急性心力衰竭患者远期死亡的预测因素分析

目的 探讨急性心力衰竭(AHF)患者远期死亡的预测因素。方法 连续入选南方医科大学顺德医院2012年6月—12月因AHF住院的患者512例,根据出院后1年内是否死亡分为存活组(n＝323)和死亡组(n＝189)。记录患者的基线资料。对出院患者进行中位随访时间20.2月的随访,记录全因死亡事件。使用Cox比例风险回归模型分析死亡的危险因素。结果 1年内全因死亡率为36.9%。单因素Cox比例风险回归模型分析提示,AHF病史(HR 1.41,95%CI 1.02～1.95,P＜0.05)、心率增快(HR 1.01,95%CI 1.00～1.02,P＜0.05)、脑钠肽升高(HR 1.78,95%CI 1.05～3.01,P＜0.05)、低白蛋白(HR 0.94,95%CI 0.92～0.97,P＜0.001)、低血钠(HR 0.97,95%CI 0.94～1.00,P＜0.05)是AHF患者远期死亡的独立预测因素。多因素Cox比例风险回归模型分析提示,AHF病史(HR 1.41,95%CI 1.06～1.88,P＝0.018)、心率增快(HR 1.01,95%CI 1.00～1.01,P＝0.024)、低白蛋白(HR 0.96,95%CI 0.94～0.99,P＝0.003)、低血钠(HR 0.97,95%CI 0.94～0.99,P＝0.010)是AHF患者远期死亡的危险因素。结论 AHF病史、心率增快、低白蛋白、低血钠是AHF患者远期死亡的预测因素。     

Predictors of re-hospitalization in patients with chronic heart failure

Heart failure (HF) is a chronic, progressive illness that is highly prevalent in the United States and worldwide. This morbid illness carries a very poor prognosis, and leads to frequent hospitalizations. Repeat hospitalization in HF is both largely burdensome to the patient and the healthcare system, as it is one of the most costly medical diagnoses among Medicare recipients. For years, investigators have strived to determine methods to reduce hospitalization rates of HF patients. Despite such efforts, recent reports indicate that rehospitalization rates remain persistently high, without any improvement over the past several years and thus, this topic clearly needs aggressive attention. We performed a key-word search of the literature for relevant citations. Published articles, limited to English abstracts indexed primarily in the PubMed database through the year 2011, were reviewed. This article discusses various clinical parameters, serum biomarkers, hemodynamic parameters, and psychosocial factors that have been reviewed in the literature as predictors of re-hospitalization of HF patients. With this information, ourhope is that the future holds better risk-stratification models that will allow providers to identify high-risk patients, and better customize effective interventions according to the needs of each individual HF patient.     

Effect of concomitant digoxin and carvedilol therapy on mortality and morbidity in patients with chronic heart failure

We retrospectively performed stepwise logistic regression analysis on 1,509 patients with chronic heart failure in 4 multicenter United States studies and 1 Australia-New Zealand study to examine the effect of digoxin in patients randomized to carvedilol or placebo. Patients receiving digoxin had more advanced heart failure, the incidence of hospitalization for any cause and the combination of all-cause death and all-cause hospitalization were the same in the digoxin versus no-digoxin groups.     

Effects of candesartan on mortality and morbidity in patients with chronic heart failure: the CHARM-Overall programme

Patients with chronic heart failure (CHF) are at high risk of cardiovascular death and recurrent hospital admissions. We aimed to find out whether the use of an angiotensin-receptor blocker could reduce mortality and morbidity.     

Markers of oxidative damage and antioxidant enzyme activities as predictors of morbidity and mortality in patients with chronic heart failure

BackgroundAlthough the majority of previous findings unequivocally confirmed the existence of systemic oxidative stress in chronic heart failure (CHF) patients, data on prognostic potential of biomarkers of oxidative lipid and protein damage are limited. We aimed to address the relation of oxidative stress markers to severity and prognosis in CHF secondary to ischemic cardiomyopathy.Methods and ResultsPlasma malondialdehyde (MDA), protein thiol groups (P-SH), reactive carbonyl derivatives (RCD), together with glutathione peroxidase (GSH-Px) and superoxide dismutase (SOD) activities were determined in 120 CHF patients and 69 healthy controls. Increased lipid peroxidation (MDA) and oxidation of plasma proteins (RCD; P-SH) s well as downregulated GSH-Px activity were found in CHF patients compared with controls. Significant correlation was obtained only for RCD content and remodeling indices (LVEDV: r = 0.469, P = .008; LVESV: r = 0.452; P = .011). Cox regression analysis demonstrated only MDA (HR = 3.33; CI: 1.55–7.12; P = .002) as independent predictor of death, whereas SOD was associated with unstable angina pectoris (HR = 2.09; CI: 1.16–3.78; P = .011).ConclusionsIn the course of CHF progression, carbonyl stress is implicated in the LV remodeling. Malondialdehyde level might be a useful parameter for monitoring and planning management of CHF patients.     

Predictors of stable outcome in treating chronic heart failure patients with carvedilol

Carverdilol has a variable outcome in treating patients with chronic heart failure. This prospective single-center study evaluated the predictors of clinical variables in determining favorable outcomes in treating chronic heart failure patients with carvedilol. The relation between clinical variables and maintenance doses of carvedilol was also determined. Seventy chronic heart failure patients (mean age, 62.2 years, 50 males and 20 females) with a left ventricular ejection fraction < 35% and functional class II-III were enrolled in the study. The patients were clinically followed-up for at least 24 months. Patients were considered to have a favorable outcome if they had no decreases in functional class or quality-of-life score, an increase in left ventricular ejection fraction>5%, were not admitted to hospital due to worsening heart failure, and free of cardiac mortality. Patients with favorable outcomes had a younger age (P = 0.021), higher baseline systolic blood pressure (P = 0.080), better baseline functional class (P = 0.001), and a higher tolerated dose of carvedilol (P = 0.026) than those in the unfavorable group. In this primarily Chinese cohort of chronic heart failure patients, those with favorable outcomes were likely to be young, have a high baseline systolic blood pressure, and good baseline functional class.     

Predictors of prognosis in severe chronic heart failure.

A total of 127 patients with chronic heart failure referred to our exercise laboratory were studied retrospectively to identify parameters predictive of prognosis. Patients were followed for a mean of 14.6 months. The group as a whole had severe ventricular dysfunction with a median ejection fraction of 17% and a median peak rate of oxygen consumption of 13.7 ml/kg/min. During the follow-up period 23 patients (18%) died and 18 (14%) underwent cardiac transplantation. The effect of the following variables on outcome (death or transplantation) were examined: age, cause of heart failure, cardiothoracic ratio on chest radiography, left ventricular end-systolic dimension on echocardiography, left ventricular ejection fraction on radionuclide ventriculography, mean dose of diuretic, plasma sodium and urea concentrations, and peak oxygen consumption during exercise. Although all variables except cause of heart failure affected outcome on univariate analysis, multivariate analysis identified three variables that were statistically significant and independent predictors of outcome. In order of importance these were plasma sodium level, left ventricular ejection fraction and peak oxygen consumption. Even in this group of patients with severe heart failure, these variables were predictive of outcome.     

A propensity-matched study of the association of cardiothoracic ratio with morbidity and mortality in chronic heart failure

A high cardiothoracic ratio (CTR) is a marker of an enlarged heart and is associated with poor outcomes in patients with heart failure (HF). To what extent this association is independent of other confounders is not well known. However, to study this, propensity score matching was used to design a study in which HF patients with normal (0.50) CTRs were well balanced on all measured baseline covariates. In the Digitalis Investigation Group trial (n=7,788), 4,690 patients had high (>0.50) CTRs. Propensity scores for high CTR were calculated for each patient and were then used to match 2,586 pairs of patients with normal and high CTRs. Matched Cox regression analyses were used to estimate associations of high CTR with mortality and hospitalization during 37 months of median follow-up. All-cause mortality occurred in 28.5% (rate 919 per 10,000 patient-years of follow-up) of patients with normal CTRs and 34.3% (rate 1,185 per 10,000 patient-years) of patients with high CTRs (hazard ratio 1.35, 95% confidence interval [CI] 1.21 to 1.51, p<0.0001). All-cause hospitalization occurred in 64.8% (rate 3,513 per 10,000 patient-years) of patients with normal CTRs and 66.2% (rate 3,932 per 10,000 patient-years) of patients with high CTRs (hazard ratio 1.10, 95% CI 1.01 to 1.20, p=0.032). Respective hazard ratios for other outcomes were 1.48 (95% CI 1.30 to 1.68, p<0.0001) for cardiovascular mortality, 1.57 (95% CI 1.28 to 1.92, p<0.0001) for HF mortality, 1.18 (95% CI 1.08 to 1.30, p=0.001) for cardiovascular hospitalization, and 1.27 (95% CI 1.13 to 1.44, p<0.0001) for HF hospitalization. In conclusion, a baseline CTR>0.50 was associated with increased mortality and morbidity in ambulatory patients with chronic HF.     

贫血增加慢性心力衰竭患者死亡率

目的调查贫血在慢性心力衰竭(CHF)住院患者中发生率,以及与CHF患者死亡率的关系。方法收集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,根据是否贫血[血红蛋白<120 g/L(男性)或110 g/L(女性)]分为两组,贫血组和对照组,并进行电话随访。结果共242例患者入选,对197例进行随访,14例(7.1%)失访,经过平均(20±9)个月(2～41个月)随访,共36例(20%)发生全因死亡,包括贫血组13例(34%)和对照组23例(16%)(χ2=6.415,P=0.011)。结论贫血在CHF住院患者中常见,贫血增加CHF死亡率,因此在积极抗心力衰竭治疗同时应高度重视贫血的纠正,以更好地改善CHF患者预后。     

Impact of atrial fibrillation on mortality in patients with chronic heart failure

Chronic heart failure and atrial fibrillation often occur together. The aim of the study is to review the available literature on the impact of atrial fibrillation on mortality in patients with heart failure. Using MEDLINE six full papers were identified. In the studies with severe heart failure atrial fibrillation did not emerge as an independent predictor of mortality beyond standard clinical variables. In contrast, atrial fibrillation was associated with increased mortality in case of mild-to-moderate heart failure.     

Clinical characteristics, treatment and short-term morbidity and mortality of patients with heart failure followed in heart failure clinics. Results of the BADAPIC Registry

INTRODUCTION AND OBJECTIVES: Despite recent improvements in therapy, heart failure is still associated with high mortality and hospitalization rates. New management strategies such as heart failure clinics could help to improve this situation. PATIENTS AND METHOD: We analyzed the clinical features, treatment, morbidity and mortality of 3909 patients with heart failure followed at 62 heart failure clinics in Spain in the last 3 years (BADAPIC Registry). Mean follow-up time was 13 +/- 4 months. RESULTS: Mean age was 66 +/- 12 years (40% of the patients were older than 70 years), and 67% were male. Etiology was ischemic heart disease in 41% of the cases, systemic hypertension in 19%, idiopathic dilated cardiomyopathy in 17%, valvular disease in 17% and other in the remaining 6%. Left ventricular ejection fraction was < 45% in 68% of the patients. After inclusion in the BADAPIC Registry, 86% of the patients received diuretics, 37% received digoxin, 87% were given angiotensin-converting enzyme inhibitors or angiotensin receptor antagonists, 32% received spironolactone, 59% received beta blockers and 28% were given nitrates. Actuarial survival at 24 months was 87%, admission-free survival was 80% and event-free survival was 76%. Survival was similar in men and women, higher in patients younger than 70 years (P<.05), and slightly higher in those with left ventricular ejection fraction > 45% (P=.08). CONCLUSIONS: The treatment received by patients included in the BADAPIC Registry closely approached the recommended standards. Their short-term survival rate was very high.