心力衰竭易损期管理的研究进展
Research Progress in the Management of Heart Failure Vulnerable Period
DOI: 10.12677/jcpm.2025.42158, PDF,   
作者: 赵 萱:济宁医学院临床学院,山东 济宁;柴程程:山东第一医科大学研究生院,山东 济南;梁 英*:山东第一医科大学第一附属医院(山东省千佛山医院)全科医学科,山东 济南
关键词: 心力衰竭易损期过渡期管理模式全科医师改善预后Heart Failure Vulnerable Period Transitional Management Mode General Practitioner Improved Prognosis
摘要: 心力衰竭(HF)是一种全身性疾病,其死亡率逐年升高,是全球医务工作者亟待解决的重大问题。在这篇文章中,我们强调了心衰易损期管理的概念,介绍了各国对于心力衰竭出院后过渡期不同管理模式及不同医疗角色引导的利弊。分析在心衰易损期管理过程中全科医师承担的责任及心衰易损期优化的潜在障碍,如临床惰性、全科医师角色的缺失等等。最后,它还试图提供未来可能的研究方向,以改善患者的预后。
Abstract: Heart failure (HF) is a systemic disease with an increasing mortality rate, posing a significant challenge that urgently needs to be addressed by medical professionals worldwide. In this article, we emphasize the concept of vulnerability period management of HF and discuss the advantages and disadvantages of different management models and roles of various healthcare providers in the post-discharge transition period for heart failure patients across countries. We analyze the responsibilities of general practitioners in managing the vulnerability period of HF and the potential obstacles to optimizing this period, such as clinical inertia and the absence of a defined role for general practitioners. Finally, the article also attempts to suggest potential future research directions to improve patient outcomes.
文章引用:赵萱, 柴程程, 梁英. 心力衰竭易损期管理的研究进展[J]. 临床个性化医学, 2025, 4(2): 159-163. https://doi.org/10.12677/jcpm.2025.42158

参考文献

[1] Metra, M., Gheorghiade, M., Bonow, R.O. and Dei Cas, L. (2010) Postdischarge Assessment after a Heart Failure Hospitalization. Circulation, 122, 1782-1785. [Google Scholar] [CrossRef] [PubMed]
[2] Greene, S.J., Fonarow, G.C., Vaduganathan, M., Khan, S.S., Butler, J. and Gheorghiade, M. (2015) The Vulnerable Phase after Hospitalization for Heart Failure. Nature Reviews Cardiology, 12, 220-229. [Google Scholar] [CrossRef] [PubMed]
[3] McDonagh, T.A., Metra, M., Adamo, M., et al. (2021) 2021 ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure. European Heart Journal, 42, 3599-3726
[4] Heidenreich, P.A., Bozkurt, B., Aguilar, D., et al. (2022) 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Journal of the American College of Cardiology, 79, e263-e421. [Google Scholar] [CrossRef] [PubMed]
[5] McDonagh, T.A., Metra, M., Adamo, M., Gardner, R.S., Baumbach, A., Böhm, M., et al. (2023) 2023 Focused Update of the 2021 ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure. European Heart Journal, 44, 3627-3639. [Google Scholar] [CrossRef] [PubMed]
[6] van Walraven, C., Jennings, A. and Forster, A.J. (2011) A Meta‐Analysis of Hospital 30‐Day Avoidable Readmission Rates. Journal of Evaluation in Clinical Practice, 18, 1211-1218. [Google Scholar] [CrossRef] [PubMed]
[7] McDonagh, T.A., Metra, M., Adamo, M., Gardner, R.S., Baumbach, A., Böhm, M., et al. (2022) 2021 ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure. European Journal of Heart Failure, 24, 4-131. [Google Scholar] [CrossRef] [PubMed]
[8] 张健, 张宇辉, 周蕾. 国家心力衰竭指南2023 (精简版) [J].中国循环杂志, 2023, 38(12): 1207-1238.
[9] Laveau, F., Hammoudi, N., Berthelot, E., Belmin, J., Assayag, P., Cohen, A., et al. (2017) Patient Journey in Decompensated Heart Failure: An Analysis in Departments of Cardiology and Geriatrics in the Greater Paris University Hospitals. Archives of Cardiovascular Diseases, 110, 42-50. [Google Scholar] [CrossRef] [PubMed]
[10] Van Spall, H.G.C., Rahman, T., Mytton, O., Ramasundarahettige, C., Ibrahim, Q., Kabali, C., et al. (2017) Comparative Effectiveness of Transitional Care Services in Patients Discharged from the Hospital with Heart Failure: A Systematic Review and Network Meta‐Analysis. European Journal of Heart Failure, 19, 1427-1443. [Google Scholar] [CrossRef] [PubMed]
[11] Liu, S., Xiong, X.Y., Chen, H., Liu, M.D., Wang, Y., Yang, Y., et al. (2023) Transitional Care in Patients with Heart Failure: A Concept Analysis Using Rogers’ Evolutionary Approach. Risk Management and Healthcare Policy, 16, 2063-2076. [Google Scholar] [CrossRef] [PubMed]
[12] Al Sattouf, A., Farahat, R. and Khatri, A.A. (2022) Effectiveness of Transitional Care Interventions for Heart Failure Patients: A Systematic Review with Meta-Analysis. Cureus, 14, e29726. [Google Scholar] [CrossRef] [PubMed]
[13] DeWalt, D.A., Broucksou, K.A., Hawk, V., Baker, D.W., Schillinger, D., Ruo, B., et al. (2009) Comparison of a One-Time Educational Intervention to a Teach-to-Goal Educational Intervention for Self-Management of Heart Failure: Design of a Randomized Controlled Trial. BMC Health Services Research, 9, Article No. 99. [Google Scholar] [CrossRef] [PubMed]
[14] Li, X. and Liu, Y. (2024) Effect of Transitional Care Strategies on Health-Related Quality of Life (HRQoL) in Heart Failure with Reduced Ejection Fraction (HFrEF): A Systematic Review and Meta-Analysis of Randomized Controlled Trails. Alternative Therapies in Health and Medicine, 30, 148-153.
[15] Li, Y.A., Fu, M.R., Fang, J.B., Zheng, H. and Luo, B.R. (2021) The Effectiveness of Transitional Care Interventions for Adult People with Heart Failure on Patient-Centered Health Outcomes: A Systematic Review and Meta-Analysis Including Dose-Response Relationship. International Journal of Nursing Studies, 117, Article 103902. [Google Scholar] [CrossRef] [PubMed]
[16] Li, M., Li, Y., Meng, Q., Li, Y., Tian, X., Liu, R., et al. (2021) Effects of Nurse-Led Transitional Care Interventions for Patients with Heart Failure on Healthcare Utilization: A Meta-Analysis of Randomized Controlled Trials. PLOS ONE, 16, e0261300. [Google Scholar] [CrossRef] [PubMed]
[17] Wu, X.X., Li, Z., Tian, Q.X., Ji, S.M. and Zhang, C. (2024) Effectiveness of Nurse-Led Heart Failure Clinic: A Systematic Review. International Journal of Nursing Sciences, 11, 315-329. [Google Scholar] [CrossRef] [PubMed]
[18] McKay, C., Park, C., Chang, J., Brackbill, M., Choi, J., Lee, J.H., et al. (2019) Systematic Review and Meta-Analysis of Pharmacist-Led Transitions of Care Services on the 30-Day All-Cause Readmission Rate of Patients with Congestive Heart Failure. Clinical Drug Investigation, 39, 703-712. [Google Scholar] [CrossRef] [PubMed]
[19] Chauhan, U. and McAlister, F.A. (2022) Comparison of Mortality and Hospital Readmissions among Patients Receiving Virtual Ward Transitional Care vs Usual Postdischarge Care. JAMA Network Open, 5, e2219113. [Google Scholar] [CrossRef] [PubMed]
[20] Stewart, S. and Horowitz, J.D. (2002) Home-Based Intervention in Congestive Heart Failure. Circulation, 105, 2861-2866. [Google Scholar] [CrossRef] [PubMed]
[21] Naylor, M.D., Brooten, D.A., Campbell, R.L., Maislin, G., McCauley, K.M. and Schwartz, J.S. (2004) Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial. Journal of the American Geriatrics Society, 52, 675-684. [Google Scholar] [CrossRef] [PubMed]
[22] Stewart, S., Carrington, M.J., Marwick, T.H., et al. (2012) Impact of Home versus Clinic-Based Management of Chronic Heart Failure: The WHICH? (Which Heart Failure Intervention Is Most Cost-Effective & Consumer Friendly in Reducing Hospital Care) Multicenter, Randomized Trial. Journal of the American College of Cardiology, 60, 1239-1248.
[23] Khan, M.S., Fonarow, G.C. and Greene, S.J. (2024) Guideline‐Directed Medical Therapy for Heart Failure: The Key Ingredient for Successful In‐Hospital and Post‐Discharge Care. European Journal of Heart Failure, 26, 355-358. [Google Scholar] [CrossRef] [PubMed]
[24] Logeart, D., Berthelot, E., Bihry, N., Eschalier, R., Salvat, M., Garcon, P., et al. (2021) Early and Short‐Term Intensive Management after Discharge for Patients Hospitalized with Acute Heart Failure: A Randomized Study (ECAD-HF). European Journal of Heart Failure, 24, 219-226. [Google Scholar] [CrossRef] [PubMed]
[25] Ponikowski, P., Voors, A.A., Anker, S.D., Bueno, H., Cleland, J.G.F., Coats, A.J.S., et al. (2016) 2016 ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure. European Journal of Heart Failure, 18, 891-975. [Google Scholar] [CrossRef] [PubMed]
[26] 杨巧, 刘玉琳, 王崇杰, 等. 重庆市基层全科医师儿童支气管哮喘防治服务评价研究[J]. 中国全科医学, 2024, 27(22): 2780-2788.
[27] 张若岩, 张金佳, 张启龙, 等. 三级甲等医院全科医学科-社区联合对社区老年高血压病/糖尿病患者健康管理的效果研究[J]. 中国医药, 2024, 19(3): 346-350.