编者按：在ESC2020大会上，舒张性心力衰竭（diastolic heart failure，DHF）的诊治作为临床热点，被列入Late-Breaking Science环节讨论，西安交通大学第一医院马爱群教授团队对DHF相关研究及诊疗进展进行了总结。现整理如下，以飨读者。
目前DHF的诊断主要是结合心衰的症状及体征，心电图、X线片、超声心动图、氨基末端脑钠肽前体（NT-proBNP）进行综合分析，但仍缺乏严格、统一的诊断标准，这也是DHF相关大型临床面临的严峻挑战。现临床用于评估心室舒张功能的心动超声图参数主要包括：
① E峰、A峰值：是测量心脏舒张期二尖瓣口前向血流速度的两个峰值，E峰是左心室舒张早期最大血流，A峰是二尖瓣心房收缩期最大血流。而E/A比值可以进一步评估舒张功能，并进行舒张功能分级。
② e’速度（e’ velocity）：是指左室间隔侧和侧壁侧的二尖瓣环运动频谱，经组织多普勒（TDI）测量，若间隔侧e’＜7cm/s或侧壁侧e’＜10 cm/s提示舒张功能异常。
另外还包括左心室质量指数（LVMI）、左室整体长轴应变（GLS）、左室相对室壁厚度（relative wall thickness，RWT）等反映左心功能及形态的指标。
DHF患者尽管存在舒张功能障碍，但某些测量值可能仍在正常范围内，因此诊断时不应单独使用任何指标来评估舒张功能。欧洲心脏病学会（ESC）心力衰竭协会（HFA）颁布的共识建议应用HFA-PEFF诊断流程进行DHF的诊断，具体分为以下4个步骤。
对于任何出现心衰相关症状和/或体征的患者，应进行初始评估。通常在门诊进行，评估内容包括心衰症状和体征、典型的临床和人口统计学情况（肥胖、高血压、糖尿病、老年人、心房颤动）、诊断性实验室检测（包括血常规、肝肾功、电解质等）、心电图以、标准超声心动图及运动试验。排除其他导致呼吸困难的心源性及非心源性原因，同时LVEF正常，利钠肽（natriuretic peptide，NP）升高或正常，至少有一个DHF的危险因素，则疑诊DHF，进行下一评估。
对于DHF疑似患者，应结合超声心动图测量的心脏结构和功能的综合情况以及NP水平来判断，如图1所示。若得分≥5分提示明确的HFpEF，≤1分诊断为HFpEF的可能性小；2~4分表明诊断存在不确定性，建议进一步评估。评分详见表1。
表1. 基于心动超声图及利钠肽的评分
经运动负荷超声图检查，若平均E/e’≥15，则在第二步的评分系统中加2分，若平均E/e’≥15且TRPV＞3.4m/s，则加3分。重新评分，若得分≥5分则可诊断DHF。若得分仍＜5分，或者不能完成运动负荷超声图，建议进行侵入性血流动力学监测。
侵入性血流动力学监测包括左心及右心导管检查。经监测，静息状态下，若左室舒张时间常数τ＞48 ms或左心室舒张末压（LVEDP）≥16 mm Hg或肺毛细血管楔压（PCWP）≥15 mm Hg，则可诊断DHF；运动负荷状态下，PCWP ≥25 mm Hg可诊断DHF。而静息状态下的高PCWP和运动状态下病理性升高的PCWP是DHF预后不良的预测指标。
来自澳大利亚国家超声数据库（NEDA）最新研究数据表明，无论是LVEF保留还是LVEF受损的患者，与舒张功能正常者相比，舒张功能障碍增加了死亡风险。在单独分析各项舒张功能指标时，E、e’、E/e’及LAVI是增加心血管相关死亡风险的关键点。当E≥90cm/s、e’≤9cm/s、E/e’≥9及LAVI≥32 ml/m2时，死亡率明显增加（图1）。而LVEF受损和年龄增加均可明显影响舒张功能。
确定HFpEF病因或具有类DHF样表现的相似疾病。共识中推荐可以进一步进行心脏核磁、核素显像、PET/CT、病理学检查（如心脏或非心脏的活检）、免疫炎性因子及代谢因子检测、基因检测等。其中心脏核磁在缺血性心肌病、肥厚型心肌病、心肌致密化不全、心肌浸润性疾病、微血管病变等方面具有很高的诊断及鉴别诊断价值。尤其对于年轻、有心肌病/心衰家族史、没有或仅有轻微的危险因素/合并症、左室肥厚、局部心室运动异常、室性心律失常、严重的右心扩张、存在心肌瘢痕组织的人群，更进一步的检测是必要的。而病因或其他相关疾病的诊断，对于DHF的精准治疗意义重大。
目前，尚无可降低DHF患病率和死亡率的确切治疗。特别是，用于HF的传统药物并不能使HFpEF的发病率和死亡率降低，一些DHF治疗相关的大型临床研究也均未得到满意结果。较早的CHARM试验未能证明坎地沙坦对DHF有益，随后一些针对肾素-血管紧张素系统的治疗亦不能降低DHF的死亡率。在PARAGON-HF试验中，与缬沙坦相比，沙库巴曲缬沙坦也不能改善HFpEF患者的DHF再住院率和心源性死亡率，但也有研究表明沙库巴曲缬沙坦具有的抗纤维化特性可能对DHF患者有益。TOPCAT试验研究结果显示，螺内酯仅可降低部分地区DHF患者的心血管死亡和心衰住院率，对于EF≥50％的患者，使用β受体阻滞剂与甚至与心衰住院的风险增加相关。因此目前治疗DHF患者的主要是是病因治疗和对症治疗。
积极治疗常见且对DHF临床进程有明显促进作用的危险因素和合并症，如肥胖、高血压、冠心病、心房颤动、糖尿病、慢性阻塞性肺病、贫血、慢性肾脏病和睡眠呼吸障碍等。这也是DHF患者治疗中最为重要的部分。其中，心动过速时舒张期充盈时间缩短，进一步影响心搏量，因此合并心房颤动的DHF患者，转复并维持窦性心律是首选，慢性心房颤动应控制心室率、积极抗凝]。
总之，DHF是一种组复杂的系统性临床综合征，常伴有多脏器多系统病变，以功能受限、预后差为特点。DHF是老年人中一种快速增长的疾病，NEDA最新研究也表明年龄可以显著影响舒张功能，因此DHF可以认为是衰老并影响所有器官系统的老年综合症，包括多种表型，这可能是诸多针对任何具体、单一治疗方法的临床试验不能获得阳性结果的原因之一。因此，对DHF病理生理、发病机制的进一步认知，并采用表型特异性治疗方法可能是成功管理DHF的关键。
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