慢性射血分数降低心力衰竭患者出院用药调查及对预后的影响

目的了解慢性射血分数降低心力衰竭(简称心衰)患者服用指南推荐药物情况及其对预后的影响。方法这是一项单中心回顾性研究,对2007年1月1日至2009年12月31日在本院住院诊断为慢性心衰且左室射血分数(LVEF)≤0.45的患者通过查阅住院、门诊病历和电话随访进行研究。研究出院时服用药物对全因死亡,以及全因死亡或心源性再住院的影响。结果共187例患者组成研究人群,中位数随访18个月(2～41个月),92%患者出院时服用β受体阻滞剂,79%患者服用血管紧张素转换酶抑制剂/血管紧张素Ⅱ受体拮抗剂(ACEI/ARB),67%患者服用他汀类药物,62%患者服用利尿剂,40%患者服用醛固酮受体拮抗剂,34%患者服用地高辛。全因死亡率为19%,全因死亡或首次心源性再住院率为41%。LVEF≤0.35慢性心衰患者全因死亡率以及全因死亡或首次心源性再住院率分别为27%和53%。校正多重因素后全因死亡的预测因子为年龄(HR 1.34/每增加10岁,95%可信区间1.01～1.77)、NYHA心功能分级(HR 3.17/NYHA每增加1级,95%可信区间1.94～5.19)和慢性肾脏病(CKD)分期(HR 1.85/CKD每增加1期,95%可信区间1.12～3.05),以及出院时服用β受体阻滞剂(HR 0.38,95%可信区间0.15～0.93)和他汀类药物(HR 0.44,95%可信区间0.22～0.88)。结论大多数慢性射血分数降低患者出院时服用了指南推荐的药物,但这部分患者预后差,特别是LVEF≤0.35患者。β受体阻滞剂、ACEI/ARB和他汀类药物能改善预后。     

静息心率与射血分数降低性心力衰竭伴心房颤动患者预后的关联

目的 探讨静息心率与射血分数降低性心力衰竭伴心房颤动(HFrEF-AF)患者预后的关联.方法 入选2017年7月至2019年7月安徽医科大学第三临床学院合肥市第三人民医院心内科收住的HFrEF-AF患者84例.依据患者静息心率分为两组:高心率组(心率＞80次/min)和低心率组(心率≤80次/min).分析两组临床基本资料特征和静息心率与预后的关系.结果 Spearman等级相关性分析显示,静息心率与肾小球滤过率(rs=-0.223,P=0.041)、胺碘酮(rs=-0.230,P=0.036)、地高辛(rs=0.230,P=0.014)呈轻度等级相关(P＜0.05).Kaplan-Meier生存分析显示,1年随访高心率组累积生存率小于低心率组(Log-Rank x2=9.644,P=0.002).多因素Cox回归分析显示,心率＞80次/min(HR=7.096,95％CI 1.293～38.958,P=0.024)、年龄(HR=6.720,95％CI 1.097～41.188,P=0.039)、β受体阻滞剂(HR =0.225,95％CI 0.059～0.861,P=0.029)是HFrEF-AF死亡的影响因素.结论 HFrEF-AF患者出院时,静息心率＞80比≤80次/min者的死亡率更高.     

肺动脉压对左心室射血分数正常心力衰竭患者预后的预测价值

目的分析肺动脉压(PAP)在左心室射血分数正常的心力衰竭(HFn EF)患者中的诊断、评估及预后价值。方法入选我院心内科2011年1月至2014年1月临床诊断为HFn EF的210例患者,对其临床资料进行回顾性分析,依照纽约心脏病协会(NYHA)心功能分级分为Ⅱ级(70例)、Ⅲ级(70例)和Ⅳ级(70例)3组,比较3组间PAP和N末端脑钠肽前体(NT-pro BNP)水平等,对PAP特点及住院死亡率、再入院率进行分析。结果 HFn EF患者的左心室射血分数正常(45%~62%),E/A比值均小于1,NT-pro BNP水平明显升高(973~6 100 ng/L),随心功能分级增加,超声心动图显示左心房及右心室明显增大,PAP逐渐升高,心功能Ⅳ级组PAP(67±11)mm Hg高于心功能Ⅲ级组[(45±4)mm Hg,P=0.03],均明显高于心功能Ⅱ级组PAP[(25±5)mm Hg,P<0.01];随PAP升高,重度PAP升高组(>60 mm Hg)3、6和12个月再入院率均高于中度PAP升高组(40~60 mm Hg,P=0.04、0.03和0.02),均高于轻度PAP升高组(20~40 mm Hg,均为P<0.01);重度PAP组的3、6和12个月死亡率均高于中度和轻度PAP升高组(均为P<0.05)。结论 PAP可作为HFn EF诊断、评估及预后的有效指标。     

心房颤动对慢性收缩性心力衰竭患者远期预后影响分析

目的 探讨心房颤动(房颤)对慢性收缩性心力衰竭(chronic systolic heart failure,CSHF)住院患者远期预后的影响.方法 回顾性调查和分析湖北地区8地市12家三级甲等医院2000年至2010年CSHF住院患者资料,单因素Kaplan-Meier曲线分析房颤和非房颤组总死亡、心血管病死亡、心脏泵功能衰竭死亡(心力衰竭死亡)、心脏性猝死和栓塞相关死亡差异.多因素Cox生存分析确认心力衰竭患者不同预后的危险因素.结果 ①共16681例患者纳入本次研究.房颤组与非房颤组相比,年龄(64.54 ±13.61)岁比(62.19±15.07)岁(P＜0.01)、左心室射血分数(LVEF)37.43± 12.72比38.42±13.96(P＜0.01)、心功能Ⅲ～Ⅳ级(NYHA分级)患者(5547/81.49％比7121/72.12％,P＜0.01)和病因等因素存在差异.②单因素Kaplan-Meier曲线分析发现,房颤组和非房颤组在总死亡、心血管病死亡、心力衰竭死亡和栓塞相关死亡存在差异,而在心律失常相关的心脏性猝死两组间差异无统计学意义.③多因素Cox回归分析发现房颤不是总死亡、心血管病死亡、心力衰竭死亡和心脏性猝死增加的独立危险因素,而增加栓塞相关死亡(HR=2.134,95％ CI,1.846～2.430,P＜0.0l)结论 房颤不增加CSHF患者远期总死亡、心血管病死亡、心力衰竭死亡和心脏性猝死,而增加栓塞相关死亡.提示房颤引起CSHF患者远期预后不良的原因可能在于其并发症.     

射血分数中间范围心力衰竭预后的研究进展

射血分数中间范围心力衰竭(HFmrEF)作为一种特殊类型的心力衰竭表型,处于射血分数降低性心力衰竭(HFrEF)与射血分数保留性心力衰竭(HFpEF)之间的"灰色区域",目前研究对于HFmrEF是为一个独立的临床综合征还是介于HFrEF和HFpEF之间的"过渡阶段"存在一定争议.现对HFmrEF的流行病学、机制、治疗和...     

射血分数中间值心力衰竭新进展

心力衰竭（心衰）是心脏疾病发展的终末阶段。既往研究通过左心室射血分数对心力衰竭进行分类,分为射血分数降低性心力衰竭与射血分数保留性心力衰竭。近年研究发现介于上述两种心衰的灰色区域,2016年欧洲心脏病学会（ESC）慢性心衰指南首次提出,并将这个灰色区域命名为射血分数中间值心衰。本文对射血分数中间值心衰近年的研究进行综述。     

射血分数正常心力衰竭

本文简述了射血分数正常心力衰竭,又称为射血分数保存心力衰竭(收缩功能保存心力衰竭)的流行病学,并比较了其与射血功能低下心力衰竭(收缩功能低下心力衰竭)的预后。概述了其病因与病理生理特点、诊断要点及治疗原则。     

左心室射血分数保留的心力衰竭研究现状

心室的收缩与舒张功能异常均可能使心脏排血量降低并导致心力衰竭。长期以来我们更多关注的是因心室收缩功能障碍所致的心力衰竭,而对于左室收缩功能正常的心力衰竭的病理生理机制以及诊疗策略却所知很少。在临床实践中因心室舒张功能障碍所导致的心力衰竭约占患者总数的50%左右,其预后与收缩性心力衰竭相似,但猝死的发生更为常见。现结合近年来发表的相关文献对其研究现状进行简要总结。     

住院患者慢性心力衰竭并发心房颤动的调查分析

目的了解慢性心力衰竭(简称心衰)住院患者心房颤动(简称房颤)发生的相关因素。方法回顾性调查分析湖北孝感市中心医院2000年1月1日至2010年5月31日住院的心衰患者,多因素logistic回归分析房颤相关危险因素。结果心衰住院患者房颤发生率为40.12%。多因素logistic回归分析发现:①房颤的发生风险随年龄增加而增加:与<40岁组相比,40～50,50～60,60～70,70～80和≥80岁组房颤HR(95%CI)分别为1.452,2.167,2.457,2.805和3.157;P均<0.05或0.01②房颤发生风险随左室射血分数(LVEF)降低而显著增加:与LVEF 0.41～0.50组相比,LVEF 0.31～0.40,0.21～0.30和≤0.20组房颤HR分别为1.565,1.640和2.104;P均<0.05。结论慢性心衰住院患者房颤常见;慢性心衰患者房颤发生率随年龄增加和LVEF减低而增加。     

射血分数正常的心力衰竭

左室射血分数在正常范围内的心力衰竭近来受到关注,现将其在病因、病理生理、组织多普勒成像及治疗策略方面的研究进展综述如下。     

利尿剂对慢性收缩性心力衰竭患者心房颤动发生的影响

目的 探讨慢性心力衰竭(chronic systolic heart failure,CSHF)患者利尿剂种类和用量对心房颤动(房颤)发生风险和预后的影响.方法 回顾性分析湖北地区16 681例CSHF住院患者(包括多次入院患者的首次和末次入院)临床资料,所有患者电话随访.以随访结果将患者分为死亡组和存活组;根据多次入院患者首次及末次临床资料将患者分为房颤组和无房颤组、不同利尿剂组、利尿剂不同剂量组.多因素Cox回归分析影响CSHF患者房颤发生风险和总死亡的独立危险因素,ROC曲线评价利尿剂对房颤预测的敏感性和特异性;多因素Cox风险比例模型分析不同利尿剂组、利尿剂不同剂量组房颤发生风险.结果 ①利尿剂(HR 1.549,95％ CI l.246 ～1.854,P＜0.01)是CSHF患者房颤发生的独立危险因素,ROC曲线分析发现,利尿剂增加预测房颤发生的特异性(83.9％对82.3％);②氢氯噻嗪和呋塞米增加房颤发生风险;氢氯噻嗪＞40 mg/d和呋塞米≥40 mg/d增加房颤发生风险;③不同种类利尿剂均不增加CSHF患者总死亡率.结论 利尿剂是CSHF患者房颤发生的独立危险因素.氢氯噻嗪＞40 mg/d和呋塞米≥0 mg/d增加房颤发生风险.     

Clinical characteristics and prognostic impact of atrial fibrillation in patients with chronic heart failure

AIM To assess the prevalence, clinical characteristics and independent prognostic impact of atrial fibrillation(AF) in chronic heart failure(CHF) patients, and the potential protective effect of disease-modifying medications, particularly beta-blockers(BB). METHODS We retrospectively reviewed the charts of patients referred to our center since January 2004, and collected all clinical information available at their first visit. We assessed mortality to the end of June 2015. We compared patients with and without AF, and assessed the association between AF and all-cause mortality by multivariate Cox regression and Kaplan-Meyer analysis, particularly accounting for ongoing treatment with BB.RESULTS A total of 903 patients were evaluated(mean age 68 ± 12 years, 73% male). Prevalence of AF was 19%, ranging from 10% to 28% in patients ≤ 60 and ≥ 77 years, respectively. Besides the older age, patients with AF had more symptoms(New York Heart Association II-III 60% vs 44%), lower prevalence of dyslipidemia(23% vs 37%), coronary artery disease(28% vs 52%) and left bundle branch block(9% vs 16%). On the contrary, they more frequently presented with an idiopathic etiology(50% vs 24%), a history of valve surgery(13% vs 4%) and received overall more devices implantation(31% vs 21%). The use of disease-modifying medications(i.e., BB and ACE inhibitors/angiotensin receptor blockers) was lower in patients with AF(72% vs 80% and 71% vs 79%, respectively), who on the contrary were more frequently treated with symptomatic and antiarrhythmic drugs including diuretics(87% vs 69%) and digoxin(51% vs 11%). At a mean follow-up of about 5 years, all-cause mortality was significantly higher in patients with AF as compared to those in sinus rhythm(SR)(45% vs 34%, P value 0.05 for all previous comparisons). However, in a multivariate analysis including the main significant predictors of allcause mortality, the univariate relationship between AF and death(HR = 1.49, 95%CI: 1.15-1.92) became not statistically significant(HR = 0.98, 95%CI: 0.73-1.32). Nonetheless, patients with AF not receiving BB treatment were found to have the worst prognosis, followed by patients with SR not receiving BB therapy and patients with AF receiving BB therapy, who both had similarly worse survival when compared to patients with SR receiving BB therapy.CONCLUSION AF was highly prevalent and associated with older age, worse clinical presentation and underutilization of disease-modifying medications such as BB in a population of elderly patients with CHF. AF had no independent impact on mortality, but the underutilization of BB in this group of patients was associated to a worse long-term prognosis.     

Empagliflozin in heart failure with preserved ejection fraction with and without atrial fibrillation

Aims

Atrial fibrillation/flutter (AF) is common in heart failure (HF) with preserved left ventricular ejection fraction (LVEF) and associated with worse outcomes. Empagliflozin reduces cardiovascular death or HF hospitalizations and slows estimated glomerular filtration rate (eGFR) decline in patients with HF and LVEF >40%. We aimed to assess the efficacy and safety of empagliflozin in improving outcomes in patients with HF and LVEF >40% with and without AF.

Methods and results

In this pre-defined secondary analysis of EMPEROR-Preserved, we compared the effects of empagliflozin versus placebo on the primary and secondary endpoints and safety outcomes, stratified by baseline AF, defined as AF reported in any electrocardiogram before empagliflozin initiation or in medical history. Among 5988 patients randomized, 3135 (52%) had baseline AF; these patients were older, with worse functional class, more previous HF hospitalizations and higher natriuretic peptides compared to those without AF (all p < 0.001). After a median of 26 months, empagliflozin reduced cardiovascular death or HF hospitalization compared to placebo to a similar extent in patients with and without AF (hazard ratio [HR] 0.78 [95% confidence interval 0.66–0.93] vs. 0.78 [0.64–0.95], interaction p = 0.96). Empagliflozin also reduced total HF hospitalizations (HR 0.73 [0.57–0.94] vs. 0.72 [0.54–0.95], interaction p = 0.94) and annual eGFR decline (difference = 1.368 vs. 1.372 ml/min/1.73 m²/year, interaction p = 0.99) consistently in patients with and without AF. There was no increase in serious adverse events with empagliflozin versus placebo in patients with and without AF.

Conclusions

In patients with HF and ejection fraction >40%, empagliflozin reduced the risk of serious HF events and slowed the eGFR decline regardless of baseline AF.     

收缩性心力衰竭患者发生心房颤动之前的血清醛固酮水平

目的 测定收缩性心功能不全患者发生心房颤动(简称房颤)之前醛固酮的血清浓度变化.方法 选择收缩性心功能不全伴无房颤患者243例,所有患者在入选后均行心脏超声、Holter和血生化检查.随访结束后根据随访结果 将患者分为房颤组和窦性心律(简称窦律)组.结果 随访28±5个月,224例完成随访,其中有47例记录到房颤.房颤...     

Natriuretic peptides in patients with atrial fibrillation and advanced chronic heart failure: determinants and prognostic value of (NT-)ANP and (NT-pro)BNP.

AIMS: To study the determinants of natriuretic peptides in advanced chronic heart failure (CHF) patients with and without atrial fibrillation (AF) and to evaluate the prognostic value of natriuretic peptides in AF compared with sinus rhythm patients with advanced CHF. METHODS AND RESULTS: The study group comprised 354 advanced CHF patients [all New York Heart Association (NYHA) III/IV], including 76 AF patients. AF patients were older (70+/-7 vs. 67+/-8; P=0.01), and non-ischaemic CHF was more common (42 vs. 19%; P=0.002) than in sinus rhythm patients, but left-ventricular ejection fraction was comparable (0.23+/-0.08 vs. 0.24+/-0.07; P=ns). At baseline, (NT-)ANP and NT-proBNP levels were significantly higher in AF patients, compared with those in sinus rhythm. By multivariate regression analysis, AF was identified as independent determinant of (NT-)ANP, but not of (NT-pro)BNP levels. After a mean follow-up of 3.2+/-0.9 (range 0.4-5.4) years, cardiovascular mortality was comparable (55 vs. 47%; P=ns). In both groups, AF and sinus rhythm, NT-proBNP [AF: adjusted HR 5.8 (1.3-25.4), P=0.02; sinus rhythm: adjusted HR 3.1 (1.7-5.7), P<0.001] was an independent risk indicator of cardiovascular mortality. CONCLUSION: In advanced CHF patients, AF affects (NT-)ANP levels, but not (NT-pro)BNP levels. NT-proBNP is an independent determinant of prognosis in advanced CHF, irrespective of the rhythm, AF, or sinus rhythm.     

T波峰末间期对慢性收缩性心力衰竭患者预后的预测价值

目的探讨T波峰末间期(TpTe)对慢性收缩性心力衰竭(简称心衰)患者预后的预测价值。方法回顾性调查和分析湖北地区8地市12家三级甲等医院2000年至2010年心衰住院患者临床资料,所有患者电话随访。根据TpTe四分位间距分为≥114 ms、88～113 ms、68～87 ms和≤67 ms组。单因素Kaplan-Meier曲线分析TpTe各组总死亡、心血管病死亡、心衰死亡、和心源性猝死有差异性。多因素Cox生存分析确认心衰患者不同预后的危险因素。受试者工作特征曲线(ROC曲线)分析TpTe、槡TpTe/RR是否增加预测的灵敏度和特异度。结果①共11067例患者纳入本次研究。将性别、年龄、心率、左室射血分数、病因、肾功能、心房颤动及治疗措施等指标加入多因素Cox回归分析,发现TpTe延长是总死亡、心血管病死亡和心衰死亡增加的独立危险因素,风险(95%CI,P)分别为1.002(1.001～1.002,<0.01)、1.002(1.001～1.003,<0.01)和1.002(1.001～1.003,<0.01);②ROC曲线分析发现不包含QTc、TpTe和槡TpTe/RR的预测模型预测总死亡、心血管病死亡、心衰死亡和心源性猝死的响应率分别为79.30%(Chic-square 1 893.25,P<0.01)、72.20%(Chic-square 2 771.33,P<0.01)、73.90%(Chic-square 2998.21,P<0.01)和71.90%(Chic-square 323.07,P<0.01)。分别加入QTc、QTc和TpTe、QTc和槡TpTe/RR的模型不增加预测模型的灵敏度和特异度。结论虽然TpTe延长增加慢性收缩性心衰患者的死亡风险,但不增加预测的灵敏度和特异度。     

慢性心力衰竭患者血清尿酸水平与心房颤动发生的关系及预测价值

目的 探讨慢性心力衰竭患者血清尿酸(SUA)水平与心房颤动(房颤)发生的关系及预测价值.方法 回顾性分析湖北地区2000年1月1日至2010年5月31日期间心力衰竭住院患者(包括多次入院患者的首次和末次入院)临床资料,所有患者均电话随访.按随访结果将患者分为房颤组和无房颤组、死亡组和存活组.单因素和多因素Cox分析心力衰竭患者房颤的危险因素,多元Logistic回归分析和ROC曲线评价SUA水平对房颤预测的敏感性和特异性.结果 入选的16681例患者中,房颤6807例.多因素分析显示SUA水平与房颤密切相关.平均随访5年后,多元Logistic回归分析显示SUA水平(HR 1.084,95％ CI 1.017-1.144,P＜0.001)、利尿剂(HR 1.549,95％ CI 1.246-1.854,P＜0.001)和心功能(NYHA分级,HR 1.237,95％ CI 1.168-1.306,P＜0.001)是房颤发生的独立预测因子.ROC曲线显示SUA增加房颤发生的敏感性和特异性(Wald x2 1494.88,P＜0.001;95％ CI 57.7％-60.0％).结论 SUA水平与心力衰竭患者房颤的发生有密切关系.     

Effect of atrial fibrillation on long-term survival in patients hospitalised for heart failure with preserved ejection fraction

BACKGROUND: The prognostic importance of atrial fibrillation (AF) in heart failure (HF) is not clearly established. Studies conducted in systolic HF have led to discordant results. AIMS: To evaluate the relation between AF and long-term survival in patients with heart failure and preserved ejection fraction (HFPEF). METHODS AND RESULTS: We prospectively included 368 consecutive patients hospitalised for a first episode of HFPEF during 2000 and compared the 5-year outcome of patients according to the presence or absence of AF on the baseline electrocardiogram. Propensity scores were used to reduce imbalance in baseline characteristics. Baseline AF was observed in 36% (n=132) of the study population. Patients with AF were older and more often had hypertensive heart disease. On univariate analysis, baseline AF was associated with an increased risk of 5-year overall mortality (HR=1.36; 95%CI 1.03-1.79; p=0.03). After adjustment for covariates, baseline AF was no longer a predictor of reduced survival. The risk of adjusted cardiovascular death in patients with and without AF was comparable. In the propensity-matched patients, AF was not related to a poorer outcome (HR=1.08; 95%CI 0.78-1.51; p=0.63). CONCLUSION: In patients hospitalised for HFPEF, AF is frequent and associated with an excess mortality mainly related to the advanced age of these patients. After adjustment for covariates, baseline AF is not an independent predictor of long-term mortality.