重度慢性心力衰竭患者血尿酸水平与预后的关系

目的 分析血清尿酸（SUA）水平与重度慢性收缩性心力衰竭（CHF）患者预后的关系。 方法 收集2014年4月~2015年1月于我院住院纽约心脏病协会（NYHA）心功能Ⅳ级CHF患者189例,对其随访6个月,终点事件为全因死亡。分析入院SUA水平与CHF住院患者6个月内全因死亡的关系。 结果 按随访结果将患者分为死亡组和存活组。死亡组入院SUA水平明显高于存活组[（514±30） μmol/L vs.（432±32） μmol/L,P<0.01]。Pearson分析显示N末端脑钠尿肽前体（NT-proBNP）与SUA具有正相关性（r=0.345,P<0.05）。多因素Logistic回归分析显示,SUA水平（OR=1.213,95%CI:1.081-3.621,P<0.05）,NT-proBNP（OR=1.456,95%CI:1.113-5.432,P<0.01）,糖尿病（OR=2.105,95%CI:1.221-4.553,P<0.05）是CHF患者6个月全因死亡事件发生的独立危险因素。 结论 血清SUA水平与重度CHF预后有相关性。     

Long-term prognosis of patients with congestive heart failure

Factors determining prognosis in 100 patients with recent onset of congestive heart failure (CHF) were evaluated. The 1 year, 3 year, 5 year, and 10 year survival rates in the entire CHF group were 78.5%, 59.8%, 50.4% and 14.7%, respectively. No correlations between age, sex, heart rate and cardiothoracic ratio, and the cumulative survival rate were found. The prognosis of patients with CHF due to underlying coronary artery disease or primary cardiomyopathy was poor compared with that of patients with other types of heart disease. Patients whose NYHA classification was class III or VI had a significantly lower survival rate than those in class II. Patients with lower left ventricular stroke work and consecutive ventricular premature depolarization also had a significantly lower survival rate. These results suggest that functional status, underlying heart disease, left ventricular stroke work, and the presence of ventricular tachycardia provide important information regarding the long-term prognosis in patients with congestive heart failure.     

Dynamic cyclic changes in coronary sinus caliber in patients with and without congestive heart failure

M-mode echography of the coronary sinus in the apical 2-chamber view enabled us to measure coronary sinus caliber at specific phases of the cardiac cycle. Coronary sinus narrowing occurs consistently during atrial contraction, but is always absent in atrial fibrillation; in patients with congestive heart failure and systemic venous congestion, this narrowing is significantly attenuated.     

Muscle strength as a predictor of long-term survival in severe congestive heart failure

AIMS: The objective of the study was to test the relationship between isolated muscle strength and outcome, and its significance in the context of other exercise variables. METHODS AND RESULTS: 122 consecutive patients (LVEF 21+/-7%) were enrolled in the study. Isokinetic strength testing of the knee extensor and flexor muscles were performed. A subset of 51 patients underwent additional upright bicycle testing with gas exchange analysis. The outcome up to 60 months was defined by event-free survival (group A, n=59) or death (group B, n=34). Patients who had been transplanted were excluded from further analysis. The peak strength of the quadriceps muscle was comparable in both groups (N.S.). In contrast, the index (value adjusted for weight) did reveal significant differences (P<0.04), similar to the peak torque of the knee flexor muscle (P<0.04), whose index was even more significant with regard to differences (P<0.01). Multivariate analysis including muscle strength variables, pVO2 and workload into one model show that the flexor strength index is the only independent variable (x2=9 P<0.003). A cut-off point of 68 Nm x 100/kg in the strength index of the flexor muscles was used to establish a significant difference between groups with regard to outcome (P<0.01). Thus, the isokinetic strength of the knee flexor muscles is related to outcome. Moreover, this parameter is superior to variables such as peakVO2 and workload.     

Decreased skeletal muscle vasodilation in patients with congestive heart failure.

In congestive heart failure (CHF), excessive vasoconstriction is present, which is due to overactive vasoconstrictor mechanisms although vasodilator mechanisms may be impaired. In the present study, we examined vasodilation in CHF by measuring forearm blood flow with a strain gauge plethysmograph. Patients with CHF had higher forearm vascular resistance than normal control subjects. Patients with CHF had decreased forearm vasodilation in response to intra-arterial infusions of atrial natriuretic peptide (ANP) and acetylcholine, but not in response to sodium nitroprusside or nitroglycerin. Oral captopril did not alter the degree of forearm vasodilation during handgrip exercise. These results suggest that endothelium-dependent and ANP-induced forearm vasodilation is impaired in patients with CHF but the decreased vasodilation is not due to impaired vascular smooth muscle responsiveness to a vasodilator. The renin-angiotensin system does not seem to play a major role in the maintenance of vascular resistance during exercise in CHF.     

Very low frequency power of heart rate variability is a powerful predictor of clinical prognosis in patients with congestive heart failure.

BACKGROUND: The present study examined whether the very low frequency (VLF) power of heart rate variability (HRV) is predictive of clinical prognosis in patients with congestive heart failure (CHF). METHOD AND RESULTS: The study recruited 54 consecutive CHF patients with emergency admission because of exacerbation of pulmonary congestion. Holter monitoring was performed after improvement of pulmonary congestion. The frequency components of HRV were calculated in the frequency domain (VLF, low frequency (LF), high frequency (HF), total power (TP) and the ratio of LF to HF power). The left ventricular ejection fraction was calculated, and plasma brain natriuretic peptide (BNP) and norepinephrine were also measured at discharge. Within a mean follow-up period of 19.8 +/- 11.7 months, 18 patients experienced cardiovascular events; 7 patients died and 11 patients required rehospitalization because of worsening of CHF. In univariate analysis, diabetes mellitus (DM), BNP and New York Heart Association (NYHA) functional class were significant as risk factors for cardiac events. VLF power, LF power and TP were the strong predictors for cardiac events in HRV. In multivariate analysis, VLF power predicted cardiac events independently of LF power, TP, DM, BNP and NYHA functional class (chi-square=6.24, p=0.01). CONCLUSIONS: VLF power is an independent risk predictor in patients with CHF.     

T wave alternans is a predictor of death in patients with congestive heart failure

Few data are available about the prognostic role of T wave alternans in patients with congestive heart failure. To assess the ability of T wave alternans, used alone or in combination with other risk markers, to predict cardiac death in decompensated patients, we enrolled 46 patients, mean age 59+/-9, males 89%, ischemic etiology 61%, NYHA class III 35%, left ventricular ejection fraction 29+/-7%. After 1.6 years follow-up, seven patients died from cardiac death (16%), non-sudden in six (86%) and sudden in one (14%). T wave alternans was positive in 24 (52%), negative in 13 (28%), indeterminate in nine patients (20%). T wave alternans was positive in all patients with events (100%) but only in 16 of 37 patients without (41%) (P=0.02). Other predictors of cardiac death were O(2) consumption at the peak of exercise (P=0.03), standard deviation of all NN intervals (P=0.05) and Wedge pressure (P=0.03). When receiver operator characteristics curves were calculated, the highest area (0.73) was found for O(2) consumption at the peak of exercise considering the single variables and for O(2) consumption at the peak of exercise plus T wave alternans (0.79) for combination of them; the comparison of the two receiver operator characteristics curves did not reach statistical difference (P=0.5). In conclusion, this is the first study reporting that T wave alternans can predict cardiac death, with a marginal additional prognostic power when used in combination with measurement of O(2) consumption at the peak of exercise.     

Effects of metoprolol in chagasic patients with severe congestive heart failure

BACKGROUND: Beta-blockers are the most effective and promising treatment for congestive heart failure secondary to left ventricular dysfunction and sympathetic activation. METHODS: Since chagasic patients with severe congestive heart failure have left ventricular systolic dysfunction and neurohormonal activation, we administered metoprolol to nine chagasic patients who were in severe congestive heart failure. Metoprolol (5 mg p.o. daily) was uptitrated on a weekly basis. RESULTS: Patients were receiving digitalis, diuretics and angiotensin converting enzyme inhibitors and had left ventricular dilatation (6.77+/-0.89 cm), depressed ejection fraction (0.20+/-0.06), low systolic blood pressure (93+/-11 mm Hg), sinus tachycardia (115+/-17 beats/min) and sympathetic activation 400+/-246 pg/ml). One patient was in New York Heart Association Functional class III and eight patients were in functional class IV. At the end of the fifth week of treatment (metoprolol 25 mg), seven patients were in functional class III and two were in functional class II. Heart rate decreased to 85+/-15 beats/min (P<0.05) and the systolic blood pressure increased to 108+/-18 mm Hg (P<0.01). There were no significant changes in left ventricular ejection fraction. By the end of the tenth week of treatment (metoprolol 50 mg), four patients were now in functional class I and five were in functional class II. Left ventricular ejection fraction increased to 0.27+/-0.05 (P<0.01) and the left ventricular systolic diameter decreased from 6.38+/-0.90 at baseline to 5.89+/-0.59 and 5.76+/-0.96 after 25 and 50 mg of metoprolol treatment, respectively (P<0.04). Plasma norepinephrine decreased non-significantly to 288+/-91 pg/ml. CONCLUSION: Beta-blockers improve the clinical status and the left ventricular function of chagasic patients with severe congestive heart failure.     

Cardiovascular effects of berberine in patients with severe congestive heart failure

Berberine, an alkaloid of the protoberberine family, has been shown to have strong positive inotropic and peripheral resistance-lowering effects in dogs with and without heart failure. To determine the acute cardiovascular effects of berberine in humans, 12 patients with refractory congestive heart failure were studied before and during berberine intravenous infusion at rates of 0.02 and 0.2 mg/kg per min for 30 minutes. The lower infusion dose produced no significant circulatory changes, apart from a reduction in heart rate (14%). The 0.2 mg/kg per min dose elicited several significant changes: (a) Decreases in systemic (48%, p less than 0.01) and pulmonary vascular resistance (41%, p less than 0.01), and in right atrium (28%, p less than 0.05) and left ventricular end-diastolic pressures (32%, p less than 0.01). (b) Increases in cardiac index (45%, p less than 0.01), stroke index (45%, p less than 0.01), and LV ejection fraction measured by contrast angiography (56%, p less than 0.01). (c) Increases in hemodynamic and echocardiographic indices of LV performance: peak measured velocity of shortening (45%, p less than 0.01), peak shortening velocity at zero load (41%, p less than 0.01), rate of development of pressure at developed isovolumic pressure of 40 mmHg (20%, p less than 0.01), percent fractional shortening (50%, p less than 0.01), and the mean velocity of circumferential fiber shortening (54%, p less than 0.01). (d) Decrease of arteriovenous oxygen difference (28%, p less than 0.05) with no changes in total body oxygen uptake, arterial oxygen tension, or hemoglobin dissociation properties.(ABSTRACT TRUNCATED AT 250 WORDS)     

Decreased heart rate recovery after exercise in patients with congestive heart failure: effect of beta-blocker therapy

BACKGROUND: Decreased heart rate recovery (HRR) is a predictor of mortality in patients with coronary artery disease and preserved left ventricular function. We investigated the changes in HRR and assessed the impact of beta-blockade therapy on these parameters in patients with symptomatic congestive heart failure (CHF). METHODS AND RESULTS: HRR, defined as the difference from peak exercise heart rate (HR) to HR measured at 1, 2, and 3 minutes after maximal exercise test, was studied in 23 stable CHF patients and 12 healthy subjects. Patients with CHF performed a maximal exercise test using a Ramp protocol before and after 6 months of therapy with either metoprolol or carvedilol. Patients with CHF exhibited a significantly attenuated HRR compared with healthy subjects at 1 minute (17.8 +/- 5.8 versus 26.8 +/- 16.2 beats), 2 minutes (34.0 +/- 10.6 versus 48.0 +/- 11.2 bpm) and 3 minutes (41.0 +/- 12.4 versus 60.0 +/-12.4 bpm) after exercise (P<.05 for all parameters). Beta-blocker therapy for 6 months did not significantly improve HRR. CONCLUSION: HRR is markedly attenuated in stable CHF patients compared with healthy subjects. Long-term beta-blocker therapy appears to cause no significant improvement in HRR up to 3 minutes after maximal exercise.     

Decreased renal function as an independent predictor of re-hospitalization for congestive heart failure.

BACKGROUND: Patients with congestive heart failure (CHF) are often re-hospitalized, worsening both their quality of life and prognosis. Although renal dysfunction reportedly increases the risk of CHF, the association between renal dysfunction and re-hospitalization for CHF remains unclear. METHODS AND RESULTS: Patients with CHF and decreased renal function were reviewed. The estimated glomerular filtration rate (GFR) was calculated with the Modification of Diet in Renal Disease equation. Patients with decreased renal function (estimated GFR on admission <45 ml .min(-1) . 1.73 m(-2)) were re-hospitalized more frequently than were patients with preserved renal function (estimated GFR on admission >or=45). Patients with decreased renal function were older and had higher rates of anemia, worsening renal function during hospitalization, and previous hospitalization for CHF. Independent predictors of re-hospitalization for CHF identified with multivariate analysis were age, previous hospitalization for CHF, decreased renal function, and non-use of an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker. CONCLUSIONS: Renal dysfunction is an independent predictor of re-hospitalization for CHF, so careful follow-up is needed, even after discharge.     

Decreased spontaneous heart rate variability in congestive heart failure

Heart rate (HR) variability is a noninvasive index of the neural activity of the heart. Although also dependent on the sympathetic activity of the heart, HR variability is mainly determined by the vagal outflow of the heart. Several HR abnormalities have been described in patients with congestive heart failure (CHF); however, there are no data on HR variability in CHF patients. In the present study HR variability was assessed in 20 CHF patients and 20 control subjects from 24-hour Holter tapes. HR variability was evaluated by calculating the mean hourly HR standard deviation and by analyzing the 24-hour RR histogram. Mean hourly HR standard deviation was markedly and significantly reduced in CHF patients both over the 24-hour period (97.5 +/- 41 vs 233.2 +/- 26 ms, p less than 0.001) as well as during most of the individual hours examined. The 24-hour RR histogram of CHF patients had a different shape and had a decreased variation compared to control subjects (total variability 356 +/- 102 vs 757 +/- 156 ms, p less than 0.001). Thus, CHF patients with depressed ejection fraction (less than 30%) have a low HR variability compared to normal individuals. This result can be interpreted as adjunctive evidence for decreased parasympathetic activity to the heart during CHF.     

Acute pulmonary embolism is an independent predictor of adverse events in severe decompensated heart failure patients

BACKGROUND: Congestive heart failure (CHF) is a well-recognized risk factor for venous thromboembolism (VTE) and is associated with higher mortality in patients with an acute pulmonary embolism (PE). There are very few data on how acute PE affects the clinical course of patients with heart failure. The purpose of this study was to determine the impact of an acute PE on the short-term prognosis of patients hospitalized for decompensated CHF. METHODS: This was a prospective cohort study of 198 patients admitted to a coronary care unit between July 2001 and March 2003 with severe decompensated CHF. The primary outcome measure was death or rehospitalization at 3 months. RESULTS: PE was confirmed in 18 of 198 patients enrolled (9.1%). The groups with and without PE were comparable with regards to demographics, the prevalence of comorbid conditions, and severity of CHF (p > 0.05). The prevalence of cancer (p = 0.0001), previous VTE (p = 0.003), and right ventricular overload (p = 0.006) was higher in the PE group. The presence of PE was also associated with a longer hospital stay (37.5 +/- 71.6 days vs 15.4 +/- 15.0 days, p = 0.001) [mean +/- SD] and a higher incidence of death or rehospitalization at 3 months (72.2% vs 43.9%, p = 0.02). In a multiple logistic regression analysis, PE remained an independent predictor of death or rehospitalization at 3 months (odds ratio, 4.0; 95% confidence interval, 1.1 to 15.1; p = 0.038). CONCLUSIONS: Acute PE commonly complicates the hospital course of patients with severe CHF, increasing the length of hospital stay and the chance of death or rehospitalization at 3 months.