射血分数保留型心力衰竭的治疗进展

Treatment Progress of Heart Failure with Preserved Ejection Fraction

摘要: 射血分数保留型心力衰竭(HFpEF)是心力衰竭的一种亚型，定义为具有心衰的症状及体征，伴有左室射血分数(LVEF) ≥ 50%。近年来，HFpEF的流行病学特征发生显著变化，已成为心衰的主要类型，且患病率持续上升。尽管HFpEF患者的短期死亡率低于射血分数降低的心力衰竭(HFrEF)，但其长期预后仍严峻，住院率与HFrEF相当，且非心血管死亡占比较高。目前，对HFpEF的病理生理机制研究尚未完全阐明，临床管理上缺乏特异性疗法。本文综述了HFpEF的治疗现状及当前针对其潜在治疗靶点的探索。药物治疗方面，钠–葡萄糖协同转运蛋白2抑制剂(SGLT2i)作为里程碑式突破，通过多重机制改善HFpEF症状及预后。盐皮质激素受体拮抗剂(MRA)、血管紧张素受体–脑啡肽酶抑制剂(ARNI)、血管紧张素转换酶抑制剂/血管紧张素受体拮抗剂(ACEI/ARB)及β受体阻滞剂等药物的临床疗效存在显著异质性。此外，本文还讨论了HFpEF合并症的管理，包括肥胖、心房颤动、高血压、糖尿病、慢性肾病及阻塞性睡眠呼吸暂停等，并指出了未来研究方向，即从传统治疗模式向精准医学策略转型。

Abstract: Heart failure with preserved ejection fraction (HFpEF) is a subtype of heart failure defined by the presence of heart failure symptoms and signs, accompanied by a left ventricular ejection fraction (LVEF) ≥ 50%. In recent years, the epidemiological characteristics of HFpEF have undergone significant changes, making it the predominant type of heart failure, with a continuously rising prevalence. Although the short-term mortality of HFpEF patients is lower than that of heart failure with reduced ejection fraction (HFrEF), their long-term prognosis remains severe, with hospitalization rates comparable to HFrEF and a higher proportion of non-cardiovascular deaths. Currently, the pathophysiological mechanisms of HFpEF have not been fully elucidated, and specific therapies are lacking in clinical management. This paper reviews the current treatment status of HFpEF and the exploration of potential therapeutic targets. In terms of pharmacotherapy, sodium-glucose cotransporter 2 inhibitors (SGLT2i) have emerged as a milestone breakthrough, improving symptoms and prognosis in HFpEF through multiple mechanisms. The clinical efficacy of mineralocorticoid receptor antagonists (MRA), angiotensin receptor-neprilysin inhibitors (ARNI), angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARB), and β-blockers varies significantly. Additionally, this paper discusses the management of HFpEF comorbidities, including obesity, atrial fibrillation, hypertension, diabetes, chronic kidney disease, and obstructive sleep apnea, and points out future research directions, namely, the transition from traditional treatment models to precision medicine strategies.