Zubin Eapen博士 美国杜克临床研究所

　　<Internation Circulation>: How should heart failure care system， including teaching hospitals and primary care， work together to improve post-discharge management to readmission rate?

　　Dr. Eapen: I think your point is a good one. We have not been coordinated to date， and especially in the United States， there have been hospitals that work independently of practices， and sometimes there are providers that work in both but often times the patient journey is very fragmented. This has lead to many issues of inefficient care and now it has come to the issue of readmission. Care fragmentation and inefficiencies are sometimes preventable. So we are working to better coordinate care from hospital to home.

　　《国际循环》：包括教学医院与初级保健在内的心力衰竭保健系统应如何共同努力改善患者的出院后管理已降低其住院率？

　　Eapen博士：我认为你的观点非常好。目前为止，尚缺乏团结协作，尤其是在美国一直以来医院的工作都是相对较为独立的。虽然有时也有医务工作者同时在教学医院和初级保健机构工作，但更多的时候对患者的管理还是非常分散的。这导致出现了很多低效管理问题以及住院率增高。有时管理分散与低效是可以预防的。因此，我们正在努力实现更好的从医院到家的管理。

　　<Internation Circulation>:  What is the value of readmission for heart failure in predicting the prognosis of patients with heart failure?

　　Dr. Eapen:  It’s interesting because they say that as low as 12% of heart failure readmissions may be preventable. A lot of these patients are already sick and have a significant amount of comorbidities and for that reason， readmission in and of itself portents may be a poor prognosis. We know that after an indexed hospitalization， looking at Medicare beneficiaries in the United States， about 2 out of 3 are readmitted within a year and within one year， 1 in 3 will die. So readmission is not only an issue in this country and across the world regarding costs and inefficient care but it’s also a sign of patients who may be doing more poorly.

　　《国际循环》：因心力衰竭再住院对心力衰竭患者的预后有何价值？

　　Eapen博士：非常有趣的是仅12%的心力衰竭再住院是可以预防的。这些患者很多身体已经非常弱，存在很多合并症。正是因为如此，若患者再住院或出现再住院的征兆可能提示其预后较差。我们知道从美国医疗保险受益人的数据来看，心力衰竭患者住院后未来一年内将有三分之二的患者会再次住院，有三分之一死亡。因此，再住院是患者预后较差的标志，就成本及其低效管理而言，不仅仅是美国所要面临的问题，也是世界共同的难题。

　　<Internation Circulation>: How should we set the target heart rate for patients with heart failure? What are the key points of the heart rate management in heart failure patients?

　　Dr. Eapen: Heart rate is an interesting target and we will be discussing this at a session later in the week at AHA 2013. HR is a target that people have usually looked at with new drugs， certainly current evidence-based therapies do affect heart rate although it’s not known if that’s the clear benefit from them. Beta-blockers are a good example of a medication that modulates heart rate but is beneficial for many other reasons in heart failure. There are newer drugs， such as Ivabridine， which may also modulate HR and be an indicator of how we may be able to improve therapies in heart failure. SHIFT trial is a good example. I think it’s still unclear if HR by itself is a marker that can be modulated， but we do know that it can be a prognosticator of how people do. That is， people with higher HR particularly on admission or discharge may have poor prognosis compared with those with lower HR. Certainly patients with atrial fibrillation (AF)， a common comorbidity with heart failure， is often accompanied by higher HR and patients with AF tend to do worse. We have some new analyses coming out， I’m presenting one of these posters on this， that whether you have reduced or preserved ejection fraction in patients with heart failure and AF tend to do worse at 30 days; they have higher rate of mortality compared to heart failure patients without AF. So in that regard， HR also can be a sign of those comorbidities that can portend to poorer prognosis.

　　《国际循环》：我们应如何设定心力衰竭患者的心率控制目标值？心力衰竭患者心率管理的要点有哪些？

　　Eapen博士：心率是个非常有趣的控制靶标。我们在本周晚些时候将在AHA 2013年会的一个专题研讨会上专门对其进行讨论。人们已经观察了新药对心率的影响。目前以循证为基础的治疗确实能够影响患者的心率，但尚不确定这些治疗能否为患者带来明确的获益。β受体阻滞剂是个非常好的例子，其虽能调节心率，但对心力衰竭患者的获益可能是由其他原因/机制所致。新型药物如伊伐布雷定也能调节心率，是我们探讨如何改善心力衰竭患者心率的有用工具。SHIFT试验是个非常好的例子。我认为，目前尚不确定心率本身是否是个可用于改善心衰患者预后的可调节指标。但是，我们知道，其能作为预测患者预后的指标。与心率较低者相比，住院或出院时心率较高的患者其预后更差。当然，伴有心房颤动这一心力衰竭常见合并症的患者，通常心率较快，预后也较差。我们已经有了一些新的分析数据。其中我的一篇相关壁报将探讨伴有心房颤动的射血分数保留或降低的心力衰竭患者30天时的预后是否更差。结果发现，与不伴有心房颤动者相比，其死亡率更高。因此，从这个方面来说，心率也是一种预示患者预后较差的合并症。