NA0589降糖药物对糖尿病合并心力衰竭患者左室功能的影响内容降糖治疗与心力衰竭的联系：从担忧到潜在获益降糖药物对糖尿病合并心力衰竭的左
室功能影响心力衰竭概述：临床诊断分型标准《中国心力衰竭诊断和治疗指南2018》多种原因导致心脏结构和/或功能的异常改变，使心室收
缩和/或舒张功能发生障碍，从而引起的一组复杂临床综合征，主要表现为呼吸困难、疲乏和体液潴留（肺淤血、体循环淤血及外周水肿）1心力衰
竭的分型及诊断标准11.症状和/或体征2.射血分数水平射血分数降低的心力衰竭(LVEF<40%)HFwithreduced
ejectionfraction(HFrEF)3.利钠肽升高，并伴有至少1项：a.左心室肥厚和/或左心房扩大b.舒张功能异
常射血分数中间值的心力衰竭(LVEF40~49%)HFmid-rangeejectionfraction(HFmrEF)
新增射血分数保留的心力衰竭(LVEF>50%)HFwithpreservedejectionfraction(HFpEF
)1.中华医学会心血管病分会,中华心血管病杂志编辑委员会.《中国心力衰竭诊断和治疗指南2018》，中华心血管病杂志,201
8,46(10)：769-789.心力衰竭功能失调的重要特征：心室重构舒张性与收缩性心力衰竭的心室重构肥厚型心脏(舒张性心力衰
竭）扩张型心脏(收缩性心力衰竭)正常心脏射血分数保留的心力衰竭HFpEF保留左室收缩功能无左室扩张左室舒张功能障碍左室向心性
重构射血分数降低的心力衰竭HFrEF左室收缩功能障碍及左室扩张左室舒张功能障碍左室外扩性重构Jessupetal.NEn
glJMed.2003;348:2007–2018不同类型心力衰竭的诊断鉴别存在困难65岁以上人群因劳力性呼吸困难初次就诊，
约1/6心力衰竭未能识别，其中大部分是HFpEF2《中国心力衰竭诊断和治疗指南2018》1《2019ESC-HFA射血分数保
留性心力衰竭诊断共识》3慢性心力衰竭的诊断流程根据下表各项检查的HFA-PEFF评分进行诊断生物标志物超声心动图注：HFA-PE
FF评分≥5分，诊断为HFpEF；2~4分，舒张负荷试验或有创血液动力学检查；≤1分，HFpEF可能性极低无深入建议如何鉴别LAV
I:左房容量指数，LVMI：左室质量指数，RWT：左室相对厚度1.中华医学会心血管病分会,中华心血管病杂志编辑委员会.《中
国心力衰竭诊断和治疗指南2018》，中华心血管病杂志,2018,46(10)：769-789.2.PonikoeskiP
etal.,EurHeartJ,2016,37(27):2129-2200.3.PieskeBetal.,E
urHeartJ,2019,40(40):3297-3317鉴别心力衰竭分型的意义：具有人群特点及药物治疗差异射血分数中间值
型衰心(HFmrEF)目前认识不足，根据治疗反应,可转化为HFrEF或HFpEF心力衰竭分型3HFpEF(LVEF>50%
)HFmrEF(LVEF40-50%)HFrEF(LVEF<40%)老年人++++++男性/性别++++++CAD+++++++
+Characteristics患病率++++/++++++死亡率+++++++OutcomesACEIX?√(l)ARB√(l
lB)√(llB)√(l)ARNI??√(l)BBX?√(l)MRA√(llB)√(llB)√(l)Guideline-Direc
tedMedicalTherapiesACEI,angiotensin-convertingenzymeinhibitor
s;ARB,angiotensinreceptorblocker;ARNI,angiotensinreceptor-
neprilysininhibitor血管紧张素受体脑啡肽酶抑制剂;BB,beta-blockersβ受体阻滞剂;CA
D,coronaryarterydisease冠心病;HFmrEF,heartfailurewithmid-r
angeejectionfraction射血分数中间值的心力衰竭;HFpEF,heartfailurewithpre
servedejectionfraction射血分数保留的心力衰竭;HFrEF,heartfailurewithr
educedejectionfraction射血分数降低的心力衰竭;LVEF,leftventricularejec
tionfraction左心室射血分数;MRA,mineralocorticoidreceptorantagonist
盐皮质激素受体拮抗剂HsuJJetal.JACCHeartFail2017,5:763-771现有心力衰竭治疗药
物对HFpEF的疗效不足，治疗策略仍局限在并发症及临床症状管理A20AT–p≤0.001CR–p≤0.001HFrE
FHFpEFHFpEF：饮食运功干预部分有效死亡或心力衰竭入院风险比15%ChangepeakVO2(ml/kg/min
)10I-PRESERVE5CHARM-AlternativeCHARM-Preserved0PEP-CHF-5SOLVDCRCR
+ATControlATBDIG-PreservedDIG50AT–p=0.431CR–p=0.004OPTI
MIZE-BBOPTIMIZE-BB40OPTIMIZE-ACEOPTIMIZE-ACE30OPTIMIZE-BB%Chang
eKCCQoverallscoreOPTIMIZE-BB200.40.50.60.70.80.91.01.11.2100C
RCR+ATControlATinelderlypopulationeffectivenessofBBinHF
,24,689patientswithHFaged65andolderAT,aerobicexercise
training，CR,caloricrestriction;CHARM,CandesartaninHeartFa
ilure:AssessmentofReductioninMortalityandMorbidity;HF,he
artfailure;HFpEF,heartfailurewithpreservedejectionfractio
n;HFrEF,heartfailurewithreducedejectionfraction;I-PRESERV
EindicatesIrbesartaninHeartFailureWithPreservedEjectionF
ractionStudy;KCCQ,KansasCityCardiomyopathyQuestionnaire;PE
P-CHF,PerindoprilforElderlyPeopleWithChronicHeartFailure;
SOLVD,StudiesofLeftVentricularDysfunction;DIG,DigitalisI
nvestigationGroup;OPTIMIZE,OrganizedProgramtoInitiateLifes
avingTreatmentinHospitalizedPatientsBorlaugBAetal.Circula
tion2011;123:2006–2013;ShahSJetal.Circulation2016;134:73–9
0糖尿病是引起心力衰竭的常见病因之一1糖尿病是心力衰竭的重要风险因素2–4相比于无糖尿病人群，基线时无心力衰竭的糖尿病患者发展
为心力衰竭的风险增加约2~5倍，糖尿病前期（HbA1c≥5.5?6.4%)人群增加20-40%的心力衰竭风险7过去近30年，心力
衰竭治疗领域几乎无进展，预防及延缓心力衰竭进展更加重要8X2-51.CosentinoFetal.EurHear
tJ2019;00:1?69;2.AronowWSetal.AmJCardiol1999;84:611–61
2,A9;3.ChenYTetal.AmJMed1999;106:605–612;4.Gottdiener
JSetal.AmCollCardiol2000;35:1628–1637;5.NicholsGAetal
.DiabetesCare2004;27:1879–1884;6.NicholsGAetal.Diabetes
Care2001;24:1614–1619;7.MatsushitaKetal.Diabetes2010;59:2
020–2026；8.PatrickRossignol.etal.,Lancet2019;393:1034–44.H
FpEF与代谢因素的关联更加密切以肥胖及代谢特征相关指标的心力衰竭分型260PredictorOutcomeHRMultivar
iable-adjusted95%CIPBMIIncidentHFpEF1.34(1.24–1.45)<0.0001I
ncidentHFrEF1.18(1.10–1.27)<0.0001WCIncidentHFpEF1.32(1.22–
1.44)<0.0001IncidentHFrEF1.19(1.10–1.29)<0.0001WHRIncidentHFp
EF1.19(1.10–1.29)<0.0001IncidentHFrEF1.14(1.06–1.22)0.001HOM
A-IRIncidentHFpEF1.20(1.05–1.37)0.006IncidentHFrEF0.99(0.88
–1.11)0.81TG/HDLratioIncidentHFpEF1.06(0.96–1.17)0.27Inciden
tHFrEF1.13(1.04–1.23)0.003FastingglucoseIncidentHFpEF1.15(1.
08–1.23)<0.0001IncidentHFrEF1.07(0.99–1.16)0.08SBPIncidentH
FpEF1.20(1.11–1.20)<0.0001IncidentHFrEF1.19(1.11–1.27)<0.000
1GWTG-HF:N=110,621例住院心力衰竭中HFpEF患病率变化趋150~50%EF>50%40~35%EF<40%
住院心力衰竭患者比例(%)3020~15%EF40-50%100年2005200620072008200920102011
201220132014201520162017201820192020至2020,65%的住院心力衰竭患者EF>40
%Pfordifference<0.05usingLunn-McNeilmethodtocompareHRf
orHFpEFversusHFrEFBMI,bodymassindex;GWTG-HF,GetWithThe
Guidelines-HeartFailure;HOMA-IR,homeostaticmodelassessmento
finsulinresistance;HF,heartfailure;HFpEF,heartfailurewit
hpreservedejectionfraction;HFrEF,heartfailurewithreduced
ejectionfraction;HR,hazardratio;WC,waistcircumference;WHR
,waist-to-hipratio;TG/HDLratio,triglyceride-to-highdensity
lipoproteinratio;SBP,systolicbloodpressure1.OktayAAetal.
CurrHeartFailRep2013;10:401–410;2.SavjiNetal.JACCHea
rtFail.2018;6:701-709合并糖尿病的患者因心力衰竭入院的比例更高累积发病率(%)累积发病率(%)3CV死
亡or心力衰竭入院全因死亡6060Diabetes(LowEF)4040Diabetes(PreservedEF)Dia
betes(LowEF)Nodiabetes(LowEF)Nodiabetes(LowEF)Diabetes(P
reservedEF)2020Nodiabetes(PreservedEF)Nodiabetes(Preserved
EF)0000.511.522.533.500.511.522.533.5Follow-up(years)Follow-up(
years)糖尿病是心力衰竭患者的CV患病率及死亡率的独立预测因子，无论HF的LVEF水平HFpEF合并糖尿病的患者vs.低EF无
糖尿病的患者，因心力衰竭入院的比例更高HHF,hospitalizationforheatfailure心力衰竭入院Mac
DonaldMRetalEurHeartJ2008,29:1377-85罗格列酮事件引发糖尿病药物治疗的心血管疾
病安全性担忧降糖药物可能导致T2DM患者心血管疾病风险的增加荟萃分析显示：罗格列酮治疗可导致T2DM患者心血管疾病风险增加，尤其是
慢性心力衰竭风险增加NissenSEetal.NEnglJMed2007;156:2457–71FDA对降糖药的
心血管结局研究（CVOT)标准化ACE(Acarbose,AGI)n=6522;duration~8yrsQ22017
–RESULTSREWIND(Dulaglutide,OWGLP-1RA)n=9622;duration~6.5yr
sQ42018-TOPLINERESULTS肥胖&糖尿病药物的CVOT研究汇总EXSCEL(ExenatideER,O
WGLP-1RA)n=14,752;follow-up~3yrsQ32017–RESULTSCARMELINA(L
inagliptin,DPP-4i)n=7003;duration~4yrsQ32018–RESULTSDEVOT
E(Insulindegludec,insulin)n=7637;duration~2yrsQ22017–RESU
LTSTECOS(Sitagliptin,DPP-4i)n=14,671;duration~3yrsQ42014–R
ESULTSLookAHEAD(+/-orlistat,lipaseinhibitor)n=5145;follow-u
p9.6–13.5yrsQ32013–RESULTSALECARDIO(Aleglitazar,PPAR-αγ)n=
7226;follow-up2yrsTermin.Q32013–RESULTSPIONEER6(Oralsem
aglutide,GLP-1RA)n=3183;duration~1.5yrsQ42018–TOPLINERESU
LTSAMPLITUDE-O(Efpeglenatide,OWGLP-1RA)n=4000;duration~3yr
sCompletionQ22021HARMONYOUTCOMES(Albiglutide,OWGLP-1RA)n=957
4;duration~4yrsQ32018-RESULTSSUSTAIN6(Semaglutide,OWGLP-
1RA)n=3297;duration~2.8yrsQ32016–RESULTSCANVAS-R(Canagliflo
zin,SGLT-2i)n=5826;duration~3yrsQ22017–RESULTSELIXA(Lixise
natide,GLP-1RA)n=6068;follow-up~2yrsQ12015–RESULTSSCORED(S
otagliflozin,SGLT-1i&SGLT-2i)n=10,500;duration~4.5yrsComp
letionQ12022VERTISCV(Ertugliflozin,SGLT-2i)n=8000;duration~
6yrsCompletionQ32019SELECT(Semaglutide,OWGLP-1RA)n=17,500;
Duration:eventdriven,1225MACECompletionQ32023SOUL(Oralsem
aglutide,ODGLP-1RA)n=12,546;duration~3.5–5yrsCompletionQ2
2024SAVOR-TIMI53(Saxagliptin,DPP-4i)n=16,492;follow-up~2yrs
Q22013–RESULTSFREEDOM(ITCA650,GLP-1RAinDUROS)n=4000;dura
tion~2yrsQ22016–TOPLINERESULTSCANVAS(Canagliflozin,SGLT-2i
)n=4418;duration4+yrsQ22017–RESULTSCREDENCE(cardio-renal)(
Canagliflozin,SGLT-2i)n=4464;duration~5.5yrsQ32018–CANCEL
LED(+veefficacy)CAMELLIA-TIMI53(Lorcaserin,5-HT2CRA)n=12,000;
duration~3.3yrsQ32018–RESULTSCAROLINA(Linagliptin,DPP-4i
vsSU)n=6103;duration~8yrsCompletionQ12019PPAR-αγSGLT-2iEXA
MINE(Alogliptin,DPP-4i)n=5380;follow-up~1.5yrsQ32013–RES
ULTSEMPA-REGOUTCOME(Empagliflozin,SGLT-2i)n=7000;durationupt
o5yrsQ32015–RESULTSLEADER(Liraglutide,GLP-1RA)n=9340;dura
tion3.5–5yrsQ22016–RESULTSTOSCAIT(Pioglitazone,TZD)n=3028;
duration~10yrsQ42017?–RESULTSDPP-4iInsulinGLP-1RATZDDECLAR
E-TIMI58(Dapagliflozin,SGLT-2i)n=17,276;duration~6yrsQ32018
-COMPLETEDAGI5-HT2CRA201320142015201620172018201920202021202220
232024Estimatedenrolment;?Stoppedearlyafteramedianfollow-
upof57.4monthsfollowingfutilityanalysisTrialswithfilled
boxesarecompleted.Trialswithawhitebackgroundareongoing5
-HT2CRA,serotonin2Creceptoragonist;AGI,alpha-glucosidasein
hibitor;CVOT,cardiovascularoutcomestrial;DPP-4i,dipeptidyl
peptidase-4inhibitor;ER,extendedrelease;GLP-1RA,glucagon-li
kepeptide1receptoragonist;ITCA650,continuoussubcutaneous
deliveryofexenatide;PPAR-αγ,peroxisomeproliferator‐activated
receptors-αandγ;OW,onceweekly;SGLT-1i,sodium-glucoseco-t
ransporter1inhibitor;SGLT-2i,sodium-glucoseco-transporter2
inhibitor;SU,sulphonylurea;TZD,thiazolidinedioneClinicalTrial
s.gov.Accessed27November2018CVOT研究分析发现SGLT-2抑制剂降低心力衰竭入院风险恩格列
净安慰剂恩格列净、卡格列净、达格列净EMPA-REGOUTCOME1CANVASProgram2DECLARE-TIMI5
83达格列净安慰剂卡格列净安慰剂Cumulativeincidence(%)Hospitalisationforhea
rtfailurePatientswithevent(%)Patientswithevent(%)HR:0.65
(95%CI0.50;0.85)p=0.002HR:0.67(95%CI0.52;0.87)p=0.002HR:
0.83(95%CI0.73;0.95)p=0.005forsuperiorityWeekssincerando
misationDayssincerandomisationMonthssincerandomisationACS,a
cutecoronarysyndrome;DM,diabetesmellitus;DPP-4,dipeptidyl
peptidase-4;GLP-1RA,glucagon-likepeptide-1receptoragonist;H
F,heartfailure;HFrEF,heartfailurewithreducedejectionfrac
tion;SGLT2,sodium-glucosecotransporter2;T2D,type2diabetes
.CI,confidenceinterval;HR,hazardratio;1.ZinmanBetal.N
EnglJMed2015;373:2117–2128;2.NealBetal.NEnglJMed2017
;377:644–657;3.WiviottSDetal.NEnglJMed2019;380:347–357S
GLT-2抑制剂：既往有无心力衰竭病史均可降低因心衰入院风险Patients(n/N)Eventsper1000PYWei
ght(%)HR(95%CI)TxPlaceboEventsTxPlacebo有心力衰竭病史的患者EMPA-REGOUT
COME462/706244/70612463.685.523.60.72(0.50;1.04)CANVASProgram
803/1461658/146120335.456.834.10.61(0.46;0.80)DECLARE-TIMI5885
2/1724872/172431445.155.542.40.79(0.63;0.99)Fixedeffectsmodel
forhistoryofheartfailure(p<0.0001)0.71(0.61;0.84)无心力衰竭病史患
者EMPA-REGOUTCOME4225/63142089/631433915.524.930.00.63(0.51;0.7
8)CANVASProgram4992/86813689/868144913.615.232.40.87(0.72;1.06)
DECLARE-TIMI587730/154367706/154365998.910.537.60.84(0.72;0.99
)Fixedeffectsmodelfornohistoryofheartfailure(p<0.0001)0.
79(0.71;0.88)HR(95%CI)FavourstreatmentFavoursplacebo1.0HHF,
hospitalisationforheartfailure;HR,hazardratio;n,numbero
fpatientsineachgroup;N,totalnumberofpatients;PY,patien
tyears;Tx,treatmentZelnikerTAetal.Lancet.2019Jan5;393(1
0166):31-39CVOT研究：GLP-1受体激动剂不增加心力衰竭入院风险利拉鲁肽,司美鲁肽,利司那肽,艾塞那肽和度拉糖肽
心力衰竭入院风险ELIXA,LEADER,SUSTAIN6,EXSCEL,HARMONYoutcomes,PION
EER6andREWIND1-7HR(95%CI)FavoursstudydrugFavoursplacebo1
.Pfefferetal.NEnglJMed2015,373:2247–57;2.Marsoetal.
NEnglJMed2016,375:311–22;3.Marsoetal.NEnglJMed2016,
375:1834–44;4.Holmanetal.NEnglJMed2017,377:1228–39;5.
HernandezAFetal.Lancet2018,392:1519–1529;6.HussainMet
al.NEnglJMed2019,DOI:10.1056/NEJMoa1901118;7.GersteinHC
etal.Lancet.2019,pii:S0140-6736(19)31149-3GLP-1受体激动剂：Meta分析
提示降低心力衰竭入院风险心力衰竭入院风险GLP-1RAn/N(%)Placebon/N(%)HR(95%CI)NNT(
95%CI)pvalueELIXA122/3034(4)127/3034(4)0.96(0.75;1.23)0.75L
EADER218/4668(5)248/4672(5)0.87(0.73;1.05)0.14SUSTAIN659/164
8(4)54/1649(3)1.11(0.77;1.61)0.57EXSCEL219/7356(3)231/7396(
3)0.94(0.78;1.13)0.51HARMONY79/4731(2)111/4732(2)0.71(0.53;
0.94)<0.0001REWIND213/4949(4)226/4952(5)0.93(0.77;1.12)0.46PI
ONEER621/1591(1)24/1592(2)0.86(0.48;1.44)0.59Overall(I2=0·0%
,p=0·595)936/27977(3)1016/28027(4)0.91(0.83;0.99)312(165;
2810)0.028FavoursGLP-1RAFavoursPlaceboHR(95%CI)CI,confide
nceinterval;CVOTs,cardiovascularoutcometrials;GLP-1RA,glu
cagon-likepeptide-1receptoragonist;HR,hazardratio;NNT,num
berneededtotreatKristensenSLetal.LancetDiabetesEndocrino
l.2019Oct;7(10):776-785.DPP-4抑制剂的CVOT研究结果不完全一致DPP-4抑制剂西格列汀、利格列
汀、阿格列汀&沙格列汀超过2年随访期，沙格列汀治疗组因心力衰竭入院比例高于安慰剂组（3.5%vs.2.8%）心力衰竭入院风险心
力衰竭入院SAVORTIMI535:SAVOR-TIMI53,EXAMINE,TECOStrialsandCA
RMELINE1-4SaxagliptinPlacebo1.Sciricaetal.NEnglJMed2013
;369:1317–26;2.Whiteetal.NEnglJMed2013;369:1327–35;3.G
reenetal.NEnglJMed2015;373:232–42;4.RosenstockJetal.
JAMA.2019Jan1;321(1):69-795.SciricaBMetal.Circulation20
14;130:1579–1588降糖药物对心力衰竭的影响DPP-4抑制剂GLP-1受体激动剂噻唑烷二酮SGLT2抑制剂二甲双胍
沙格列汀获益Benefit中性Neutral潜在风险Potentiallyunsafe由于DPP-4抑制剂之一沙格列汀(Sa
xagliptin),可能增加心力衰竭,应用时需要更加谨慎DPP-4i,dipeptidylpeptidaseinhibi
tor;SGLT2i,sodium/glucoselikecotransporter-2inhibitorOfstad
APetal.Heartfailurereviews2018,23:303-323小结《2019ESC/EASD指南
：糖尿病、糖尿病前期和心血管疾病》现状心力衰竭与糖尿病存在密切联系，心力衰竭的治疗方案策略因诊断分型存在差异鉴别诊断心力衰竭类型的
主要评估方法：超声心动图+利钠肽，必要时行舒张负荷试验或有创血液动力学检查一系列CVOT研究发现，不同降糖药物对糖尿病合并心力衰竭
患者的心力衰竭入院及死亡风险不同未来研究方向新型降糖药物如何改善心力衰竭结局:降糖药物对左室功能不全的改善机制？EurHeart
J.2020Jan7;41(2):255-323.内容降糖治疗与心力衰竭的联系：从担忧到潜在获益降糖药物对糖尿病合并心力衰
竭的左室功能影响降糖药物对左心室功能不全的影响心室功能改变机制结局症状Zhang?et?al.CardiovascDiabe
tol,2020Jan22;19(1):10.研究方法检索筛选自2019-10-18以前发表、不限语言种类的RCT及少量队
列研究1774篇文献，最终纳入48篇文献36项RCT研究，12项队列研究，研究人数n=4790人研究人群：17项为T2DM患者，
22项为T2DM+CVD患者，9项为CVD患者Zhang?et?al.CardiovascDiabetol,2020Jan
22;19(1):10.研究主要评估指标-1：心脏超声心动图评估的各项左心室功能及结构指标左室收缩功能收缩功能最主要指标左室
射血分数（LVEF）：左心室的每搏输出量占左心室舒张末容积的百分比LVEF=[（左心室舒张末期容积-左心室收缩末期容积）/左心室
舒张末期容积]×100%）左心室收缩功能功能改善功能减退左室射血分数治疗后升高治疗后降低左心室容积舒张末期容积LVEDV治疗后降
低治疗后升高收缩末期容积LVESV左心室内径舒张末期内径LVEDD收缩末期内径LVESD左室充盈血液量反映左心室前负荷1.
中华医学会心血管病分会,中华心血管病杂志编辑委员会.《中国心力衰竭诊断和治疗指南2018》，中华心血管病杂志,2018,46
(10)：769-789.GLP-1受体激动剂可升高糖尿病合并CVD患者左室射血分数LVEF(%)2型糖尿病合并CVD患者CVD
无T2DM患者Zhang?et?al.CardiovascDiabetol,2020Jan22;19(1):10.DP
P-4抑制剂升高左室舒张末期容积,GLP-1受体激动剂降低左室收缩末期容积LVEDV(ML)LVESV(ML)左室舒张末期容
积（LVEDV)，左室收缩末期容积(LVESV)：评估左室收缩功能的指标Zhang?et?al.CardiovascDiabe
tol,2020Jan22;19(1):10.SGLT-2抑制剂可降低左室舒张末期内径LVEDD(MM)LVESD(MM)
左室舒张末期内径（LVEDD)，左室收缩末期内径(LVESD)：评估左室收缩功能的指标Zhang?et?al.Cardiova
scDiabetol,2020Jan22;19(1):10.研究主要评估指标-2：心脏超声心动图评估左心室功能及结构指标
左室舒张功能超声心动图探头示意图左心室舒张功能功能改善功能减退二尖瓣瓣口舒张早期左室血流充盈速度/二尖瓣环舒张早期运动速度E/e
`<8治疗后降低治疗后升高左心室质量指数LVMI左心室重量/体表面积左心室舒张早期速度与舒张晚期速度之比E/A>1.0治
疗后升高治疗后降低特异性低e`Ea`A仅超声心动图可评估舒张功能不全，且单一参数不足准确评估，建议多参数综合评估1.中华医学
会心血管病分会,中华心血管病杂志编辑委员会.《中国心力衰竭诊断和治疗指南2018》，中华心血管病杂志,2018,46(10)
：769-789.GLP-1受体激动剂和SGLT-2抑制剂可降低E/e`比值E/e’LVMIE/AE/e`，二尖瓣瓣口血流舒张
早期左室充盈速度与组织多普勒成像二尖瓣环舒张早期运动速度的比值，E/e`>13：左室舒张功能受损，E/e`<8：左室舒张功能正常
；E/A，左室舒张早期速度与舒张晚期速度之比，可以反映心脏舒张功能;左室重量指数（LVMI)，LVM（左心室重量）/BSA(体
表面积)，反映左室肥厚程度及舒张功能Zhang?et?al.CardiovascDiabetol,2020Jan22;1
9(1):10.Ee’降糖药物治疗对糖尿病合并心力衰竭患者左室功能影响的启示HFrEF左室收缩功能障碍及左室扩张左室舒张功能障碍
左室外扩性重构HFpEFHFmrEF保留左室收缩功能无左室扩张左室舒张功能障碍左室向心性重构GLP-1受体激动剂SGLT-2抑
制剂神经-内分泌-体液心血管疾病失代偿病因原发性心肌损害和异常代偿心肌重塑改善舒张功能障碍改善心力衰竭症状体征心肌肥厚-功能输出心
肌负荷异常收缩功能障碍非心血管疾病1.中华医学会心血管病分会,中华心血管病杂志编辑委员会.《中国心力衰竭诊断和治疗指南201
8》，中华心血管病杂志,2018,46(10)：769-7892.Zhang?et?al.CardiovascDiabe
tol,2020Jan22;19(1):10.总结心力衰竭合并糖尿病患者的治疗是健康管理的沉重负担，随着新型降糖药物的C
VOT研究进展，成为降低心力衰竭风险的治疗选择分析降糖药物对糖尿病合并心力衰竭患者治疗后左室功能影响，发现GLP-1受体激动剂及S
GLT-2抑制剂可以改善左室收缩及舒张功能，具体作用机制仍待进一步明确NA0589HFpEFisahaemodynamic
disorderwhereintheheartfailstokeepupwiththecirculatory
demandsofthebody,ordoessoattheexpenseofraisedleftve
ntricularfillingpressures与近年国外指南分型一致，但是射血分数中间值亚组的临床特征、治疗方式和预后尚不
清楚,单独列出此组有利于促进对此部分心力衰竭患者特点、病理生理机制和治疗的研究，分数临界值心力衰竭根据治疗反应,可转化为HF
rEF或HFpEF。同时现有的分型也不能完成展示心力衰竭的临床特征及治疗特点。Generalcomparisonsoft
heclinicalcharacteristics,outcomes,andguideline-directedmed
icaltherapiesforeachheartfailuregroup.Classofrecommendat
ionisdenotedinparentheses,ifapplicable.Followingthedefini
tionofHFmrEFbytheAHA/ACCFandESC,anumberofstudieshave
helpedtoelucidatesomeofthemysteriesofthis“mid”areaofH
F,includingitsprevalence,clinicalcharacteristics,andoutcom
es(CentralIllustration).However,aswithHFpEF,therecurrentl
yarenoeffective,guideline-directedmedicaltherapiesthatimp
rovemajoroutcomesinthisvulnerablepopulationofpatients.Wi
ththeongoingstruggleoffindingeffectivetherapiesforpatien
tswithHFpEF,aspecificfocusonand/orinclusionofpatientsw
ithHFmrEFmayleadtomorepromisingresults.Specificallytarget
ingtheHFmrEFpopulationinclinicaltrialsischallenging,and
recenttrialsstudyingpatientswiththemiddlerangeofLVEFhad
tobestoppedearlyduetodifficultieswithenrollment.Inaddi
tion,thevariabilityofLVEFmeasurementsbasedonechocardiogra
phyisratherhigh,andthepotentialmisclassificationsofpatie
ntswithHFintothedifferentHFgroupsmaycloudthetrueeffic
acyoftherapiesbeingstudied.Thus,therearelimitationstoa
classificationsystembasedonLVEFalone,andfurtherrefinement
oftheparticularHFetiologies(i.e.,ischemic,familial,hyper
tensive)anddetailedpheno-typingmayhelptomaximizethedisco
veryofmoreeffectivetreatmentstrategies.WhetherthisEFclas
sificationapproachadoptedinrecentversionsoftheguidelines
increasesclarity,facilitatesimprovedcare,andhelpsmovethe
fieldforwardremainstobeseen.Hazardratioper1-standarddev
iationincreaseincontinuouspredictorHOMA-IR,triglycerides,andTG/HDLratiowerelog-transformedThemultivariablemodelwasadjustedforage,sex,SBP(exceptSBPanalyses),hypertensiontreatment,diabetes,smoking,prevalentmyocardialinfarction,TC,HDL(exceptTG/HDLanalyses),leftbundlebranchblockorleftventricularhypertrophy.HOMA-IRanalysesexcludedparticipantswithdiabetesVersion15.0Figure3:Meta-analysisofSGLT2itrialsonhospitalisationforheartfailureandCVDstratifiedbyhistoryofheartfailureHistoryofheartfailure:Q-statistic2.02,p-value0.37,I20.8%Nohistoryofheartfailure:Q-statistic5.89,p-value0.0527,I266%Thepvalueforsubgroupdifferenceswas0.51.TestsforsubgroupdifferenceswerebasedonFtestsinarandomeffectmeta-regressionestimatedusingrestrictedmaximumlikelihoodandHartungKnappadjustment.纳入/排除标准：followPRISMAguidelines，RCT,少量cohortstudies，包含至少1种降糖药。无胰岛素及类似物。人群T2DM±CVD，或者仅CVD患者？研究终点：至少一种cardiacfunction：LVEF.LVEDD,LVESD,LVEDV,LVESV,LVMI,e’,E/A,E/e’A：前侧；P：后侧；R：右侧；L：左侧；RVOT：右室流出道；RA：右房；TV：三尖瓣；PV：肺动脉瓣；AV：主动脉瓣；LA：左房；LCC：左冠状动脉瓣；RCC：右冠状动脉瓣；NCC：无冠状动脉瓣；RV：右室；IVS：室间隔；IAS：房间隔；AML：二尖瓣前叶；PML:二尖瓣后叶；MVO：二尖瓣口；PW：后壁；DAO：降主动脉；AO：主动脉；LV：左室；APEX:心尖部；BASE：基底部；ATL：三尖瓣前叶；STL：三尖瓣隔叶；PPM：后乳头肌；SV：取样容积。 |
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