慢性肾脏疾病增加慢性心力衰竭患者死亡率

目的探讨慢性肾脏疾病(CKD)对慢性心力衰竭(CHF)患者死亡率的影响。方法对2007年1月1日至2009年12月31日在北京协和医院心内科住院,年龄≥21岁,临床诊断为心力衰竭,且左心室射血分数(LVEF)≤45%的缺血性(心肌梗死后至少40 d以上)或非缺血性心肌病患者进行回顾性研究,根据肾小球滤过率(eGFR)情况分为两组,一组为eGFR<60 ml.min-1.1.73 m-2(CKD组),另一组为eGFR≥60 ml.min-1.1.73 m-2(对照组),并进行电话随访。结果共筛选242例患者,除外41例不符合入选标准者,对201例进行随访,14例(7%)失访,经过2～41个月[平均(20±9)个月]的随访,共36例(19%)发生全因死亡,包括CKD组21例(30%)和对照组15例(13%)(P=0.003)。结论 CKD增加CHF患者死亡率。合并CKD的CHF患者,积极处理CHF的同时应高度重视CKD处理。     

Non-Gaussian heart rate as an independent predictor of mortality in patients with chronic heart failure

BACKGROUND: Morbidity and mortality due to chronic heart failure remain unacceptably high despite effective drug therapies, and the search for a better risk predictor is ongoing. Statistics derived from beat-to-beat fluctuations in heart rate or heart rate variability (HRV) have been used for this purpose, but the current predictability level is low or moderate at best. OBJECTIVE: The purpose of this study was to evaluate whether a recently proposed non-Gaussian index of HRV is a significant and independent mortality predictor in patients with congestive heart failure (CHF). METHODS: Twenty-four-hour Holter ECGs from 108 CHF patients were evaluated. Thirty-nine (36.1%) of the patients died during the follow-up period of 33 +/- 17 months. Cox proportional hazards regression analysis was performed to determine factors related to all-cause mortality. The factors evaluated derived from clinical information, including plasma brain natriuretic peptide, conventional time- and frequency-domain and fractal HRV measures, and a recently proposed non-Gaussian index lambda of HRV. RESULTS: The short-term (<40 beats) non-Gaussian index lambda(40) (hazard ratio per increment of unit standard deviation 1.64, 95% confidence interval [1.23, 2.18], P <.001) and the long-term (<1,000 beats) index lambda(1000) (hazard ratio 1.42, 95% confidence interval [1.07, 2.18], P <.02), together with brain natriuretic peptide (hazard ratio 2.26, 95% confidence interval [1.45, 3.53], P <.001), are significant univariate risk predictors of mortality. In a multivariate model, lambda(40) (1.49, [1.13, 1.96], P <.005) and brain natriuretic peptide (2.39, [1.53, 3.75], P <.001) are independent predictors of the survival statistics of patients. None of the conventional HRV measures have predicted the mortality of patients in a significant and independent manner. CONCLUSION: The results of this study indicate the usefulness of the short-term non-Gaussian index of HRV for risk prediction in patients with CHF.     

Blunted erythropoietin production and defective iron supply for erythropoiesis as major causes of anaemia in patients with chronic heart failure.

AIMS: Anaemia is often observed in patients with chronic heart failure (CHF), and it may be associated with a worse prognosis. Aim of this study was to identify the individual mechanisms of anaemia in CHF patients. METHODS AND RESULTS: One hundred and forty-eight consecutive patients with haemoglobin concentration <13 g/dL (if males) or <12 g/dL (if females) were enrolled. Factors responsible for anaemia were investigated by evaluating endogenous erythropoietin (Epo) production, serum cytokines levels, body iron status, and iron supply for erythropoiesis. Most patients (57%) presented anaemia of chronic disease and among them, 92% showed evidence of a defective endogenous Epo production. This was indicated by an observed/predicted log(serum Epo) ratio less than 0.8 and/or a defective iron supply for erythropoiesis diagnosed by low transferrin saturation and/or increased value of soluble transferrin receptor. According to regression analysis sex, renal failure, and serum Epo were correlated with anaemia. CONCLUSION: According to our study, about half of anaemic CHF patients showed anaemia of chronic disease with blunted endogenous Epo production and/or a defective iron supply for erythropoiesis. Determination of the individual mechanisms of anaemia in CHF could justify a rational therapeutic approach to anaemia.     

口服袢利尿剂剂量与慢性心力衰竭全因死亡率的关系

目的研究口服袢利尿剂剂量与慢性心力衰竭(心衰)患者全因死亡率的关系。方法入选并随访1197例(1120例获得用药资料)慢性心衰患者.男性占81.7%,平均年龄56.5±13.6岁,平均左室射血分数(LVEF)35.6±8.9%;全因死亡为随访终点。先比较不同口服袢利尿剂剂量(0、≤20、20～40、>40mg/日呋塞米当量)人群其他预后相关因素分布的差异,再应用Kaplan-Meier曲线及Log-rank检验对不同剂量人群的生存率进行描述及比较,多元Cox回归用于分析口服袢利尿剂剂量是否为心衰死亡的独立预测因子。结果完成随访1025例(失访率14.4%),死亡360例(35.1%);随访中位数44个月。平均袢利尿剂剂量34.26±2.67mg/日呋塞米当量。应用不同袢利尿剂剂量的心衰患者在合并症、血压、LVEF、多种检验项目及用药方面存在显著差异。不同剂量心衰人群的死亡率分别为19.2%、29.6%、39.8%及55.4%,随着袢利尿剂应用剂量增加而增高(P<0.001);校正其他影响因素后,口服袢利尿剂剂量与心衰患者不良预后独立相关。剂量每增加10mg/日呋塞米当量,心衰死亡风险增加1.072倍(P<0.001)。服用≤20mg/日、20-40mg/日及>40mg/日呋塞米当量心衰人群的死亡风险分别是未服用者的1.575倍(P=0.023)、1.958倍(P=0.001)及2.543倍(P<0.001)。结论虽然年龄、体重指数、LVEF、合并室速、是否应用血管紧张素转换酶抑制剂/血管紧张素受体拮抗剂、应用袢利尿剂剂量、血红蛋白、总胆红素、尿酸均与心衰预后相关。应用袢利尿剂且随着剂量增加,心衰的死亡风险增高。     

Excessive ventilation during early phase of exercise: a new predictor of poor long-term outcome in patients with chronic heart failure

BACKGROUND: Studies demonstrating prognostic value of excessive exercise ventilation in chronic heart failure (CHF) have focused on data derived from the whole cardiopulmonary exercise test (CPET). Whether ventilatory response to early phase of exercise is useful for risk stratification in CHF is unknown. METHODS AND RESULTS: We evaluated 216 patients with systolic CHF who underwent CPET (age: 60+/-11 years, NYHA class [I/II/III/IV]: 18/104/77/17). Ventilatory response to exercise (slope of regression line relating ventilation to carbon dioxide production) was calculated from the whole exercise test (VE-VCO(2)-all) and from the first 3 min of exercise (early phase - VE-VCO(2)-3 min). During follow-up (mean: 40+/-20 months, >3 years in survivors), 89 (41%) CHF patients died. High VE-VCO(2)-all and VE-VCO(2)-3 min predicted poor outcome in single predictor analyses, and in multivariable models when adjusted for prognosticators (age, NYHA class, ejection fraction, peak VO(2)) (P<0.0001). In receiver operating characteristic curve analysis, areas under curve for 3-year follow-up were similar for VE-VCO(2)-all and VE-VCO(2)-3 min. VE-VCO(2)-3 min maintained its prognostic value in patients taking beta-blockers (P<0.0001) and those unable to perform maximal CPET (P=0.0009). CONCLUSIONS: In CHF patients, excessive ventilation assessed over the first 3 min predicts poor outcome. Assessment of ventilatory response to exercise for prognostic stratification may be extended to patients unable to perform maximal CPET.     

Anaemia in chronic heart failure is not only related to impaired renal perfusion and blunted erythropoietin production, but to fluid retention as well.

AIMS: Anaemia is prevalent in the chronic heart failure (CHF) population, but its cause is often unknown. The present study aims to investigate the relation between anaemia, renal perfusion, erythropoietin production, and fluid retention in CHF patients. METHODS AND RESULTS: We studied 97 patients with CHF, of which 15 had anaemia (Hb<13.0 g/dL in men and Hb<12.0 g/dL in women), without haematinic deficiencies. Glomerular filtration rate (GFR) and extracellular volume (ECV) were measured as the clearance and the distribution volume of constantly infused 125I-iothalamate, respectively. Effective renal plasma flow (ERPF) was determined as the clearance of 131I-hippuran. Anaemic CHF patients displayed significantly reduced GFR (P=0.002), ERPF (P=0.005) and EPO production (P=0.001), and an elevated ECV (P=0.015). Multivariable analysis demonstrated that lower GFR (P=0.003), lower ERPF (P=0.004), lower EPO production (P=0.006), and a higher ECV (P=0.001) were significant independent predictors of lower haemoglobin levels. CONCLUSION: Anaemia in CHF is not only independently associated with impaired renal perfusion and blunted EPO production, but to fluid retention as well.     

康复医疗在慢性充血性心衰病人治疗中的应用（附42例报告）

目的 :观察在慢性心衰病人临床治疗中配合应用康复医疗的作用。方法 :42例 度慢性充血性心衰病人 ,按心功能分级 ( ～ 级 )分成 3组。待病情稳定后开始分阶段的康复运动 ,同时进行教育、心理调整。结果 :病人全部康复 ,出院时心功能均达 级 ,平均住院时间为 14.5 5± 7.0 2天 ,安全性达 95 % (40 / 42 )。结论 :慢性心衰病人临床治疗中配合应用本康复程序可以达到早下床、早活动、早出院 ,促进康复的目的 ,且安全性高。     

慢性心力衰竭患者动态心率震荡分析

目的：探讨窦性心率震荡（HRT）的新测量指标动态心率震荡（TD）及HRT测量指标震荡初始（TO）、震荡斜率（TS）在慢性心力衰竭（CHF）患者中的变化,分析其与传统高危预测指标的相关性及预测CHF患者价值。方法纳入2011年9月~2013年6月在天津市胸科医院就诊的CHF患者120例作为CHF组,同期纳入非器质性心脏病患者30例作为对照组,将CHF组按NYHA分级分为轻度CHF组（心功能Ⅰ~Ⅱ级,n=72）和中重度CHF组（心功能Ⅲ~Ⅳ级,n=48）。所有患者行放射免疫法检测B型脑钠肽（BNP）水平,超声心动图检查左房内径（LAD）、左室舒张末径（LVEDD）、左室射血分数（LVEF）;24 h动态心电图检查记录心率变异性时域（SDNN）、平均心率、室性早搏前心率（HRVPC）以及RR间期,计算HRT指标（包括TO、TS和TD）。比较各组之间的差异,分析HRT各指标与年龄、性别、LAD、LVEDD、LVEF、BNP的相关性。结果与对照组相比,CHF组SDNN缩短[（95.67±30.22） msvs.（131.65±20.71）ms],TO和TD更高[TO：（-1.50±2.71）%vs.（0.61±1.95）%;TD：（0.012±0.004）mm/RRIvs.（0.063±0.031）mm/RRI],LAD和LVEDD更高[LAD：（36.11±2.24）mmvs.（47.65±2.13）mm;LVEDD：（43.65±7.33）mmvs.（62.13±8.70）mm],BNP明显升高[（80.05±32.30）pg/ml vs.（941.00±139.17）pg/ml],TS和LVEF更低[TS：（12.13±3.67）vs.（6.80±5.33）;LVEF：（67.30±5.21）% vs.（38.22±12.75）%],而且随着CHF程度的加重,上述改变更加明显。CHF组TO与TS、LVEF、SDNN负相关（P＜0.05）;TS与SDNN正相关（P＜0.05）,与HRVPC、BNP负相关（P＜0.05）。结论 CHF患者HRT明显减弱,其中TO和TS均受到SDNN的影响,而TD与HRVPC、SDNN、LVEF、BNP指标无关。     

Anaemia, independent of chronic kidney disease, predicts all-cause and cardiovascular mortality in type 2 diabetic patients

Objective

There is limited and controversial information on whether anaemia is a risk factor for cardiovascular mortality in type 2 diabetes, and whether this risk is modified by the presence of chronic kidney disease (CKD). We assessed the predictive role of lower hemoglobin concentrations on all-cause and cardiovascular mortality in a cohort of type 2 diabetic individuals.

Methods

The cohort included 1153 type 2 diabetic outpatients, who were followed for a mean period of 4.9 years. The independent association of anaemia (i.e., hemoglobin <120 g/l in women and <130 g/l in men) with all-cause and cardiovascular mortality was evaluated by Cox proportional hazards regression models and adjusted for several potential confounders, including kidney function measures.

Results

During follow-up, 166 (14.4%) patients died, 42.2% (n = 70) of them from cardiovascular causes. In univariate analysis, anaemia was associated with increased risk of all-cause (hazard ratio HR 2.62, 95% confidence intervals 1.90–3.60, p < 0.001) and cardiovascular mortality (HR 2.70, 1.67–4.37, p < 0.001). After adjustment for age, sex, body mass index, smoking, hypertension, dyslipidemia, diabetes duration, hemoglobin A1c, medication use (hypoglycemic, anti-hypertensive, lipid-lowering and anti-platelet drugs) and kidney function measures, the association of anaemia with all-cause (adjusted HR 2.11, 1.32–3.35, p = 0.002) and cardiovascular mortality (adjusted HR 2.23, 1.12–4.39, p = 0.020) remained statistically significant.

Conclusions

Anaemia is associated with increased risk of all-cause and cardiovascular mortality in type 2 diabetic individuals, independently of the presence of CKD and other potential confounders. The advantage to treat anaemia in type 2 diabetes for reducing the risk of adverse cardiovascular outcomes remains to be demonstrated.     

Anaemia is an independent predictor of mortality in patients with left ventricular systolic dysfunction following acute myocardial infarction

BACKGROUND: In patients with chronic heart failure (HF), mortality is inversely related to haemoglobin (hgb) concentration. We investigated the prognostic importance of anaemia in patients with acute myocardial infarction (AMI) and left ventricular systolic dysfunction (LVSD) with and without HF. METHODS AND RESULTS: We studied 1731 patients with AMI and left ventricular ejection fraction 相似文献   

Short to long term mortality of patients hospitalised with heart failure in the Czech Republic--a report from the EuroHeart Failure Survey

BACKGROUND AND AIM: The European Society of Cardiology initiated the EuroHeart Failure Survey to obtain more data about the quality of care in patients hospitalised with suspected heart failure (HF). The Czech Republic was 1 of the 24 European Society countries included in the survey. The aim of this report is to extend the original follow-up period of 12 weeks out to 4 years to assess mortality. METHODS: All admitted patients were screened according to the EuroHeart Survey Protocol, over a 6-week period in six hospitals in Pilsen, Prague and Brno in the year 2000. Annual mortality and cause of death were obtained from the Prague Institute for Health Statistical Information (UZIS Praha). RESULTS: A total of 2365 patients were screened and about 25% of all admitted patients fulfilled the criteria for HF. About 14% of patients died between admission and the 12-week follow-up, 36% of male and 42% of female patients died during the 4-year follow-up (2000-2003). Cardiovascular diseases were the main causes of death (92%). Deceased patients were significantly older, had lower haemoglobin and total plasma cholesterol level, and had renal insufficiency and higher levels of big endothelin and BNP than the survivors. Mortality risk was increased independently by positive history of previous myocardial infarction OR=2.39 (1.59-3.59), by age OR=1.03 (1.01-1.05) and by plasma creatinine level OR=1.04 (1.01-1.07). Treatment with diuretics and digoxin was associated with a higher risk of death; by contrast, a protective effect of beta-blockers and statins was found in these HF patients. CONCLUSION: Patients with HF were older and had a poor prognosis; approximately one third of the patients will die within 3 years.     

Chronic kidney disease: an independent risk factor of all-cause mortality for elderly Chinese patients with chronic heart failure

Objective

To evaluate the prognostic value of chronic kidney disease (CKD) in elderly Chinese patients with chronic heart failure (CHF).

Methods

The study consisted of 327 elderly patients with CHF. All-cause mortality was chosen as an endpoint over the median follow-up period of 345 days. Cox regression analysis was used to identify the risk factors of mortality.

Results

The median age of the entire cohort was 85 years (60–100 years). The mortality for 168 elderly patients with CHF and CKD (51.4% of entire cohort) was 39.9% (67 deaths), which was higher than the mortality for CHF patients without CKD [25.2% (40/159 deaths)] and the mortality for entire cohort with CHF [32.7% (107/327 deaths)]. The Cox regression analysis showed that old age [hazard ratio (HR): 1.033; 95% confidence interval (95% CI): 1.004–1.064], CKD (HR: 1.705; 95% CI: 1.132–2.567), CHF New York Heart Association (NYHA) class IV (HR: 1.913; 95% CI: 1.284–2.851), acute myocardial infarction (AMI) (HR: 1.696; 95% CI: 1.036–2.777), elevated resting heart rate (HR: 1.021; 95% CI: 1.009–1.033), and decreased plasma albumin (HR: 0.883; 95% CI: 0.843–0.925) were independent risk factors of mortality for elderly patients with CHF.

Conclusions

CKD was an independent risk factor of mortality for elderly Chinese patients with CHF.     

Urotensin II in patients with chronic heart failure

BACKGROUND: Human Urotensin II (hU-II) is the most potent vasoconstrictor known to date. HU-II receptors are predominant in the human heart and arterial vessels, suggesting hU-II to be of importance as a cardiovascular mediator. METHODS: We studied 32 consecutive patients (60+/-12 years) with chronic heart failure (CHF) and 10 control subjects (54+/-12 years, n.s.) with cardiopulmonary exercise testing. Blood samples for the measurement of plasma hU-II and big-endothelin-1 (big-ET1) were obtained at rest and at peak exercise. RESULTS: Peak VO(2) was significantly higher in controls than in CHF patients (19.8+/-3.8 vs. 14.7+/-3.6 ml min(-1) kg(-1), P<0.001). Big-ET1 levels were increased in CHF compared to controls at rest (2.8+/-1.8 vs. 1.7+/-0.1 fmol/ml, P<0.01) and at peak exercise (2.7+/-1.7 vs. 1.6+/-0.2 fmol/ml, P<0.005). HU-II concentrations were comparable in patients with CHF and controls at rest (2990+/-1104 vs. 3290+/-508 pg/ml, n.s.) and peak exercise (3063+/-1185 vs. 3213+/-1188 pg/ml, n.s.). Resting hU-II levels demonstrated no correlation with peak VO(2) in controls or CHF patients. CONCLUSIONS: The measurement of circulating plasma levels of hU-II does not seem to be very helpful in studying the effects of hU-II in human cardiovascular regulation. A local paracrine or autocrine mediator effect of hU-II in CHF is possible.     

慢性心力衰竭患者的心率变异性分析

目的 探讨慢性心力衰竭患者心率变异性的变化。方法 观察76例心力衰竭患者（观察组）和24例健康人（对照组）的心率变异性时域指标,比较两组各指标及与心功能程度NYHA分级、原发病和心力衰竭类型的关系。结果 观察组较对照组SDNN、SDANN显著降低（P均〈0.05、〈0.01）。心功能Ⅳ级者较Ⅱ、Ⅲ级SDNN、SDANN显著降低（P〈0.05、〈0.01）。右侧心力衰竭者较对照组SDNN、SDANN显著降低（P均〈0.01）;全心心力衰竭者较对照组和单侧心力衰竭SDNN、SDANN均显著降低（P〈0.01、〈0.05）。各种病因者较对照组SDANN均显著降低（P〈0.05、0.01）,但各种病因者差异无显著性意义（P〉0.05）结论 慢性心力衰竭患者HRV部分指标变化可作为判定慢性心力衰竭严重程度的参考指标;各项指标变化可能与原发病无关,但部分似与心力衰竭类型有关。