引言

• 2022年发表的立场文件补充了欧洲心脏病学会（ESC）心力衰竭指南
• 出现更多预防射血分数降低（HFrEF）和保留（HFpEF）心力衰竭的证据
• 本声明强调整体和个性化管理多风险因素的重要性
• 预防心力衰竭在心血管医学中至关重要
• 筛查项目、生活方式改变和预防性药物治疗可降低心力衰竭风险

心力衰竭的流行病学和风险分层

流行病学

• 心力衰竭是重大医疗问题，发病率、死亡率、住院率高，影响残疾和医疗成本
• 欧洲估计有超1400万例心力衰竭患者，每年约250万例新发病例和220万例住院病例

风险因素

• 多种风险因素导致心力衰竭，围绕共同病理生理机制聚集
• 心血管 - 肾脏 - 代谢（CKM）综合征有助于识别风险因素簇
• 合并症存在不能完全解释心力衰竭发生

病理生理机制

• 包括内皮功能障碍、全身炎症、神经激素激活等

风险预测

生物标志物

• 利钠肽（如BNP和NT - proBNP）
• 心肌损伤标志物（如高敏心肌肌钙蛋白）
• 肾功能受损标志物（如尿白蛋白与肌酐比值UACR）
• 全身炎症标志物（如高敏C反应蛋白）

其他预测因素

• 静息心率升高
• SCORE2和SCORE2 - Diabetes未经验证用于预测心力衰竭风险
• 心力衰竭风险预测模型：PCP - HF、PREVENT、SCORE2 - HF

主要风险因素及干预

动脉高血压

• 是心力衰竭主要风险因素
• 病理生理：压力过载导致左心室肥厚和舒张/收缩功能障碍
• 干预：血压目标120 - 129/70 - 79 mmHg，药物治疗包括噻嗪类利尿剂、ACE抑制剂、ARB、β - 阻滞剂、CCB
• 证据：收缩压降至<120 mmHg与心力衰竭发生率降低38%相关

2型糖尿病

• 糖尿病患者发生心力衰竭相对风险为2.06
• 病理生理：炎症、微血管功能障碍等
• 干预：糖化血红蛋白目标<7%或<53 mmol/mol，使用SGLT2i、GLP - 1ra，强化血压控制
• 证据：多项试验显示SGLT2i和GLP - 1ra可降低心力衰竭住院率和心血管死亡风险
• HF is a frequent CV outcome in type 2 diabetes
• Choice of antidiabetic agent is key to preventing HF
• SGLT2i are the first drugs to prevent HF in type 2 diabetes
• Common comorbidity
• Intensive BP control may improve CV outcomes
• Sodium-glucose co-transporter2-inhibitors (SGLT2i)：First drugs to prevent HF in type 2 diabetes；Reduce HF hospitalizations and CV mortality；Reduce HF hospitalizations by 30% and CV death or HF hospitalizations by 21%
• Glucagon-like peptide 1 receptor agonists (GLP-1ra)：Improve CV outcomes in type 2 diabetes；Reduce risk of myocardial infarction and stroke；Lower risk of HF hospitalizations by 11%；Benefits for preventing HF alone are less certain than SGLT2i
• Other antidiabetic medications：Some have neutral effect, others may be harmful in HF；Thiazolidinediones may have negative impact due to fluid retention；DPP-4 inhibitors show different impacts based on molecule；Metformin is neutral or potentially beneficial；Sulfonylureas may have higher risk of HF；Insulin glargine and/or degludec did not demonstrate any effect on HF risk

慢性肾脏疾病

• 是HFpEF和HFrEF的风险因素
• 病理生理：内皮功能障碍、全身炎症等
• 干预：使用SGLT2i、非甾体盐皮质激素拮抗剂（MRA）、ACEi/ARB、GLP1ra
• 证据：多项试验显示这些药物可降低肾脏疾病进展、心力衰竭住院和心血管死亡风险
• Strong risk factor for CV disease and HF
• Albuminuria and low GFR are associated with increased risk
• Kidney-heart interactions contribute to reciprocal risk amplification
• Routine screening for CKD and other CKM risk factors is needed
• ACE-i/ARB：Advised in patients with diabetes, hypertension, and albuminuria；Prevent worsening kidney function and HF
• SGLT2i：Major trials testing SGLT2i in patients with CKD；Reduce HF hospitalizations and kidney disease progression；Mitigate longitudinal rise in biomarkers’ concentrations
• Glucagon-like peptide 1 receptor agonists：Have established CV disease and renal benefits；Semaglutide reduces risk of HF events or CV death and of HF events alone；Support use in patients with diabetes and CKD to prevent HF
• Mineralcorticoidreceptor antagonist：Finerenone reduces risk of HF hospitalizations and composite CV outcome；Recommended for prevention of HF hospitalization in patients with CKD and diabetes

肥胖

• 与新发心力衰竭相关，尤其HFpEF
• 病理生理：慢性全身炎症状态、内皮功能障碍等
• 干预：生活方式干预、药物治疗、减肥手术
• 证据：LOOKAHEAD试验、SELECT试验显示体重减轻与心力衰竭事件减少相关
• Associated with new-onset HF, especially HFpEF
• Lifestyle interventions, pharmacological approaches, or weight loss surgery can reduce weight
• GLP1-RAs reduce risk of HF hospitalizations
• Further dedicated trials are warranted

其他风险因素及干预

久坐习惯

• 干预：达到每周8.75 MET小时的身体活动水平，增加每日步数
• Established risk factor for CV events and HF
• Physical activity reduces HF incidence
• Achieving recommended physical activity can prevent premature deaths

血脂异常

• 干预：随机研究未显示他汀类药物对心力衰竭的保护作用
• Statins are effective for primary prevention of atherosclerotic cardiovascular disease
• Recent study shows statin therapy may reduce risk of HF in individuals with atrial fibrillation
• Relationship between Lp(a) and HF remains unclear

吸烟习惯

• 干预：戒烟，戒烟时间越长，心力衰竭风险越低
• Potent, independent risk factor for HF
• Dose-response relationship for pack-years of smoking and HF
• Longer smoking cessation is associated with lower risk of HF

酒精和物质滥用

• 干预：限制酒精摄入，避免使用大麻、阿片类和兴奋剂
• Linked to higher HF prevalence and hospitalizations
• Substance misuse contributes to ischaemic heart disease and atrial fibrillation risk
• Socio-economic risks and genetic predispositions may amplify HF risk

化疗和放疗

• 干预：优化风险因素控制，高风险患者使用ACE - I/ARB、β - 阻滞剂和他汀类药物，使用右丙亚胺和脂质体蒽环类药物，依赖技术进步预防放疗损伤
• CTR-CVT risk varies according to cancer type and stage
• Primary prevention aims to avoid or minimize HF development
• Optimize CV risk factor control and evaluate CV risk at baseline
• HF therapies exhibit conflicting results in CTRCD primary prevention
• SGLT2i may reduce risk of developing CTRCD
• Strategies to manage anthracycline-related toxicity include adjusting infusion time and dose intensity

感染

• 干预：流感疫苗接种可降低全因死亡率
• Influenza, SARS-CoV-2, and other respiratory infections are associated with increased risk of HF events
• Vaccinations may reduce incidence and/or severity of respiratory infections and prevent HF hospitalization

女性特定风险因素

• 干预：对高风险女性进行心力衰竭和围产期心肌病筛查
• Overall lifetime risk of HF is comparable between women and men
• Risk factors, HF phenotypes, and prognosis differ significantly
• Female-specific reproductive factors are associated with increased risk of HF
• Sleep disorder breathing and peripartum cardiomyopathy are known causes of HF in women

空气污染

• 干预：支持清洁能源和政策改变
• Air quality is a significant CV risk factor
• Short-term exposure to pollutants is linked to acute HF hospitalizations and mortality
• Chronic exposure to pollutants is associated with higher risk of myocardial infarction and HF
• Strategies to mitigate HF risk include reducing atmospheric emissions and using air filters

社会经济地位

• 干预：解决食物不安全、贫困和社会隔离问题
• 影响因素：粮食不安全（增加心力衰竭风险，美国少数族裔中常见，通过不良营养增加风险，面临粮食不安全的成年人患心力衰竭风险高1.5倍）；社会隔离（显著增加心力衰竭发病率、死亡率和医疗成本，通过增加炎症等加剧风险）；邻里因素（如空气污染等通过强化不良行为和限制医疗服务参与加剧风险）
• 公共卫生策略：解决社会隔离和粮食不安全；解决更广泛社会经济障碍；识别高危个体；利用社区资源和社会处方；使用远程医疗和虚拟支持平台

睡眠呼吸障碍

• 干预：阻塞性睡眠呼吸暂停男性患者需关注心力衰竭风险

心力衰竭亚型：射血分数保留的心力衰竭（HFpEF）和射血分数降低的心力衰竭（HFrEF）

• 共同风险因素：动脉高血压、糖尿病、慢性肾脏病、肥胖
• HFpEF特定风险因素：女性特定因素（如早绝经等）、空气污染、心房颤动、心肌梗死病史等
• HFrEF特定风险因素：酒精和/或物质滥用、化疗和/或放疗暴露、血脂异常、慢性缺血性心脏病史

结论

• 预防策略：管理传统心血管危险因素、考虑更广泛风险因素
• 高危个体识别：有多种心血管危险因素者、根据现有风险预测模型分类为高危者
• 高危个体随访策略：定期监测和优化管理心血管危险因素、促进生活方式改变
• 风险患者筛查：基于NP生物标志物筛查、团队式护理、需进一步研究确定成本效益等