Kumar Ashwani, Meyerrose Gary, Sood Vineeta, Roongsritong Chanwit
Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, USA.
Drugs Aging. 2006;23(4):299-308. doi: 10.2165/00002512-200623040-00003.
The overall incidence of heart failure increases with age, affecting up to 10% of people >65 years of age. Diastolic heart failure is also age-dependent, increasing from <15% in middle-aged patients to >40% in patients > or =70 years of age. Elderly patients usually have other co-morbid conditions such as hypertension, diabetes mellitus, coronary artery disease and atrial fibrillation that can adversely affect the diastolic properties of the heart. The clinical manifestations of diastolic heart failure are similar to those of systolic heart failure. In practice, the diagnosis is generally based on the finding of typical symptoms and signs of heart failure with preserved left ventricular ejection fraction and no valvular abnormalities on echocardiography. Altered ventricular relaxation and abnormal ventricular filling are the hallmarks of diastolic heart failure. Cardiac fibrosis and cellular disarray lead to the alterations in the diastolic properties of the heart. Diffuse foci of fibrosis in the myocardium have been reported with advancing age. Aldosterone has been shown to play a crucial role in the development of cardiac fibrosis via a direct effect on the mineralocorticoid receptors within the myocardium. Unlike the situation with treatment of systolic heart failure, few clinical trials are available to guide the management of patients with diastolic heart failure. In the absence of controlled clinical trials, patient management is based on control of the physiological factors (blood pressure, heart rate, blood volume and myocardial ischaemia) that are known to exert important effects on ventricular relaxation. Aldosterone antagonists inhibit the deposition of collagen matrix in the myocardium, thereby targeting the basic pathophysiological mechanism of diastolic dysfunction. Thus, they appear to represent a promising therapeutic approach for this condition. Currently, only small clinical trials supporting this therapy are available and large clinical trials evaluating long-term outcomes in diastolic dysfunction are therefore needed.
心力衰竭的总体发病率随年龄增长而增加，65岁以上人群中高达10%受其影响。舒张性心力衰竭也与年龄相关，从中年患者的不到15%增加到70岁及以上患者的超过40%。老年患者通常有其他合并症，如高血压、糖尿病、冠状动脉疾病和心房颤动，这些疾病会对心脏的舒张特性产生不利影响。舒张性心力衰竭的临床表现与收缩性心力衰竭相似。在实际中，诊断通常基于出现典型的心力衰竭症状和体征，同时左心室射血分数保留且超声心动图显示无瓣膜异常。心室舒张改变和心室充盈异常是舒张性心力衰竭的标志。心脏纤维化和细胞排列紊乱导致心脏舒张特性改变。据报道，随着年龄增长，心肌中会出现弥漫性纤维化病灶。醛固酮已被证明通过直接作用于心肌内的盐皮质激素受体，在心脏纤维化的发展中起关键作用。与收缩性心力衰竭的治疗情况不同，几乎没有临床试验可用于指导舒张性心力衰竭患者的管理。在缺乏对照临床试验的情况下，患者管理基于对已知对心室舒张有重要影响的生理因素（血压、心率、血容量和心肌缺血）的控制。醛固酮拮抗剂可抑制心肌中胶原基质的沉积，从而针对舒张功能障碍的基本病理生理机制。因此，它们似乎是这种疾病一种有前景的治疗方法。目前，仅有支持这种疗法的小型临床试验，因此需要大型临床试验来评估舒张功能障碍的长期预后。
