Mohan Rajeev C, Heywood J Thomas, Small Roy S
Advanced Heart Failure and Mechanical Circulatory Support Program, Pulmonary Hypertension Program, Division of Cardiology, Scripps Clinic, 9898 Genesee Avenue, AMP Suite #300, La Jolla, CA, 92037, USA.
Cardiology, Lancaster Heart and Vascular Institute, Lancaster General Hospital/Penn Medicine, Lancaster, PA, USA.
Curr Treat Options Cardiovasc Med. 2017 Mar;19(3):22. doi: 10.1007/s11936-017-0519-5.
The treatment of congestive heart failure is an expensive undertaking with much of this cost occurring as a result of hospitalization. It is not surprising that many remote monitoring strategies have been developed to help patients maintain clinical stability by avoiding congestion. Most of these have failed. It seems very unlikely that these failures were the result of any one underlying false assumption but rather from the fact that heart failure is a progressive, deadly disease and that human behavior is hard to modify. One lesson that does stand out from the myriad of methods to detect congestion is that surrogates of congestion, such as weight and impedance, are not reliable or actionable enough to influence outcomes. Too many factors influence these surrogates to successfully and confidently use them to affect HF hospitalization. Surrogates are often attractive because they can be inexpensively measured and followed. They are, however, indirect estimations of congestion, and due to the lack specificity, the time and expense expended affecting the surrogate do not provide enough benefit to warrant its use. We know that high filling pressures cause transudation of fluid into tissues and that pulmonary edema and peripheral edema drive patients to seek medical assistance. Direct measurement of these filling pressures appears to be the sole remote monitoring modality that shows a benefit in altering the course of the disease in these patients. Congestive heart failure is such a serious problem and the consequences of hospitalization so onerous in terms of patient well-being and costs to society that actual hemodynamic monitoring, despite its costs, is beneficial in carefully selected high-risk patients. Those patients who benefit are ones with a prior hospitalization and ongoing New York Heart Association (NYHA) class III symptoms. Patients with NYHA class I and II symptoms do not require hemodynamic monitoring because they largely have normal hemodynamics. Those with NYHA class IV symptoms do not benefit because their hemodynamics are so deranged that they cannot be substantially altered except by mechanical circulatory support or heart transplantation. Finally, hemodynamic monitoring offers substantial hope to those patients with normal ejection fraction (EF) heart failure, a large group for whom medical therapy has largely been a failure. These patients have not benefited from the neurohormonal revolution that improved the lives of their brothers and sisters with reduced ejection fractions. Hemodynamic stabilization improves the condition of both but more so of the normal EF cohort. This is an important observation that will help us design future trials for the 50% of heart failure patients with normal systolic function.
充血性心力衰竭的治疗费用高昂，其中很大一部分费用是因住院产生的。因此，人们开发了许多远程监测策略，旨在通过避免充血来帮助患者维持临床稳定，这并不奇怪。然而，大多数此类策略都失败了。这些失败似乎不太可能是由于任何一个潜在的错误假设，而是因为心力衰竭是一种进行性致命疾病，而且人类行为难以改变。在众多检测充血的方法中，有一个教训格外突出，即充血的替代指标，如体重和阻抗，不够可靠或无法有效指导行动，不足以影响治疗结果。太多因素会影响这些替代指标，以至于无法成功且自信地利用它们来影响心力衰竭患者的住院情况。替代指标往往很有吸引力，因为它们可以低成本地进行测量和跟踪。然而，它们只是对充血的间接估计，由于缺乏特异性，为影响替代指标所花费的时间和费用并不能带来足够的益处，因而不值得使用。我们知道，高充盈压会导致液体渗入组织，肺水肿和外周水肿会促使患者寻求医疗帮助。直接测量这些充盈压似乎是唯一一种在改变这些患者疾病进程方面显示出益处的远程监测方式。充血性心力衰竭是一个如此严重的问题，住院治疗对患者的健康和社会成本造成的负担如此沉重，以至于尽管实际的血流动力学监测成本高昂，但对于精心挑选的高危患者来说仍是有益的。受益的患者是那些曾有过住院史且目前有纽约心脏协会（NYHA）III级症状的患者。NYHA I级和II级症状的患者不需要进行血流动力学监测，因为他们的血流动力学基本正常。NYHA IV级症状的患者也无法从中受益，因为他们的血流动力学紊乱严重，除非通过机械循环支持或心脏移植，否则无法得到实质性改善。最后，血流动力学监测为那些射血分数（EF）正常的心力衰竭患者带来了巨大希望，这是一个庞大的群体，医学治疗在很大程度上对他们来说是失败的。这些患者没有从神经激素治疗变革中受益，而这种变革改善了射血分数降低的同类患者的生活。血流动力学稳定对这两类患者的病情都有改善作用，但对射血分数正常的患者群体改善作用更大。这是一个重要的观察结果，将有助于我们为50%的收缩功能正常的心力衰竭患者设计未来的试验。
