Division of Cardiology, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto, Ontario, Canada.
Division of Cardiology, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto, Ontario, Canada.
Can J Cardiol. 2021 Apr;37(4):609-620. doi: 10.1016/j.cjca.2020.12.006. Epub 2020 Dec 10.
In heart failure with reduced ejection fraction (HFrEF), diminished tonic and reflex vagal heart rate modulation and exaggerated sympathetic outflow and neural norepinephrine release are evident from disease inception. Each of these disturbances of autonomic regulation has been independently associated with shortened survival, and β-adrenoceptor antagonism and therapeutic autonomic modulation by other means have been demonstrated, in clinical trials, to lessen symptoms and prolong survival. In contrast, data concerning the autonomic status of patients with heart failure with preserved ejection fraction (HFpEF) are comparatively sparse. Little is known concerning the prognostic consequences of autonomic dysregulation in such individuals, and therapies applied with success in HFrEF have in most trials failed to improve symptoms or survival of those with HFpEF. A recent HFpEF Expert Scientific Panel report emphasised that without a deeper understanding of the pathophysiology of HFpEF, establishing effective treatment will be challenging. One aspect of such pathology may be cardiovascular autonomic disequilibrium, often worsened by acute exercise or routine daily activity. This review aims to summarise existing knowledge concerning parasympathetic and sympathetic function of patients with HFpEF, consider potential mechanisms and specific consequences of autonomic disturbances that have been identified, and propose hypotheses for future investigation.
在射血分数降低的心力衰竭（HFrEF）中，从疾病发病开始，就明显存在紧张和反射性迷走神经心率调节减弱以及交感神经输出和神经去甲肾上腺素释放过度。这些自主调节紊乱中的每一种都与生存时间缩短独立相关，临床试验已经证明，β-肾上腺素能受体拮抗剂和通过其他方式进行的治疗性自主调节可以减轻症状并延长生存时间。相比之下，关于射血分数保留的心力衰竭（HFpEF）患者自主状态的数据相对较少。对于此类人群中自主调节失调的预后后果知之甚少，并且在大多数试验中，在 HFrEF 中成功应用的治疗方法未能改善 HFpEF 患者的症状或生存。最近的 HFpEF 专家科学小组报告强调，如果没有对 HFpEF 的病理生理学有更深入的了解，那么确定有效的治疗方法将具有挑战性。该病理的一个方面可能是心血管自主神经失衡，急性运动或日常活动通常会使其恶化。这篇综述旨在总结 HFpEF 患者副交感和交感功能的现有知识，考虑已经确定的自主紊乱的潜在机制和特定后果，并提出未来研究的假设。
