure /
- sacubitril/valsartan /
- exercise therapy
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表 1 两组一般基线资料的比较
（n=30） 项目 对照组 运动疗法组 年龄（岁） 55±12 56±12 男性 23（77） 20（67） 高血压 14（47） 12（41） 高血脂 7（23） 8（28） 糖尿病 6（20） 5（17） CABG史 0（0.0） 0（0.0） 脑卒中史 0（0） 1（3） 吸烟史 11（37） 11（38） 饮酒史 3（10） 2（7） 诊断 扩张性心肌病 7（23） 7（23） 高血压性心脏病 7（23） 3（10） 缺血性心肌病 14（47） 19（63） 心律失常性心肌病 2（7） 1（3） 用药情况 β受体阻断剂 28（93） 27（90） 醛固酮受体拮抗剂 29（97） 28（93） SGLT-2抑制剂 18（60） 20（67） 沙库巴曲缬沙坦 30（100） 30（100） 表中计数资料均为[例数（%）] 
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表 2 运动疗法组与对照组治疗前后三项指标的比较
（n=30， $\bar x $ ±s）项目 对照组 运动疗法组 T0 T3 T6 T0 T3 T6 6MWT（m） 172±55 275±64b 358±86bd 173±59 317±79bf 461±94bdf SBP（mmHg） 92±3 96±5 102±7 93±3 98±4bf 106±10bdf DBP（mmHg） 56±3 57±4 61±4a 56±3 57±4 61±4b 与本组治疗前比较， aP<0.05，bP<0.01；与本组治疗3个月后比较，dP<0.01；与对照组同时间点比较，fP<0.01。
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表 3 运动疗法组与对照组治疗前后心脏功能各项指数的比较
（n=30， $\bar x $ ±s）项目 对照组 运动疗法组 T0 T3 T6 T0 T3 T6 LVEF（%） 31±4 36±3b 40±4bd 32±5 38±6bf 46±7bdf LVESV（ml） 136±19 112±18b 100±19bd 134±32 98±25bf 66±20bdf LVEDV（ml） 210±28 177±21b 157±26bd 205±50 160±28bf 111±25bdf LVESD（mm） 64±10 56±7b 52±7bd 61±9 51±6bf 40±9bdf LVEDD（mm） 74±9 66±6b 61±4bd 73±9 62±5bf 52±7bdf 与本组治疗前比较，bP<0.01；与本组治疗3个月后比较，dP<0.01；与对照组同时间点比较，fP<0.01
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[1] Alem MM. Endothelial dysfunction in chronic heart failure: assessment, findings, significance, and potential therapeutic targets[J]. Int J Mol Sci, 2019, 20(13): 3198. doi: 10.3390/ijms20133198 [2] Lam CSP, Solomon SD. Classification of heart failure according to ejection fraction: jacc review topic of the week[J]. J Am Coll Cardiol, 2021, 77(25): 3217 – 3225. doi: 10.1016/j.jacc.2021.04.070 [3] 邹玉宝, 王 倩. 关于射血分数降低的心力衰竭治疗的10个关键问题——《2021 ACC专家共识决策路径: 优化心力衰竭的治疗》解读 doi: 10.12114/j.issn.1008-5971.2021.00.036J]. 实用心脑肺血管病杂志, 2021, 29(3): 1 – 10. doi: 10.12114/j.issn.1008-5971.2021.00.036 [4] DeVore AD, Braunwald E, Morrow DA, et al. Initiation of angiotensin-neprilysin inhibition after acute decompensated heart failure: secondary analysis of the open-label extension of the pioneer-hf trial[J]. JAMA Cardiol, 2020, 5(2): 202 – 207. doi: 10.1001/jamacardio.2019.4665 [5] Solomon SD, McMurray JJV, Anand IS, et al. Angiotensin-neprilysin inhibition in heart failure with preserved ejection fraction[J]. N Engl J Med, 2019, 381(17): 1609 – 1620. doi: 10.1056/NEJMoa1908655 [6] Ambrosy AP, Vaduganathan M, Mentz RJ, et al. Clinical profile and prognostic value of low systolic blood pressure in patients hospitalized for heart failure with reduced ejection fraction: insights from the efficacy of vasopressin antagonism in heart failure: outcome study with Tolvaptan (EVEREST) trial[J]. Am Heart J, 2013, 165(2): 216 – 225. doi: 10.1016/j.ahj.2012.11.004 [7] Brubaker PH, Avis T, Rejeski WJ, et al. Exercise training effects on the relationship of physical function and health-related quality of life among older heart failure patients with preserved ejection fraction [J]. J Cardiopulm Rehabil Prev, 2020, 40(6): 427 – 433. doi: 10.1097/HCR.0000000000000507 [8] Laoutaris ID. Exercise intolerance and skeletal muscle metaboreflex activity in chronic heart failure: do we need to recruit more muscle in exercise training?[J]. Eur J Prev Cardiol, 2020, 27(17): 1858 – 1861. doi: 10.1177/2047487320912623 [9] Rhee SY, Song JK, Hong SC, et al. Intradialytic exercise improves physical function and reduces intradialytic hypotension and depression in hemodialysis patients[J]. Korean J Intern Med, 2019, 34(3): 588 – 598. doi: 10.3904/kjim.2017.020 [10] McMurray JJ, Adamopoulos S, Anker SD, et al. [ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012][J]. Turk Kardiyol Dern Ars, 2012, 40(Suppl 3): 77 – 137. [11] 中华医学会老年医学分会. 老年患者6分钟步行试验临床应用中国专家共识[J]. 中华老年医学杂志, 2020, 39(11): 1241 – 1290. doi: 10.3760/cma.j.issn.0254-9026.2020.11.001 [12] Książczyk M, Lelonek M. Angiotensin receptor/neprilysin inhibitor-a breakthrough in chronic heart failure therapy: summary of subanalysis on PARADIGM-HF trial findings[J]. Heart Fail Rev, 2020, 25(3): 393 – 402. doi: 10.1007/s10741-019-09879-x [13] Rohde LE, Chatterjee NA, Vaduganathan M,. Sacubitril/valsartan and sudden cardiac death according to implantable cardioverter-defibrillator use and heart failure cause: a paradigm-hf analysis[J]. JACC Heart Fail, 2020, 8(10): 844 – 855. doi: 10.1016/j.jchf.2020.06.015 [14] Böhm M, Young R, Jhund PS, et al. Systolic blood pressure, cardiovascular outcomes and efficacy and safety of sacubitril/valsartan (LCZ696) in patients with chronic heart failure and reduced ejection fraction: results from PARADIGM-HF[J]. Eur Heart J, 2017, 38(15): 1132 – 1143. doi: 10.1093/eurheartj/ehw570 [15] Flynn KE, Piña IL, Whellan DJ, et al. Effects of exercise training on health status in patients with chronic heart failure: HF-ACTION randomized controlled trial[J]. JAMA, 2009, 301(14): 1451 – 1459. doi: 10.1001/jama.2009.457 [16] Gianola S, Pecoraro V, Lambiase S, et al. Efficacy of muscle exercise in patients with muscular dystrophy: a systematic review showing a missed opportunity to improve outcomes[J]. PLoS One, 2013, 8(6): e65414. doi: 10.1371/journal.pone.0065414 [17] 姚芬芬, 张 芳, 张雪梅, 等. 下肢被动运动训练治疗慢性心力衰竭患者的临床观察[J]. 实用临床医学, 2020, 21(11): 1 – 4,13. doi: 10.13764/j.cnki.lcsy.2020.11.001 [18] McDaniel J, Fjeldstad AS, Ives S, et al. Central and peripheral contributors to skeletal muscle hyperemia: response to passive limb movement[J]. J Appl Physiol(1985), 2010, 108(1): 76 – 84. doi: 10.1152/japplphysiol.00895.2009 -
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