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。     

Congestive heart failure with preserved left ventricular systolic function after acute myocardial infarction: clinical and prognostic implications

AIMS: To characterise the prevalence, in-hospital complications, management, and long-term outcome of patients with congestive heart failure but preserved left ventricular systolic function after acute myocardial infarction. METHODS: 3166 consecutive patients screened for entry in the Bucindolol Evaluation in Acute Myocardial Infarction Trial with definite acute myocardial infarction and echocardiographic assessment of left ventricular systolic function were included between 1998 and 1999 in this prospective observational study. Main outcome measures were occurrences of in-hospital complications and all cause mortality. RESULTS: Congestive heart failure was seen during hospitalisation in 1464 patients (46%), 717 patients had preserved left ventricular systolic function (wall motion index > or =1.3 corresponding to ejection fraction > or =0.40), and 732 patients had systolic dysfunction (wall motion index <1.3). One year mortality in patients with no heart failure, heart failure with preserved systolic function, and heart failure with systolic dysfunction were 6, 22 and 35%, P<0.0001. Unadjusted risk of death from all causes associated with heart failure and preserved systolic function was 3.3 (95% CI 2.8-4.0), and after adjustment for baseline characteristics and left ventricular systolic function in multivariate Cox proportional hazards analysis the risk was 2.1 (95% CI 1.7-2.6), P<0.0001. CONCLUSIONS: Congestive heart failure is frequently present in patients with preserved left ventricular systolic function, and is associated with increased risk of in-hospital complications and death following acute myocardial infarction.     

急性心力衰竭患者肌钙蛋白I水平与基础病因及其预后的相关性

目的:探讨肌钙蛋白I(cTnI)在急性心力衰竭(AHF)患者中水平和变化与基础病因及AHF预后的关系。方法: 84例确诊的AHF患者,按病因分为缺血性心脏病(IHD)组(26例)、心脏瓣膜病(VHD)组(17例)、扩张型心肌病（DCM）组(25例)、高血压性心脏病(HHD)组(16例)。入院即刻与病情缓解时分别测定cTnI浓度。据入院即刻浓度分为cTnI(+)(14例)和cTnI(-)(70例)两组;据cTnI浓度分为入院即刻与病情缓解时均为cTnI(+)(1组)、入院即刻cTnI(+)与病情缓解时cTnI(-)(2组)、入院即刻与病情缓解时均为cTnI(-)(3组)3组。记录住院期间病情缓解时间,出院后1、3、6、12个月再入院及死亡例数,分析cTnI浓度与病因及其预后的相关性。结果: ①入院即刻与病情缓解时IHD组cTnI浓度均较DCM、HHD两组明显升高(分别P<0.01、P<0.05);IHD、VHD、HHD 3组缓解时cTnI浓度均较入院即刻明显回降(分别P<0.05、P<0.01、P<0.05)。 ②cTnI(+)组缓解时间较cTnI(-)组长(P<0.01)。入院即刻cTnI浓度与缓解时间呈正相关(r=0.286,P<0.01)。③cTnI(+)组住院期间病死率高于cTnI(-)组(P<0.05);出院后12个月cTnI(+)组病死率明显高于cTnI(-)组(P<0.01)。cTnI(+)组住院期间及出院后12个月累积心源性病死率明显高于cTnI(-)组(P<0.01)。出院后1、3、6、12个月cTnI(+)组再入院率较cTnI(-)组明显升高(分别P<0.05、P<0.01、P<0.01、P<0.01)。治疗前后cTnI均阳性组住院期间及出院后12个月累积病死率较治疗前后阳转阴组和均阴性组明显升高(均P<0.01)。结论: AHF患者cTnI水平及治疗前后的变化与基础病因及其预后相关。     

低镁血症与老年急性心力衰竭90天不良预后的相关性

目的探讨低镁血症和老年急性心力衰竭(AHF)患者90 d不良预后的相关性。方法入选2013年1月至2016年12月北京医院急诊科AHF患者150例,根据入院后90 d内是否发生终点事件分为预后不良组56例和非预后不良组94例,随访90 d终点事件为患者全因死亡或再次因AHF入院,分析影响患者预后的危险因素。应用SPSS 19.0统计软件对数据进行处理。组间比较采用t检验、Mann-Whitney U检验或χ~2检验。单因素和多因素logistic回归分析筛选影响预后的危险因素。结果 90 d内终点事件发生率37.3%(56/150),其中因AHF再入院31.3%(47/150),死亡发生率6%(9/150)。预后不良组血镁水平明显低于非预后不良组[(0.70±0.05)vs(0.80±0.09)μmol/L],差异有统计学意义(P=0.000)。多因素logistic回归分析结果表明血镁水平降低[OR=30.631,95%CI 5.943~157.881;P=0.000]、呼吸频率增快[OR=1.354,95%CI 1.112~1.648;P=0.003]、临床床旁分级重型[OR=3.316,95%CI 1.169~9.403;P=0.024]、N末端脑钠肽前体(NT-pro BNP)水平升高[OR=3.960,95%CI 1.318~11.892;P=0.014]为影响AHF患者90 d预后的独立危险因素。结论低镁血症是老年AHF患者90 d不良预后的危险因素,其价值值得临床医师重视。     

The role of plasma biomarkers in acute heart failure. Serial changes and independent prognostic value of NT-proBNP and cardiac troponin-T

AIMS: Brain natriuretic peptide (BNP), NT-proBNP and troponins are useful for the assessment of patients with heart failure. Few data exist about their serial changes and their prognostic value in patients with acute heart failure (AHF). METHODS AND RESULTS: NT-proBNP and troponin-T plasma levels were measured at baseline, after 6, 12, 24, 48 h and at discharge in 116 consecutive patients with AHF and no evidence of acute coronary syndrome. NT-proBNP levels were 4421 pg/mL at baseline, declined after 24 h and reached their nadir at 48 h (2703 pg/mL). Troponin-T was detectable in 48% of patients. During a median follow-up of 184 days, 52 patients died or had a non-fatal cardiovascular hospitalisation. At a multivariable analysis including clinical and echo-Doppler variables, NT-proBNP plasma levels at discharge, detectable troponin-T plasma levels, and NYHA class at discharge were the only independent prognostic factors. CONCLUSION: In patients with AHF, NT-proBNP levels decline 24 h after the initiation of intravenous therapy and troponin-T is detectable in 48% of cases. NT-proBNP levels at discharge, detectable troponin-T levels, NYHA class and serum sodium have independent prognostic value.     

A very high frequency index of heart rate variability for evaluation of left ventricular systolic function and prognosis in chronic heart failure patients using five-minute electrocardiogram

Objective A novel index based on fi-equency-domain analysis of heart rate variability （HRV） was tested on patients with reduced left ventricular systolic function. This index, namely VHFI, was defined as the very high frequency （VHF） component of the power spectrum normalized to represent its relative value in proportion to the total power minus the very low frequency component. Methods Patients （n = 130） were divided into a study group, consisting 66 patients with decreased left ventricular systolic function, and a control group, consisting 64 patients with normal heart structure and function and without severe coronary artery stenosis （〈 50%）. Results VHFI in the study group was significantly higher than that in the control group （19.17 ± 13.35 vs 11.37 ± 10.77, P 〈 0.001）. Cardiac events occurred in 18 patients during follow-up （33.34 i 3.26 months）. Defining the positive test as VHFI =15 and negative test as VHFI 〈15, achieved a sensitivity of 57.58% and a specificity of78.13% for predicting decreased left ventricular systolic function, and achieved a sensitivity of 66.67% and a specificity of 64.29% for predicting cardiac events. Univariate Cox regression analysis showed that positive VHFI test was an independent variable in predictive cardiac events. Conclusions The results suggest that VHFI is a useful tool for quick evaluation of left ventricular systolic function and prediction of prognosis     

Effect of a heart failure clinic on survival and hospital readmission in patients discharged from acute hospital care

Ambulatory care by physicians especially devoted to the management of heart failure (HF) has been reported to have beneficial effects. The aim of this work was to assess the effect of outpatient management at a HF clinic, as compared with care by the usual assistant physician, on prognosis of HF patients. In this non-randomised study, we prospectively followed 339 patients after a hospitalisation index for HF, in order to compare prognosis between two groups of HF patients according to the ambulatory assistance setting: either a specific outpatient clinic (n=157) or the usual assistant physician (n=182). The outcomes assessed were all-cause death or cardiac-cause rehospitalisation during the first month after discharge and survival over the longer term. The risk of dying or being readmitted during the first month after discharge was significantly lower in patients followed at the HF clinic (adjusted odds ratio 0.23; 95% CI 0.12-0.46). Patients followed in the HF clinic also had an independent significantly lower hazard of dying during a longer-term follow up of average length 373 days (adjusted hazard ratio 0.52; 95% CI 0.34-0.81). The results support the fact that a multidisciplinary and permanently available medical staff might be of relevance in improving outcomes in HF patients.     

Treatment with ramipril improves systolic function even in patients with mild systolic dysfunction and symptoms of heart failure after acute myocardial infarction

Background: Clinical signs of heart failure such as pulmonary rales and dyspnea, ventricular dysfunction, and ventricular arrhythmia are independent predictors of a poor prognosis after acute myocardial infarction (AMI). Hypothesis: The study aimed to assess the effect of ramipril treatment on mildly depressed left ventricular (LV) systolic function, assessed by atrioventricular (AV) plane displacement in patients with congestive heart failure after AMI. Methods:The study was a substudy in the Acute Infarction Ramipril Efficacy Study, a double-blind, randomized, placebo-controlled trial of ramipril versus placebo in patients with symptoms of heart failure after AMI. In all, 56 patients were included in the main study, 4 refused to participate in the substudy, and 4 were excluded for logistical reasons. Echocardiography was performed at entry and after 6 months. Patients who underwent coronary artery bypass grafting during the follow-up period were excluded. Results: At baseline, the patients had modest LV dysfunction, and mean AV plane displacement of 9.7 mm. During follow-up, AV plane displacement increased in ramipril-treated patients from 9.5 to 10.9 mm (p < 0.01). No statistically significant changes were seen in the placebo group. Conclusions: Ramipril improves LV systolic function in patients with clinical signs of heart failure and only modest systolic dysfunction after AMI. Measurement of AV plane displacement is a simple and reproducible method for detection of small changes in systolic function and may be used instead of ejection fraction in patients with poor image quality.     

Prevalence and prognostic significance of atrial fibrillation in outpatients with heart failure due to left ventricular systolic dysfunction

INTRODUCTION: Atrial fibrillation (AF) is common in patients with heart failure (HF) due to left ventricular systolic dysfunction (LVSD), with conflicting prognostic data. The aim of our study was to assess the prevalence and incidence of AF in patients with HF and to determine the prognostic impact of baseline AF and the development of new onset AF. METHODS AND RESULTS: We included 1019 outpatients with HF due to LVSD; follow-up time ranged from 3 to 64 months. At baseline 26.4% of patients had AF. Of the 284 patients with a follow-up ECG and baseline SR, 18.7% developed new onset AF. Patients with AF were older (p<0.001), more often male (p=0.04), and more likely to have a history of stroke (p=0.03), but were less likely to have IHD (p<0.001). Baseline rhythm was independent of LVEF and NYHA-class. Baseline AF was associated with increased all-cause mortality (HR 1.38; CI 1.07-1.78, p=0.01) and all-cause mortality/hospitalisation (HR 1.43; CI 1.22-1.68, p<0.001). When adjusted for baseline covariates, baseline AF was independently associated with an increased risk of experiencing the combined endpoint (HR 1.29; CI 1.05-1.58; p=0.02), but did not predict all-cause mortality. By multivariable analyses, new-onset AF was associated with increased risk of all-cause mortality/hospitalisation (HR 1.45; CI 1.05-2.00; p=0.02). CONCLUSION: In outpatients with HF due to LVSD, AF is a common co-morbidity, which adversely affects morbidity and mortality outcomes.     

Right bundle branch block and long-term mortality in patients with acute congestive heart failure

OBJECTIVES: Risk stratification in acute congestive heart failure (ACHF) is poorly defined. The aim of the present study was to assess the impact of right bundle brunch block (RBBB) on long-term mortality in patients presenting with ACHF. METHODS AND RESULTS: The initial 12-lead electrocardiogram was analysed for RBBB in 192 consecutive patients presenting with ACHF to the emergency department. The primary endpoint was all-cause mortality during 720-day follow-up. This study included an elderly cohort (mean age 74 years) of ACHF patients. RBBB was present in 27 patients (14%). Age, sex, B-type natriuretic peptide levels and initial management were similar in patients with RBBB when compared with patients without RBBB. However, patients with RBBB more often had pulmonary comorbidity. A total of 84 patients died during follow-up. Kaplan-Meier analysis revealed that mortality at 720 days was significantly higher in patients with RBBB when compared with patients without RBBB (63% vs. 39%, P = 0.004). In Cox proportional hazard analysis, RBBB was associated with a two-fold increase in mortality (hazard ratio 2.18, 95% CI 1.26-3.66; P = 0.003). This association persisted after adjustment for age and comorbidity. CONCLUSIONS: RBBB is a powerful predictor of mortality in patients with ACHF. Early identification of this high-risk group may help to offer tailored treatment in order to improve outcome.     

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.     

慢性心力衰竭患者血尿酸水平和房颤的关系

目的 分析慢性心力衰竭（CHF）患者血尿酸（SUA）水平与房颤（AF）的关系。方法 回顾性地分析2010年1月至2014年2月期间在商洛市中心医院心血管内科住院的218例CHF患者的人口学资料、既往相关病史、血液生化指标、超声心动图及颈部血管超声结果。根据是否AF将218例患者分为AF组和窦性心律组。结果 218例患者中,有49例合并AF,169例为窦性心律,AF发生率为22.5%。与窦性心律组相比,SUA水平在AF组明显升高。AF组的年龄比窦性心律组更高[（64.32±9.87） vs （56.78±10.14）岁,P＜0.05。];射血分数前者比窦性心律组低,差异有统计学意义（P＜0.05）;而包括左心房内径、左心室舒张末内径、左心室收缩末内径等在内的超声心动图参数,AF组比窦性心律组高;颈动脉内膜中层厚度AF组也明显高于窦性心律组（P＜0.05）。多因素logistic回归分析显示,SUA水平为发生AF的独立危险因素。结论 AF组患者有更高的SUA水平和更差的心功能。     

血浆脑钠肽及去甲肾上腺素对老年急性心力衰竭患者的预后评估

目的探讨老年急性心力衰竭患者血浆脑钠肽（BNP）和去甲肾上腺素（NE）的动态变化,研究二者对预后的判断价值。方法对117例老年急性心力衰竭患者分别于入院时、入院第3天、出院时抽血测定血浆BNP和NE浓度,分析患者血浆BNP和NE浓度的变化,出院后随访3个月心脏病意外事件的发生情况。使用ROC曲线分析出院前血浆BNP及NE水平对事件发生的预测能力。结果老年急性心力衰竭患者血浆BNP和NE水平在心力衰竭治疗后第3天均明显下降[BNP：（781±580）vs（1368±939）ng／L;NE：163（109,281）vs295（174,509）ng／L;P〈0．05],但之后BNP变化不明显,NE持续下降（P〈0．05）;出院前血浆BNP和NE浓度与患者预后相关,事件组出院前BNP和NE浓度均高于非事件组（P〈0．05）。BNP的ROC曲线下面积为0．721,NE为0．739,二者对事件发生的预测准确性中等,NE略优于BNP。慢性心力衰竭急性失代偿组事件发生率及死亡率均显著高于急性心力衰竭组（P=0．008,P=0．035）。结论出院前血浆BNP和NE水平对老年急性心力衰竭患者的预后具有预测作用,NE略优于BNP;慢性心力衰竭急性失代偿患者血浆BNP及NE水平均显著高于急性心力衰竭患者,且具有更高的事件发生率和死亡率。     

舒张性心力衰竭患者血浆Apelin-12水平变化

目的:探讨舒张性心力衰竭(心衰)患者血浆Apelin-12水平的变化及临床意义。方法:选择2010-01-2010-06期间在我院心内科住院的慢性心衰患者60例,舒张性心衰(A组)20例,收缩性心衰(B组)40例,后者再分为3个亚组,心功能Ⅱ级组9例,心功能Ⅲ级组20例,心功能Ⅳ级组11例。健康体检者20例为对照组。酶联免疫吸附法(ELISA)测定血浆Apelin-12水平。结果:A组和B组血浆Apelin-12水平均明显低于对照组[(1.55±0.18)ng/L,(0.91±0.15)ng/L∶(3.55±0.26)ng/L,均P<0.05],其中,A组高于B组,P<0.05。B组不同的心功能分级Apelin-12水平差异无统计学意义,P=0.126。结论:舒张性心衰患者和收缩性心衰患者,血浆Apelin-12水平均降低,与心功能分级无关。     

舒张性心力衰竭与收缩性心力衰竭临床特征的比较

目的:探讨舒张性心力衰竭和收缩性心力衰竭患者临床特征的差异。方法:选择心力衰竭患者253例,其中舒张性心力衰竭118例,收缩性心力衰竭135例。登记患者的临床资料,分析各组患者临床特征的差异。所有患者均检测N末端脑钠尿肽前体(NT-proBNP)及高敏C反应蛋白(hs-CRP)。结果:舒张性心力衰竭和收缩性心力衰竭均以老年患者居多,前者以女性多见(56.8%),并发高血压病(81.4%)及心房颤动(26.3%)均高于于后者(前项P0.01,后项P0.05),并发冠心病(45.8%)少于后者(P0.01);两组NT-proBNP及hs-CRP均随着NYHA心功能分级增加而显著升高(P0.01),舒张性心力衰竭组NT-proBNP低于收缩性心力衰竭组(P0.01),但hs-CRP两组间差异无统计学意义。结论:与收缩性心力衰竭相比,舒张性心力衰竭于老年女性更多见,高血压病患病率及心房颤动发生率较高,NT-proBNP水平较低。     

Prognostic factors in patients hospitalized with acute heart failure syndrome

Each year,there are over one million hospitalizations for acute heart failure syndrome(AHFS)in the United States alone, with a similar number in Western Europe.These patients have very high short-term(2-6 months)mortality and readmission rates,while the healthcare system incurs substantial costs,Until recently,the clinical characteristics,management patterns,and outcomes of these patients have been poorly understood and,in consequence,risk stratification for these patients has not been well defined.Several risk prediction models that can accurately identify high-risk patients have been developed in the last year using data from clinical trials,large registries or administrative databases.Use of multi-variable risk models at the time of hospital admission or discharge offers better risk stratification and should be encouraged,as it allows for appropriate allocation of existing resources and development of clinical trials testing new treatment strategies for patients admitted with AHFS.The emerging observation that the prognosis for the ensuing three to six months may be obtained at presentation for AHFS has major implications for development of future therapies.     

心房颤动对慢性收缩性心力衰竭患者和射血分数正常心力衰竭患者预后的影响

目的 探讨心房颤动（简称房颤）对慢性收缩性心力衰竭（CSHF）及慢性射血分数正常心力衰竭（HF-PSF）住院患者预后的影响。方法 前瞻性分析武汉地区4家三级甲等教学医院848例心力衰竭（简称心衰）患者,根据左室射血分数分为CSHF组（n=560）、HFPSF组（n=288）。 每组根据有无房颤又分为房颤与非房颤亚组。 单因素Kaplan-Meier曲线分别分析CSHF和HFPSF患者房颤亚组和非房颤亚组总死亡 、 心脏泵功能衰竭死亡（心衰死亡）、 心源性猝死和栓塞相关死亡的差异 。多因素Cox风险比例模型分别比较CSHF和HFPSF患者房颤亚组与非房颤亚组不同预后的差异。 结果 单因素分析发现, CSHF和HFPSF组房颤亚组与非房颤亚组总死亡无差异。CSHF组中与非房颤亚组（n=374）相比,房颤亚组（n = 186）心衰死亡增高（P = 0. 01）、栓塞相关死亡增加（P0.05）。 多因素Cox风险比例模型分析发现房颤增加CSHF患者栓塞相关死亡风险（HR = 2. 106,95% CI：1. 436 - 2.719,P〈0. 01）。 结论 房颤对CSHF和HFPSF患者预后的影响存在差异,仅增加CSHF患者栓塞相关死亡风险。房颤影响CSHF患者预后的原因可能不在于心律失常本身而在于其并发症。