影响心房颤动合并心力衰竭患者预后的危险因素
Predictors of prognosis of patients with atrial fibrillation and heart failure
目的:本文旨在分析导致心力衰竭(心衰)合并心房颤动(房颤)患者不良预后的危险因素,提高临床高危患者的识别并改善预后。方法连续入选2013年2月至2015年8月于阜外医院住院经超声心动图检查明确左心室射血分数<0.40且心电图证实出现房颤的患者,收集临床资料,出院后每半年随访1次。终点事件为全因死亡或接受心脏移植手术。通过多因素Cox生存分析影响心衰合并房颤者预后的危险因素。结果连续筛选265例收缩性心衰患者,其中,合并房颤的73例心衰患者纳入本研究。平均随访(16.8±10.2)个月,24例死亡(32.9%),6例(8.21%)接受心脏移植术,临床事件的总发生率为41.1%。发生临床事件的患者心功能Ⅳ级( NYHA分级)所占比例(70.0%对44.1%)、右心室内径[(27.29±5.68) mm对(24.42±4.26) mm]、基线总胆红素水平[(38.54±25.86)μumol/L对(24.41±9.36)μmol/L]、直接胆红素[(13.07±14.13)μmol/L对(6.29±4.09)μmol/L]、氨基末端脑钠肽前体(NT-Pro-BNP)水平[(5475.05±2909.21) pg/ml对(3288.09±3883.53) pg/ml]、高血压病史(26.7%对60.5%)、血管紧张素转换酶抑制剂/血管紧张素Ⅱ受体拮抗剂( ACEI/ARB )治疗(40.0%对65.1%)与无临床事件者相比存在差异(均P<0.05)。多因素Cox分析校正性别、心功能等危险因素后,发现基线总胆红素水平增高( HR=1.09,95%CI 1.01~1.18,P=0.032)、血红蛋白水平降低( HR=1.02,95%CI 1.003~1.040,P=0.032)是增加临床事件的独立危险因素,ACEI/ARB的应用(HR=0.33,95%CI 0.12~0.91,P=0.022)是降低临床事件风险的独立影响因素。结论心衰合并房颤患者病死率高,总胆红素水平增高、血红蛋白水平降低是增加临床事件风险的独立危险因素,药物治疗有助于降低临床事件风险。
更多Objective To investigate the predictors of prognosis of patients with atrial fibrillation ( AF) and heart failure ( HF) .Methods We recruited a set of consecutive patients with HF ( left ventricular ejection fraction<0.4) and AF from February 2013 to August 2015 in Fuwai Hospital .Their clinical outcomes were fol-low up once per six months , and multivariate Cox regression analysis was performed to determinate the inde-pendent risk factors of all-cause mortality and heart transplant .Results A total of 73 consecutive individuals with HF and AF were included in this study .During(16.8±10.19)months follow-up,24 patients died(32.9%), and 6 patients had a heart transplant ( 8.21%) .The total rate of clinical events was 41.1%.Significant differ-ences were observed in NYHA classes Ⅳ(70.0%vs.44.1%),hypertension history(26.7%vs.60.5%),right ventricular diameters[(27.29±5.68) mm vs.(24.42±4.26) mm],levels of bilirubin[total bilirubin(TBIL):(38.54±25.86) μmol/L vs.(24.41±9.36) μmol/L;direct bilirubin(DBIL):(13.07±14.13) μmol/L vs.(6.29±4.09) μmol/L],N-terminal fragment of brain natriuretic peptide [NT-pro-BNP,(5475.05± 2909.21) pg/ml vs.(3288.09±3883.53) pg/ml],and use of angiotensin converting enzyme inhibitors (ACEI) and angiotensin receptor blockers ( ARB,40.0%vs.65.1%) between patients with and without clinical events (all P<0.05).The multivariate Cox regression analysis showed that high level of bilirubin (HR=1.09,95%CI 1.01~1.18,P=0.032)and low level of hemoglobin (HR=1.02,95%CI 1.003~1.040,P=0.032)were in-dependently related to increased risk of clinical events .Using of ACEI and β-blocker(HR=0.33,95%CI 0.12~0.91,P=0.022)was a protective factor for clinical outcomes .Conclusions AF in patients with HF has in-creased risk of clinical events .The use of ACEI and ARB , high level of bilirubin and low level of hemoglobin might had impact on the prognosis of patients with both HF and AF .
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