Hasenfuss Gerd, Hermann Hans-Peter, Pieske Burkert
Abteilung Kardiologie und Pneumologie, Universität Göttingen, Göttingen.
Herz. 2004 Sep;29(6):602-8. doi: 10.1007/s00059-004-2621-1.
30-50% of patients presenting with symptoms of congestive heart failure exhibit a near normal left ventricular systolic function at rest, and an impaired diastolic function of the heart may be causative. Despite a better prognosis than in systolic heart failure, frequency of hospitalizations due to diastolic heart failure is comparable with systolic heart failure. According to the criteria of Vasan and Levy diagnosis of diastolic heart failure is probable, if symptoms and signs of heart failure are accompanied in proximity (within 72 h) by objective evidence of normal left ventricular systolic function. Newer echocardiographic techniques (e. g., tissue Doppler) aid to confirm the diagnosis and to determine the severity of dysfunction and may substitute invasive demonstration of impaired left ventricular relaxation, filling, compliance or stiffness for standardized diagnosis. Incorporation of biochemical test (BNP [brain natriuretic peptide]) allows differential diagnosis and may increase the accuracy of diagnosis. Due to inconsistent diagnostic criteria, data from prospective randomized controlled trials for the treatment of diastolic heart failure are rare. Basic principles include treatment of the underlying disease, i. e., control of hypertension, diabetes, or obstructive airway disease. Angiotensin 1 antagonists (ARB) have proven effective in regression of left ventricular hypertrophy (LIFE) and may reduce morbidity, but not mortality (CHARM). Maintenance of sinus rhythm, heart rate control (beta-blockers, calcium channel blockers) and anti-ischemic therapy may be indicated in view of pathophysiological aspects. Diuretics should be administered with caution in patients with symptoms of congestion, digitalis is not useful in the treatment of isolated diastolic heart failure. The results of ongoing trials (e. g., I-Preserve) may offer new therapeutic options, and evidence-based guidelines for the so far often unsatisfactory treatment of diastolic dysfunction/heart failure are awaited.
30%至50%出现充血性心力衰竭症状的患者静息时左心室收缩功能接近正常，而心脏舒张功能受损可能是病因。尽管舒张性心力衰竭的预后优于收缩性心力衰竭，但其因心力衰竭住院的频率与收缩性心力衰竭相当。根据瓦桑（Vasan）和利维（Levy）的标准，如果心力衰竭的症状和体征在近期（72小时内）伴有左心室收缩功能正常的客观证据，则舒张性心力衰竭很可能被诊断。更新的超声心动图技术（如组织多普勒）有助于确诊并确定功能障碍的严重程度，并且可以替代侵入性的左心室舒张、充盈、顺应性或僵硬度受损的证明来进行标准化诊断。结合生化检测（脑钠肽[BNP]）可进行鉴别诊断，并可能提高诊断准确性。由于诊断标准不一致，关于舒张性心力衰竭治疗的前瞻性随机对照试验数据很少。基本原则包括治疗基础疾病，即控制高血压、糖尿病或阻塞性气道疾病。血管紧张素1拮抗剂（ARB）已被证明在左心室肥厚消退方面有效（LIFE研究），并且可能降低发病率，但不能降低死亡率（CHARM研究）。鉴于病理生理方面的因素，可能需要维持窦性心律、控制心率（β受体阻滞剂、钙通道阻滞剂）和抗缺血治疗。对于有充血症状的患者，应谨慎使用利尿剂，洋地黄对单纯舒张性心力衰竭的治疗无效。正在进行的试验（如I-Preserve研究）的结果可能会提供新的治疗选择，人们期待着针对目前舒张功能障碍/心力衰竭治疗往往不尽人意的情况制定基于证据的指南。
