Фомин И.В., Виноградова Н.Г., Фарзалиев М.И-оглы, Аллахвердиева С.М-кызы, Крылова А.Н., Самарина А.С., Тюрин А.А.
Федеральное государственное бюджетное образовательное учреждение высшего образования «Приволжский исследовательский медицинский университет» Минздрава России, г. Нижний Новгород, Российская Федерация
Актуальность: Частые повторные госпитализации по причине острой декомпенсации сердечной недостаточности (ОДСН) ухудшают прогноз пациентов с хронической сердечной недостаточностью (ХСН). Это диктует необходимость создания системы эффективного контроля за проведением медикаментозной и физической реабилитации после выписки из стационара на амбулаторном этапе. Главной задачей центра лечения ХСН было создание и отработка системы ведения пациентов с ХСН.
Цель исследования: установить различия двух стратегий наблюдения пациентов с ХСН после острой декомпенсации сердечной недостаточности и определить эффективность лечения, реабилитационных мероприятий и прогноза жизни в зависимости от наблюдения в системе специализированного Городского центра лечения ХСН (ЦХСН) и реальной амбулаторной практике.
Материалы и методы: В исследование было включено 648 пациентов с ХСН старше 18 лет. Группу 1 составили 412 пациентов с ХСН, которые наблюдались по поводу острой декомпенсации сердечной недостаточности в стационарном отделении Городского центра лечения ХСН и после выписки продолжили реабилитацию в амбулаторном отделении центра. Группу 2 составили 236 пациентов с ХСН, которые после выписки по поводу острой декомпенсации сердечной недостаточности из отделения Городского центра лечения ХСН предпочли наблюдение в амбулаторно-поликлинических учреждениях (АПУ) г. Нижний Новгород.
Результаты: Через 1 год наблюдения показатель общей смертности в группе 1 составил 4,13 %, в группе 2 – 14,83 % (ОШ=4,0; 95 % ДИ: 2,2-7,4, р<0,001). Смертность от сердечно-сосудистых причин была достоверно выше в группе 2: 11,4 % против 3,3 % в группе 1 (ОШ=3,8; 95 % ДИ: 2,0-7,4; р<0,001), так же как и смертность от острой декомпенсации сердечной недостаточности: 7,6 % против 2,1 % случаев (ОШ=3,8; 95 % ДИ: 1,7-8,7; р<0,001). Нефатальные сердечно-сосудистые осложнения (ССО) регистрировались в группе 1 достоверно реже, чем в группе 2: 1,6 % против 5,1 % (ОШ=3,2; 95 % ДИ: 1,2-8,3; р=0,01). В группе 2 частота фатальных и нефатальных инфарктов мозга, венозных тромбоэмболий оказалась достоверно выше – 6,3 % против 1,4 % случаев в группе 1 (ОШ=4,4; 95 % ДИ: 1,7-11,6; р<0,001). Зарегистрировано увеличение доли повторно госпитализированных пациентов с ХСН в течение года в группе 2 по сравнению с группой 1: 50,3 % и 31,8 % пациентов соответственно (ОШ=2,2; 95 % ДИ: 1,5-3,2; р<0,001).
Заключение: Внедрение системы ведения пациентов с ХСН после эпизода острой декомпенсации сердечной недостаточности оказалось более эффективным в сравнении с общепринятым подходом. Ведение пациентов с ХСН после госпитализации по поводу острой декомпенсации сердечной недостаточности требует активной непрерывной титрации базисных лекарственных средств, физической реабилитации, а также обучения пациента самоконтролю за состоянием, что возможно только благодаря проведению школ пациента, наличию тесной связи врача, медсестры и пациента благодаря стабильному графику осмотров и телефонных звонков.
ключевые слова: хроническая сердечная недостаточность, медицинская помощь, общая и сердечно-сосудистая смертность

для цитирования: Фомин И.В., Виноградова Н.Г., Фарзалиев М.И-оглы, Аллахвердиева С.М-кы- зы, Крылова А.Н., Самарина А.С., Тюрин А.А. Эффективность наблюдения пациентов в условиях специализированного центра лечения хронической сердечной недостаточности. Неотложная кардиология и кардиоваскулярные риски, 2018, Т. 2, № 1, С. 221-229

Efficiency of observing patients in the setting of a specialized center for treatment of chronic heart failure
Fomin I.V., Vinogradova N.G., Farzaliev M.I-ogly, Allakhverdieva, S.M-kyzy, Krylova A.N., Samarina A.S., Tyurin A.A.
Relevance. Frequent repeated hospitalizations due to acute decompensation of heart failure worsen the prognosis of patients with CHF. This dictates the necessity to set up medical and physical rehabilitation system of effective control after discharge from the hospital at an outpatient stage. The main task of setting up a center for CHF treatment was to develop and refine the system of managing patients with CHF.
Objective. To establish the differences in two strategies for monitoring patients with CHF after acute heart failure decompensation and to determine the efficiency of treatment, rehabilitation methods and life expectancy, depending on monitoring them in the setting of a specialized city center for CHF (CCHF) treatment and in real outpatient practice.
Materials and methods. The study included 648 patients with CHF of any etiology older than 18 years of age. Group 1 comprised 412 patients with CHF who were monitored at the inpatient department of the CCHF with acute heart failure decompensation and after the discharge they continued rehabilitation at the outpatient department of CCHF. Group 2 comprised 236 patients with CHF who were discharged for acute heart failure decompensation from the CCHF and preferred to be monitored in other outpatient clinics in Nizhny Novgorod.
Results. After 1 year of follow-up, group 1 patients became significantly more hemodynamically stable. The overall mortality rate in group 1 was 4.13 %, and in group 2 – 14.83 % (OR = 4.0, 95 % CI: 2.2-7.4, p <0.001). Mortality from cardiovascular causes is significantly higher in group 2: 11.4 % compared to 3.3 % in group 1 (OR = 3.8, 95 % CI: 2.0-7.4, p < 0.001), as well as mortality from acute heart failure decompensation: 7.6 % vs. 2.1 % of cases (OR = 3.8, 95 % CI: 1.7-8.7, p <0.001). Nonfatal cardiovascular complications were registered significantly more rarely in group 1 than in group 2: 1.6 % vs 5.1 % (OR = 3.2, 95 % CI: 1.2-8.3, p = 0.01). In group 2, the incidence of fatal and nonfatal strokes and thromboembolic complications was significantly higher - 6.3 % compared to 1.4 % of cases in group 1 (OR = 4.4, 95 % CI: 1.7-11.6, p < 0.001). An increase in the proportion of re-hospitalized patients with CHF during the year was recorded in group 2 compared to group 1: 50.3 % and 31.8 % of patients (OR = 2.2, 95 % CI: 1.5-3, 2, p <0.001). The physical activity of patients who were observed in the department of the CCHF was significantly higher than among patients who were treated in other outpatient clinics in Nizhny Novgorod.
Conclusion. The introduction of the system of managing patients with CHF after an episode of acute heart failure decompensation turned out to be significantly more effective in comparison with the generally accepted approach. Managing patients with CHF after hospitalization for acute heart failure decompensation requires active continuous titration of basic drugs, physical rehabilitation, as well as training the patient to control his condition, which is possible only due to “patient schools”, maintaining a close contact between the doctor, nurse and patient and a stable schedule of examinations and phone calls.
keywords: chronic heart failure, medical care, cardiovascular complications, total and cardiovascular mortality

for references: Fomin I.V., Vinogradova N.G., Farzaliev M.I-ogly, Allakhverdieva S.M-kyzy, Krylo¬va A.N., Samarina A.S., Tyurin A.A. Effektivnost’ nablyudeniya pazientov v usloviyach spezializirovan- nogo zentra lecheniya chronicheskoy serdechnoy nedostatochnosti [Efficiency of observing patients in the setting of a specialized center for treatment of chronic heart failure]. Neotlozhnaya kardiologiya i kardiovaskulyamye riski [Emergency cardiology and cardiovascular risks], 2018, vol. 2, no. 1, pp. 221-229

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