张宇辉教授:2016 ESC和AHA/AHA/HFSA心力衰竭新指南解读(二)慢性心力衰竭

2016-06-03 MedSci MedSci原创

2016年5月28日,由中国医师协会心力衰竭专业委员会、国家心血管病中心、北京力生心血管健康基金会联合主办的“心力衰竭国际学院”2016年第一期会议在北京顺利召开。会上,中国医学科学院阜外医院张宇辉教授对最新发布的《2016年ESC急性与慢性心力衰竭诊断与治疗指南》以及《2016年ACC/AHA/HFSA心力衰竭指南药物治疗部分更新》进行了详细的解读,并结合《中国心力衰竭诊断和治疗指南2014

2016年5月28日,由中国医师协会心力衰竭专业委员会、国家心血管病中心、北京力生心血管健康基金会联合主办的“心力衰竭国际学院”2016年第一期会议在北京顺利召开。会上,中国医学科学院阜外医院张宇辉教授对最新发布的《2016年ESC急性与慢性心力衰竭诊断与治疗指南》以及《2016年ACC/AHA/HFSA心力衰竭指南药物治疗部分更新》进行了详细的解读,并结合《中国心力衰竭诊断和治疗指南2014》进行了比较分析。

 
张宇辉教授

张宇辉教授介绍,《2016年ESC急性与慢性心力衰竭诊断与治疗指南》提出了很多新内容和新理念。与2012ESC心衰指南相比,在慢性心衰部分, 新指南的主要变化包括:

(1)提出了一个新的术语——HFmrEF(HF with midrange HF),即LVEF范围40%-49%的心力衰竭。将HFmrEF作为一个独立的组别有助于促进相关的研究,包括基本特征、病理生理以及治疗。

(2)对HFrEF、HFmrEF和HFpEF的诊断标准做了明确的推荐。

(3)基于心衰概率评估提出了新的非急性心衰诊断流程。

(4)推荐建议旨在预防或延缓明显的心衰,在出现症状前预防患者死亡。

(5)对sacubitril/缬沙坦的适应证做了推荐,该药是第一个ARNI类药物。

(6)修改了CRT的适应证。

一、心衰的诊断和分类

2016ESC心衰指南根据左心室射血分数(LVEF)将心衰分为HFrEF、HFmrEF和HFpEF,并对诊断标准做了明确的推荐。其中HFmrEF(HF with midrange HF),即LVEF范围40%-49%的心力衰竭。

表1 心衰的分类(2016ESC心衰指南)
 

备注:①LAE =左心房扩大;②LVH =左心室肥厚;③钠尿肽水平升高: BNP>35 pg/ml和/或NT-proBNP>125 pg/mL

张宇辉教授分析,这一理念在《2014中国心力衰竭诊断和治疗指南》和2013 ACC/AHA心衰管理指南中也有类似的表述,而且中国指南的分类更加细化。中国指南对心衰的分类如下:LVEF在41%~49%被称为临界HF-PEF,其人群特征、治疗及预后均与HF-REF类似,这提示将LVEF>50%作为临床诊断标准可能更好。此外,有的患者既往出现过LVEF下降至≤40%,其临床结局与LVEF持续性保留的患者可能也不同。

二、慢性心衰的诊断和治疗

(一)慢性心衰的诊断

2016ESC心衰指南提出了慢性心衰的诊断流程(如下图)。2012ESC心衰指南强调按照生物标志物和超声心动图进行诊断;而2016ESC心衰指南强调了临床症状、NT-proBNP以及超声心动图在心衰诊断中的作用。新指南流程图中,对于疑诊心衰的患者首先要根据临床病史和临床症状体征、体格检查和心电图进行评估。

 
图1 慢性心衰诊断流程

新指南中的NT-proBNP≥125pg/ml、BNP≥35pg/ml沿用了2012ESC心衰指南的标准。事实上,这一标准也并不是公认的。 《2014中国心力衰竭诊断和治疗指南》建议根据年龄、体重和肾功能对急性和慢性心衰的BNP和NT-proBNP的临界值进行调整;合并房颤也有相应的界定。对于慢性心衰患者, BNP和NT-proBNP的检测更多地用于排除心衰。此外,中国指南还提到了心肌损伤标志物等其他指标。

知识链接:
《2014中国心力衰竭诊断和治疗指南》关于标志物的推荐:
(1)BNP和NT-proBNP测定(I,A)可用于因呼吸困难而疑为心衰患者的诊断和鉴别诊断,BNP<35pg/ml、NT-proBNP<125 pg/ml时不支持慢性心衰诊断;也可用来评估慢性心衰的严重程度和预后(I,A);
(2)心肌损伤:肌钙蛋白可用于诊断原发病如急性心肌梗死,亦可以对心衰患者进一步的危险分层(I,A);
(3)其他生物学标志物:其他如纤维化、炎症、氧化应激、神经激素紊乱及心肌和基质重塑的标记物已经广泛应用于评价心衰的预后,如反应心肌纤维化的可溶性ST2(IIa,B)及半乳糖凝集素-3(IIb,B)等指标在慢性心衰的危险分层中可能提供额外信息。

(二)预防或延缓临床型心衰发生或死亡的治疗建议
 
1. 治疗高血压,以预防或延缓心衰发生并延长生命;

2. 无论是否伴有左室收缩功能异常,冠心病或具有冠心病高危因素者应接受他汀治疗,以预防或延缓心衰发生并延长生命;

3. 吸烟或酗酒者,应督促患者戒烟限酒,以预防或延缓心衰发生;

4. 应考虑治疗其他与心衰有关的危险因素(如肥胖与糖代谢异常),以预防或延缓心衰发生;

5. 应为2型糖尿病患者考虑应用恩格列净治疗,以预防或延缓心衰发生并延长生命;

6. 推荐无症状性左室功能异常与心肌梗死病史的患者应用ACEI治疗,以预防或延缓心衰发生并延长生命;

7. 建议不伴心肌梗死病史的无症状性左室功能异常的患者应用ACEI治疗,以预防或延缓心衰发生并延长生命;

8. 即便不存在左室收缩功能异常,稳定性冠心病患者均应考虑予以ACEI治疗,以预防或延缓心衰发生并延长生命;

9. 推荐无症状性左室收缩功能异常并伴心肌梗死病史的患者应用β受体阻滞剂治疗;

10. 推荐以下患者接受ICD治疗,以预防猝死并延长生命:1)急性心肌梗死至少40天后、缺血相关性无症状性左室收缩功能异常(LVEF≤30%)的患者;2)经过最佳药物治疗后的无症状性非缺血性扩张型心肌病(LVEF≤30%)的患者。

(三)HFrEF治疗

1.治疗流程
 
图2 HFrEF治疗流程

HFrEF治疗流程非常全面,涵盖了药物治疗和非药物治疗;并且用不同颜色标注了推荐级别,绿色为一级推荐,黄色为IIa级推荐。存在充血症状和体征的患者,建议使用利尿剂;经过最佳药物治疗LVEF仍≤35%或有症状性VT/VF病史的患者,推荐植入ICD。对于症状性HFrEF患者,首先给予ACEI和β受体阻滞剂,并强调上调到基于证据的最大耐受剂量。若无症状说明液体潴留不严重,可适当考虑减少利尿剂的剂量;若仍有症状且LVEF≤35%,可加用醛固酮受体拮抗剂(MRA)。若仍有症状且LVEF≤35%,分为以下三种情况:①若能够耐受ACEI或ARB,可替换为ARNI;②窦性心律、QRS间期≥130msc,可考虑CRT;③窦性心律、心率≥70bmp,可加用伊伐布雷定。对于难治性心衰患者,可考虑地高辛/肼苯哒嗪+硝酸异山梨醇酯/LVAD,或心脏移植;经上述治疗症状改善者,可减少利尿剂剂量。与2012年ESC指南相比,新指南主要增加了ARNI并调整了CRT推荐。

2.具体药物治疗推荐

(1)IA类推荐药物包括ACEI、β受体阻滞剂和MRA,旨在以降低心衰住院和死亡风险——对于症状性HFrEF患者,应在β受体阻滞剂基础上应用ACEI以降低患者因心衰住院与死亡风险;病情稳定的症状性HFrEF患者,应在ACEI治疗基础上应用β受体阻滞剂以降低患者因心衰住院与死亡风险;经过ACEI与β受体阻滞剂治疗后仍存在临床症状的HFrEF患者,推荐加用MRA。

(2)对于存在充血体征和/或症状的患者,推荐使用利尿剂以改善症状和运动能力(I,B)、降低心衰住院风险(IIa,B)。

(3)经过ACEI、β受体阻滞剂与MRA最佳治疗后仍有症状的HFrEF患者,推荐应用沙库巴曲/缬沙坦替代ACEI以进一步降低因心衰住院和死亡风险(I,B)。

(4)经过目标剂量或最大耐受量的β受体阻滞剂、ACEI(或ARB)和MRA充分治疗后仍有症状、LVEF≤35%且窦性心率≥70次/分的患者,应考虑使用伊伐布雷定降低心衰住院与心血管死亡风险(IIa,B);对于不能耐受β受体阻滞剂或存在该药禁忌证、有症状且LVEF≤35%且窦性心率≥70次/分患者应考虑接受伊伐布雷定治疗,此类患者应继续接受ACEI(或ARB)与MRA治疗(IIa,C);

(5)为减少因心衰住院和心血管死亡风险,不能耐受ACEI治疗的症状性心衰患者应接受ARB治疗,需同时接受β受体阻滞剂与MRA治疗(I,B);不能耐受MRA的患者,经过β受体阻滞剂治疗后仍存在症状,可考虑应用ARB治疗,以降低因心衰住院与死亡风险(IIb,C)。

(6)经过ACEI(或ARB)、β受体阻滞剂与MRA充分治疗后仍有症状且为窦性心律的心衰患者,可考虑应用地高辛治疗以降低住院风险(IIb,B)。

在欧美新指南中,ARNI均为I类推荐、B级证据,但推荐顺序和理念有一定差别。美国指南具体推荐如下表:

表3 2016AHA心衰指南药物治疗推荐
 

沙库巴曲 /缬沙坦(LCZ696)应用指征:(1)症状性心衰,LVEF≤40%;(2)BNP≥150pg/ml或NT-proBNP≥600pg/ml,或近12月内因心衰住院、BNP≥100pg/ml或NT-proBNP≥400 pg/ml;(3)能够耐受依那普利10mg bid。

沙库巴曲 /缬沙坦(LCZ696)应用说明:(1)其获得推荐是基于PARADIGM试验证据;(2)LCZ696用于伴有症状的射血分数减低的适宜慢性心衰患者(NYHA Ⅱ/Ⅲ),血压正常而且耐受ACEI或ARB合理剂量(Ⅰ,B-R);(3)目前缺如ARB和ARNI头对头比较研究,但新指南推荐,对于不适宜应用ACEI或ARNI的心衰患者,均可应用ARB。 

沙库巴曲 /缬沙坦(LCZ696)应用注意事项:(1)ARNI不应与ACEI合用,也不建议在ACEI最后一剂36小时之内使用(Ⅲ,B-R);(2)有血管性水肿病史的患者不应使用ARNI(Ⅲ,C-EO);(3)ARNI使用中应注意避免低血压;(4)目前ARNI有三种已核定的剂量,之一还未经PARADIGM试验检验; (5)推荐剂量49/51mg bid,目标剂量97/103mg bid。

表4 2016ESC心衰指南药物治疗剂量推荐
 

3.器械治疗推荐

表5 ICD和CRT治疗推荐(2016ESC心衰指南)
  

(四)HFpEF治疗

1.药物治疗推荐

在HFpEF药物治疗方面目前还缺乏强有力的证据。部分患者可根据危险因素及合并症选用ACEI(或ARB)、β受体阻滞剂及利尿剂等。

2.合并症推荐

合并房颤、快速心室率:可予胺碘酮,决奈达隆不能用于心衰患者;已经应用了β受体阻滞剂但不能控制心室率者,可加用地高辛。目前心衰合并房颤患者的靶心率尚无定论,目前2016 ESC指南推荐60-120 bmp。

合并缺铁性贫血:可考虑静脉补铁,可改善症状,但不能改善预后。

合并糖尿病:噻唑烷二酮类(格列酮类)药物会加重心衰、增加心衰住院风险,不推荐用于心衰患者。将恩格列净推荐用于2型糖尿病患者心衰的一级预防。

合并中枢性睡眠呼吸暂停:不推荐自适应伺服通气。

合并关节炎:不推荐NSAID和COX-2抑制剂。

3. 慢性有症状性HFrEF不推荐药物:
对于大部分慢性心衰患者,目前无证据支持使用他汀作为起始治疗药物有获益
除了房颤患者,无证据证明口服抗凝药较安慰剂和阿司匹林有明显获益
对于不伴CAD的HF患者,抗血小板治疗无明显获益,反而可能有胃肠道出血风险
不推荐肾素抑制剂作为ACEI或ARB的替代治疗

2016 ESC 心力衰竭新指南慢性心力衰竭部分总结:

(1)推荐应用新的流程来诊断非急性状态下的心衰,这种新流程主要基于疾病的临床可能性(信息采集自病史、体格检查和静息心电图)、循环利钠肽和经胸超声心动图的评估。

(2)推荐在疑诊或已确诊的心衰患者中进行经胸超声心动图,评估心肌的结构和功能,同时检测左室射血分数(LVEF)。指南将心衰分成三种类型:射血分数下降的心衰(HFrEF,LVEF<40%)、射血分数中间值的心衰(HFmrEF,LVEF 40%~49%)、射血分数保留的心衰(HFpEF,LVEF≥50%)。

(3)推荐治疗高血压,在冠心病或冠心病高危人群中应用他汀,在无症状的左室功能不全患者中应用ACEI,在无症状的左室功能不全和既往有心梗史的患者中使用β受体阻滞剂,以预防或延缓心衰的发生,延长寿命。

(4)推荐有症状的HFrEF患者终生应用改善预后的药物治疗,包括联合ACEI(如不能耐受ACEI则选用ARB)、β受体阻滞剂和MRA。如果患者接受上述治疗后仍持续有症状,推荐将ACEI替换为脑啡肽酶抑制剂沙库巴曲 /缬沙坦(LCZ696)。在有充血症状和体征的心衰患者中,推荐使用利尿剂以改善症状和运动耐量。

(5)对发生过血流动力学不稳定的室性心律失常幸存者,或至少给予最优化药物治疗3个月以上仍有症状且LVEF≤35%的心衰患者,推荐植入ICD,以降低猝死风险和全因死亡率。不推荐在心梗后40天内植入ICD,因为此时机不改善预后。

(6)对至少给予最优化药物治疗3个月以上仍有症状且LVEF≤35%、窦性心律、QRS波群宽度≥130 ms且呈左束支传导阻滞形态的心衰患者,推荐CRT以改善症状并降低死亡率。QRS波群宽度<130 ms是植入CRT的禁忌证。

(7)推荐在多学科护理和管理体系中协作收治心衰患者,以降低心衰的住院率和死亡率。

参考文献:

1. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the specia. Eur J Heart Fail. 2016 May 20.
2. 2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure: An Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task. Circulation. 2016 May 22.
3. 中国心力衰竭诊断和治疗指南2014.中华心血管病杂志,2014,42(2):98-122

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  1. [GetPortalCommentsPageByObjectIdResponse(id=1923338, encodeId=b05f19233384a, content=<a href='/topic/show?id=1408583e45d' target=_blank style='color:#2F92EE;'>#新指南#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=22, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=58374, encryptionId=1408583e45d, topicName=新指南)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ac782500066, createdName=12498768m13(暂无昵称), createdTime=Wed Aug 10 07:25:00 CST 2016, time=2016-08-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=89206, encodeId=ee028920666, content=拜读, beContent=null, objectType=article, channel=null, level=null, likeNumber=86, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=05f71734425, createdName=WEIXIN68842e27, createdTime=Fri Jun 10 13:21:00 CST 2016, time=2016-06-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=88671, encodeId=ae56886e1e9, content=不错的文章,多学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=80, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=53751677671, createdName=沉心多思, createdTime=Sun Jun 05 21:20:00 CST 2016, time=2016-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=88545, encodeId=c7488854569, content=不错的文章,多学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=102, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=53751677671, createdName=沉心多思, createdTime=Sun Jun 05 14:54:00 CST 2016, time=2016-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1251773, encodeId=ef3d1251e731a, content=<a href='/topic/show?id=ac5d5351ea8' target=_blank style='color:#2F92EE;'>#慢性心力衰竭#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=53517, encryptionId=ac5d5351ea8, topicName=慢性心力衰竭)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=395f25, createdName=bioon1, createdTime=Sun Jun 05 04:25:00 CST 2016, time=2016-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1267306, encodeId=f2d5126e30633, content=<a href='/topic/show?id=922f21183d' target=_blank style='color:#2F92EE;'>#AHA#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=2118, encryptionId=922f21183d, topicName=AHA)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=bf3d82, createdName=zhaohui6731, createdTime=Sun Jun 05 04:25:00 CST 2016, time=2016-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1551751, encodeId=6a0a1551e51a7, content=<a href='/topic/show?id=305156401eb' target=_blank style='color:#2F92EE;'>#指南解读#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56401, encryptionId=305156401eb, topicName=指南解读)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=eb0214221999, createdName=shuangle, createdTime=Sun Jun 05 04:25:00 CST 2016, time=2016-06-05, status=1, ipAttribution=)]
  2. [GetPortalCommentsPageByObjectIdResponse(id=1923338, encodeId=b05f19233384a, content=<a href='/topic/show?id=1408583e45d' target=_blank style='color:#2F92EE;'>#新指南#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=22, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=58374, encryptionId=1408583e45d, topicName=新指南)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ac782500066, createdName=12498768m13(暂无昵称), createdTime=Wed Aug 10 07:25:00 CST 2016, time=2016-08-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=89206, encodeId=ee028920666, content=拜读, beContent=null, objectType=article, channel=null, level=null, likeNumber=86, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=05f71734425, createdName=WEIXIN68842e27, createdTime=Fri Jun 10 13:21:00 CST 2016, time=2016-06-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=88671, encodeId=ae56886e1e9, content=不错的文章,多学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=80, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=53751677671, createdName=沉心多思, createdTime=Sun Jun 05 21:20:00 CST 2016, time=2016-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=88545, encodeId=c7488854569, content=不错的文章,多学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=102, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=53751677671, createdName=沉心多思, createdTime=Sun Jun 05 14:54:00 CST 2016, time=2016-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1251773, encodeId=ef3d1251e731a, content=<a href='/topic/show?id=ac5d5351ea8' target=_blank style='color:#2F92EE;'>#慢性心力衰竭#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=53517, encryptionId=ac5d5351ea8, topicName=慢性心力衰竭)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=395f25, createdName=bioon1, createdTime=Sun Jun 05 04:25:00 CST 2016, time=2016-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1267306, encodeId=f2d5126e30633, content=<a href='/topic/show?id=922f21183d' target=_blank style='color:#2F92EE;'>#AHA#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=2118, encryptionId=922f21183d, topicName=AHA)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=bf3d82, createdName=zhaohui6731, createdTime=Sun Jun 05 04:25:00 CST 2016, time=2016-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1551751, encodeId=6a0a1551e51a7, content=<a href='/topic/show?id=305156401eb' target=_blank style='color:#2F92EE;'>#指南解读#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56401, encryptionId=305156401eb, topicName=指南解读)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=eb0214221999, createdName=shuangle, createdTime=Sun Jun 05 04:25:00 CST 2016, time=2016-06-05, status=1, ipAttribution=)]
    2016-06-10 WEIXIN68842e27

    拜读

    0

  3. [GetPortalCommentsPageByObjectIdResponse(id=1923338, encodeId=b05f19233384a, content=<a href='/topic/show?id=1408583e45d' target=_blank style='color:#2F92EE;'>#新指南#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=22, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=58374, encryptionId=1408583e45d, topicName=新指南)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ac782500066, createdName=12498768m13(暂无昵称), createdTime=Wed Aug 10 07:25:00 CST 2016, time=2016-08-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=89206, encodeId=ee028920666, content=拜读, beContent=null, objectType=article, channel=null, level=null, likeNumber=86, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=05f71734425, createdName=WEIXIN68842e27, createdTime=Fri Jun 10 13:21:00 CST 2016, time=2016-06-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=88671, encodeId=ae56886e1e9, content=不错的文章,多学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=80, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=53751677671, createdName=沉心多思, createdTime=Sun Jun 05 21:20:00 CST 2016, time=2016-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=88545, encodeId=c7488854569, content=不错的文章,多学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=102, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=53751677671, createdName=沉心多思, createdTime=Sun Jun 05 14:54:00 CST 2016, time=2016-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1251773, encodeId=ef3d1251e731a, content=<a href='/topic/show?id=ac5d5351ea8' target=_blank style='color:#2F92EE;'>#慢性心力衰竭#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=53517, encryptionId=ac5d5351ea8, topicName=慢性心力衰竭)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=395f25, createdName=bioon1, createdTime=Sun Jun 05 04:25:00 CST 2016, time=2016-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1267306, encodeId=f2d5126e30633, content=<a href='/topic/show?id=922f21183d' target=_blank style='color:#2F92EE;'>#AHA#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=2118, encryptionId=922f21183d, topicName=AHA)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=bf3d82, createdName=zhaohui6731, createdTime=Sun Jun 05 04:25:00 CST 2016, time=2016-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1551751, encodeId=6a0a1551e51a7, content=<a href='/topic/show?id=305156401eb' target=_blank style='color:#2F92EE;'>#指南解读#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56401, encryptionId=305156401eb, topicName=指南解读)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=eb0214221999, createdName=shuangle, createdTime=Sun Jun 05 04:25:00 CST 2016, time=2016-06-05, status=1, ipAttribution=)]
    2016-06-05 沉心多思

    不错的文章,多学习

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=1923338, encodeId=b05f19233384a, content=<a href='/topic/show?id=1408583e45d' target=_blank style='color:#2F92EE;'>#新指南#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=22, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=58374, encryptionId=1408583e45d, topicName=新指南)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ac782500066, createdName=12498768m13(暂无昵称), createdTime=Wed Aug 10 07:25:00 CST 2016, time=2016-08-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=89206, encodeId=ee028920666, content=拜读, beContent=null, objectType=article, channel=null, level=null, likeNumber=86, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=05f71734425, createdName=WEIXIN68842e27, createdTime=Fri Jun 10 13:21:00 CST 2016, time=2016-06-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=88671, encodeId=ae56886e1e9, content=不错的文章,多学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=80, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=53751677671, createdName=沉心多思, createdTime=Sun Jun 05 21:20:00 CST 2016, time=2016-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=88545, encodeId=c7488854569, content=不错的文章,多学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=102, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=53751677671, createdName=沉心多思, createdTime=Sun Jun 05 14:54:00 CST 2016, time=2016-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1251773, encodeId=ef3d1251e731a, content=<a href='/topic/show?id=ac5d5351ea8' target=_blank style='color:#2F92EE;'>#慢性心力衰竭#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=53517, encryptionId=ac5d5351ea8, topicName=慢性心力衰竭)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=395f25, createdName=bioon1, createdTime=Sun Jun 05 04:25:00 CST 2016, time=2016-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1267306, encodeId=f2d5126e30633, content=<a href='/topic/show?id=922f21183d' target=_blank style='color:#2F92EE;'>#AHA#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=2118, encryptionId=922f21183d, topicName=AHA)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=bf3d82, createdName=zhaohui6731, createdTime=Sun Jun 05 04:25:00 CST 2016, time=2016-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1551751, encodeId=6a0a1551e51a7, content=<a href='/topic/show?id=305156401eb' target=_blank style='color:#2F92EE;'>#指南解读#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56401, encryptionId=305156401eb, topicName=指南解读)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=eb0214221999, createdName=shuangle, createdTime=Sun Jun 05 04:25:00 CST 2016, time=2016-06-05, status=1, ipAttribution=)]
    2016-06-05 沉心多思

    不错的文章,多学习

    0

  5. [GetPortalCommentsPageByObjectIdResponse(id=1923338, encodeId=b05f19233384a, content=<a href='/topic/show?id=1408583e45d' target=_blank style='color:#2F92EE;'>#新指南#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=22, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=58374, encryptionId=1408583e45d, topicName=新指南)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ac782500066, createdName=12498768m13(暂无昵称), createdTime=Wed Aug 10 07:25:00 CST 2016, time=2016-08-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=89206, encodeId=ee028920666, content=拜读, beContent=null, objectType=article, channel=null, level=null, likeNumber=86, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=05f71734425, createdName=WEIXIN68842e27, createdTime=Fri Jun 10 13:21:00 CST 2016, time=2016-06-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=88671, encodeId=ae56886e1e9, content=不错的文章,多学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=80, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=53751677671, createdName=沉心多思, createdTime=Sun Jun 05 21:20:00 CST 2016, time=2016-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=88545, encodeId=c7488854569, content=不错的文章,多学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=102, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=53751677671, createdName=沉心多思, createdTime=Sun Jun 05 14:54:00 CST 2016, time=2016-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1251773, encodeId=ef3d1251e731a, content=<a href='/topic/show?id=ac5d5351ea8' target=_blank style='color:#2F92EE;'>#慢性心力衰竭#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=53517, encryptionId=ac5d5351ea8, topicName=慢性心力衰竭)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=395f25, createdName=bioon1, createdTime=Sun Jun 05 04:25:00 CST 2016, time=2016-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1267306, encodeId=f2d5126e30633, content=<a href='/topic/show?id=922f21183d' target=_blank style='color:#2F92EE;'>#AHA#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=2118, encryptionId=922f21183d, topicName=AHA)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=bf3d82, createdName=zhaohui6731, createdTime=Sun Jun 05 04:25:00 CST 2016, time=2016-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1551751, encodeId=6a0a1551e51a7, content=<a href='/topic/show?id=305156401eb' target=_blank style='color:#2F92EE;'>#指南解读#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56401, encryptionId=305156401eb, topicName=指南解读)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=eb0214221999, createdName=shuangle, createdTime=Sun Jun 05 04:25:00 CST 2016, time=2016-06-05, status=1, ipAttribution=)]
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    2016-06-05 zhaohui6731
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