心力衰竭加重并左室射血分数降低患者的QRS时限与预后

目的观察住院期间QRs时限对心力衰竭并左室射血分数降低预后的影响。方法回顾性分析心力衰竭并左室射血分数降低（≤40％）或正常的住院患者住院期间的QRs波群时限。结果3002例患者纳入研究,其中正常QRS波群时限1745例（〈120ms）,QRS波群延长（≥120ms）1257例。平均随访10个月,基础QRS波群时限正常患者全因死亡率为18．8％,基础QRS波群延长患者为28．3％（nR。1．62,95％CIL38～1．88）。基础QRS波群正常患者心血管死亡和心力衰竭住院率为31．5％和35．8％,延长者则为39．0％和43．6％（朋=1．40、1．42;95％CIL25-1．60、1．18-1．72）。QRS波群时限延长与增加全因死亡率危险性相关（HR=1．25：95％C11．03～1．52）,并增加心血管死亡或心力衰竭住院率（HR=1．21、1．28,95％CIL10～1．40、1．12～1．38）。基础Qas波群延长患者最后住院心电图QRS波群正常者仅为4．0％。结论延长的QRS波群在LVEF降低患者中十分多见,是出院后高患病率和高死亡率的独立预测因素。     

Evolocumab has no effects on heart failure with reduced ejection fraction injury biomarkers: The EVO-HF trial

Aim

Patients with heart failure with reduced ejection fraction (HFrEF) have not been shown to benefit from statins. We hypothesized that, by limiting disease progression in stable HFrEF of ischaemic etiology, the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor evolocumab could reduce circulating troponin levels, a surrogate biomarker of myocyte injury and atherosclerosis progression.

Methods and results

The EVO-HF multicentre prospective randomized trial compared evolocumab (420 mg/month administered subcutaneously) plus guideline-directed medical therapy (GDMT; n = 17) versus GDMT alone (n = 22) for 1 year in patients with stable coronary artery disease and left ventricular ejection fraction (LVEF) <40%, ischaemic aetiology, New York Heart Association class II, N-terminal pro-B-type natriuretic peptide (NT-proBNP) ≥400 pg/ml, high-sensitivity troponin T (hs-TnT) >10 pg/ml, low-density lipoprotein cholesterol (LDL-C) ≥70 mg/dl. The primary endpoint was change in hs-TnT concentration. Secondary endpoints included NT-proBNP, interleukin-1 receptor-like 1 (ST2), high-sensitivity C-reactive protein (hs-CRP), LDL, low-density lipoprotein receptor (LDLR), high-density lipoprotein cholesterol (HDL-C), and PCSK9 levels at 1 year. Patients were mainly Caucasian (71.8%), male (79.5%), relatively young (mean age 68.1 ± 9.4 years), with a mean LVEF of 30.4 ± 6.5%, and managed with contemporary treatments. No significant changes in hs-TnT levels were observed in any group at 1 year. NT-proBNP and ST2 levels decreased in the GDMT plus evolocumab group (p = 0.045 and p = 0.008, respectively), without changes in hs-CRP, HDL-C, or LDLR. Total and LDL-C decreased in both groups, significantly higher in the intervention group (p = 0.003), and PCSK9 levels increased in the intervention group.

Conclusions

This prospective randomized pilot trial, although with the limitation of the small sample size, does not support the benefit of evolocumab in reducing troponin levels in patients with elevated LDL-C levels, history of coronary artery disease, and stable HFrEF.     

Medication dosing for heart failure with reduced ejection fraction — opportunities and challenges

Multiple drug classes have shown incremental benefits in heart failure with reduced ejection fraction. Most of these trials were designed to achieve specific doses of the investigational agent. Clinical practice guidelines recommend using the same target dosing of therapies, as tolerated. However, with the increasing number of available therapies, clinicians face the challenge of simultaneously using several drugs, achieving target doses, and managing side effects that are often overlapping. Blood pressure, renal function, hyperkalaemia, and other factors may impede achieving target doses of all medications, leaving clinicians with dilemmas as to how to sequence and dose these various classes of drugs. The guideline‐directed eligibility for certain drugs and devices requires stability on maximally tolerated doses of background therapies. However, significant variability exists in dosing achieved in clinical practice. We discuss the existing background data regarding the doses of heart failure medications in clinical trials and in practice, and provide recommendations on how to navigate this complex therapeutic decision‐making.     

Implantable cardioverter‐defibrillators in heart failure patients with reduced ejection fraction and diabetes

Aim

There is limited information on the outcomes after primary prevention implantable cardioverter‐defibrillator (ICD) implantation in patients with heart failure (HF) and diabetes. This analysis evaluates the effectiveness of a strategy of ICD plus medical therapy vs. medical therapy alone among patients with HF and diabetes.

Methods and results

A patient‐level combined‐analysis was conducted from a combined dataset that included four primary prevention ICD trials of patients with HF or severely reduced ejection fractions: Multicenter Automatic Defibrillator Implantation Trial I (MADIT I), MADIT II, Defibrillators in Non‐Ischemic Cardiomyopathy Treatment Evaluation (DEFINITE), and Sudden Cardiac Death in Heart Failure Trial (SCD‐HeFT). In total, 3359 patients were included in the analysis. The primary outcome of interest was all‐cause death. Compared with patients without diabetes (n = 2363), patients with diabetes (n = 996) were older and had a higher burden of cardiovascular risk factors. During a median follow‐up of 2.6 years, 437 patients without diabetes died (178 with ICD vs. 259 without) and 280 patients with diabetes died (128 with ICD vs. 152 without). ICDs were associated with a reduced risk of all‐cause mortality among patients without diabetes [hazard ratio (HR) 0.56, 95% confidence interval (CI) 0.46–0.67] but not among patients with diabetes (HR 0.88, 95% CI 0.7–1.12; interaction P = 0.015).

Conclusion

Among patients with HF and diabetes, primary prevention ICD in combination with medical therapy vs. medical therapy alone was not significantly associated with a reduced risk of all‐cause death. Further studies are needed to evaluate the effectiveness of ICDs among patients with diabetes.

     

Assessment of right ventricular systolic function in heart failure with preserved,reduced and mid-range ejection fraction

BackgroundFew studies have evaluated the right ventricle systolic function in different categories of heart failure despite its effect on outcomes.Methods and resultsSingle-centre, cross-sectional study included 150 patients, 50 patients in each category of HF: group I, preserved; group II, mid-range; group III, reduced ejection fraction. Left ventricular systolic function was assessed by 3D echo, and right ventricular systolic function was assessed by fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE), tissue Doppler image (TDI), and global longitudinal strain (GLS). There was no significant difference among the three groups regarding sex, the prevalence of risk factors, but patients in group III were significantly older (p < 0.001) and had a higher prevalence of coronary artery disease (p = 0.004) than were found in the other two groups. In group I, the prevalence of RV systolic dysfunction was 18%, 22%, 14% and 26% by TAPSE, FAC, S wave velocity, and GLS, respectively. Their prevalence was higher in group II and much higher in group III than in group I. There were significant positive correlations among TAPSE, S wave velocity, GLS, and ejection fraction in groups II and III (p < 0.001).ConclusionThe prevalence and severity of RV systolic dysfunction were positively correlated with LV systolic dysfunction, and the degree of RV dysfunction in mid-range was closer to reduce than preserved ejection fraction.Study registration at clinical trial.govNCT03641599.     

QT离散度对老年严重心力衰竭病人无预后价值

目的:探讨QT离散度(QTd)对老年严重心衰(CHF)病人的预后价值。方法:362例老年严重心衰患者入院时记录基础静态12导联同步心电图,计算QT离散度,平均随访(7.2±4.8)个月。结果:随访期间142例(39.2%)病人死亡,QT离散度为(76.3±28.6)ms,存活者220例,QT离散度为(74.8±30.2)ms。两组间比较无明显差异(P>0.05);生存分析显示QT离散度对总死亡率(RR 1.00,95%CI 1.00~1.00),心源性死亡率(RR 1.00,95%CI 1.00~1.01)及心律失常性死亡率(RR 1.00,95%CI 1.00~1.01)均无预后价值(P>0.05).结论:QT离散度(QTd)对老年严重心衰病人的总死亡率,心源性死亡率及心律失常性死亡率均无预后价值。     

峰值氧耗量对非射血分数减低的心力衰竭患者预后评估的价值

目的:探讨心肺运动试验重要参数对非射血分数减低心力衰竭(HFr EF)预后评价的价值。方法:前瞻性入组2014年1月到2018年6月,我院诊断为非HFr EF患者,记录患者再入院及死亡事件,最后进行生存分析。结果:入选124例患者,平均随访(24±5)个月,10例患者死亡,32例患者因心力衰竭再住院治疗。心力衰竭组患者峰值氧耗量劣于正常健康对照组[(17.4±2.7)vs.(31.5±3.2)m L·kg^-1·min^-1,P<0.05]。事件组峰值氧耗量低于无事件组[(13.9±2.1)vs.(19.2±3.5)m L·kg^-1·min^-1,P<0.05]。多因素分析表明:峰值氧耗量是预测非HFr EF患者预后的指标(HR=0.81,95%CI:0.76~0.92,P<0.002)。结论:峰值氧耗量可以很好预测非HFr EF患者预后。     

超敏肌钙蛋白T对慢性收缩性心力衰竭患者危险分层和短期预后价值的探讨

目的 探讨超敏肌钙蛋白T（hs-TnT）对慢性收缩性心力衰竭（HF-rEF）患者危险分层和短期预后价值的影响.方法 158例HF-rEF患者入院后2h内测定血浆hs-TnT水平.经规范化治疗,随访3个月,观察终点是心血管事件（心源性死亡及心力衰竭恶化再入院）.结果 ①随着NYHA心功能分级的增高,hs-TnT水平亦呈增高趋势,Ⅱ～Ⅳ级hs-TnT水平分别为（0.011±0.740）mmol/L、（0.176±0.900）mmol/L和（0.236±0.810）mmol/L,不同级别间比较,差异均有统计学意义（P＜0.05）.②不同病因所致HF-rEF各亚组间hs-TnT水平无明显差异（P＞0.05）.③以hs-TnT均数0.014μg/L为界,升高hs-TnT亚组3个月内心血管事件发生率明显高于正常hs-TnT亚组（49.0％比27.8％,P＜0.01）.结论 检测超敏肌钙蛋白T升高提示短期预后不佳,主要心血管事件的增加可作为对早期HF-rEF患者危险分层的一个指标,并指导临床治疗.     

Time to benefit of heart rate reduction with ivabradine in patients with heart failure and reduced ejection fraction

Aims

In the SHIFT (Systolic Heart failure treatment with the I_f inhibitor ivabradine Trial, ISRCTN70429960) study, ivabradine reduced cardiovascular death or heart failure (HF) hospitalizations in patients with HF and reduced ejection fraction (HFrEF) in sinus rhythm and with a heart rate (HR) ≥70 bpm. In this study, we sought to determine the clinical significance of the time durations of HR reduction and the significant treatment effect on outcomes among patients with HFrEF.

Methods and results

The time to statistically significant reduction of the primary outcome (HF hospitalization and cardiovascular death) and its components, all-cause death, and HF death, were assessed in a post-hoc analysis of the SHIFT trial in the overall population (HR ≥70 bpm) and at HR ≥75 bpm, representing the approved label in many countries. Compared to placebo, the primary outcome and HF hospitalizations were significantly reduced at 102 days, while there was no effect on cardiovascular death, all-cause death, and HF death at HR ≥70 bpm. In the population with a baseline HR ≥75 bpm, a reduction of the primary outcome occurred after 67 days, HF hospitalization after 78 days, cardiovascular death after 169 days, death from HF after 157 days and all-cause death after 169 days.

Conclusion

Treatment with ivabradine should not be deferred in patients in sinus rhythm with a HR of ≥70 bpm to reduce the primary outcome and HF hospitalizations, in particular in patients with HR ≥75 bpm. At HR ≥75 bpm, the time to risk reduction was shorter for reduction of hospitalization and mortality outcomes in patients with HFrEF after initiation of guideline-directed medication, including beta-blockers at maximally tolerated doses.