新发的不同类型心力衰竭合并心房颤动的临床特点和远期预后分析

doi:10.3969/j.issn.1004-583X.2022.06.004

摘要/Abstract

摘要：

目的探讨新发的不同类型心力衰竭合并心房颤动(AF)的临床特点以及临床结局。方法本研究为回顾性观察性研究,连续纳入在2017年7月至2020年7月在宣城市人民医院心血管内科住院并首次确诊为射血分数降低心力衰竭(HFrEF)或射血分数中间范围型心力衰竭(HFmrEF)患者。本研究以是否合并AF分为:HFrEF合并AF组(n=41),HFrEF合并非AF组(n=59),HFmrEF合并AF组(n=58),HFmrEF合并非AF组(n=35)。比较4组的临床特点和临床不良事件。应用多元Cox回归分析HFmrEF和HFrEF患者合并AF对临床不良事件影响。结果共入选193例患者,平均随访时间为(28.87±11.13)个月。(1)4组在性别、年龄、尿酸、脑钠肽前体N末端(NT-proBNP)、左室舒张末期内径(LVEDD)、左心房内径(LAD)、左心室缩短分数、CHA₂DS₂-VASc 评分、心功能分级(NYHA)、β受体阻滞剂使用率、利尿剂使用率和主要不良心脑血管事件发生率差异有统计学意义(均P<0.05);(2)多元Cox回归分析显示:NYHA(HR=1.814,95%CI=1.051~3.131)、NT-proBNP(HR=1.076,95%CI=1.033~1.120)、CHA₂DS₂-VASc 评分(HR=1.375,95%CI= 1.022~1.851)和HFrEF合并AF(HR=5.822,95%CI=1.699~19.955)、 HFmrEF合并AF(HR=5.023,95%CI=1.565~16.118)是患者远期发生主要不良心脑血管事件的独立危险因素(均P<0.05),经Kaplan-Meier检验分析显示,4组远期主要不良心脑血管事件发生率差异有统计学意义(χ²=12.432,P=0.006)。结论新发的HFmrEF和HFrEF患者合并AF是远期发生主要不良心脑血管事件的独立影响因素。

关键词: 射血分数降低心力衰竭, 射血分数中间范围型心力衰竭, 心房颤动, 预后

Abstract:

Objective This study investigated outcomes related to new onset different type of heart failure in patients with atrial fibrillation (AF). Methods This study was a retrospective observational study. The subjects were recruited from the People's Hospital of Xuancheng City from July 2017 to July 2020. All Patients with heart failure with reduced ejection fraction (HFrEF) or heart failure with mid-range ejection fraction (HFmrEF) were initially diagnosed. According to the result of AF, the patients were divided into four groups, HFrEF with AF (n=41),HFrEF with non- AF (n=59), HFmrEF with AF (n=58), HFmrEF with non- AF (n=35). The clinical characteristics and clinical adverse events of the 4 groups were compared.Multivariate Cox regression was used to analyze the effect of HFmrEF and HFrEF patients with AF on clinical adverse events. Results A total of 193 patients were selected. The mean follow-up time was (28.87±11.13) months. Among the four groups, the difference was statistically significant in the gender, age, uric acid, N-terminal pro-B-type natriuretic peptide (NT-proBNP), Left ventricular end diastolic diameter (LVEDD), left atrial diameter (LAD), left ventricular shortening score, CHA₂DS₂ - VASc score, New York heart association (NYHA), the utilization rate of β-blockers and diuretics, and the incidence of major adverse cardiovascular and cerebrovascular events (All P<0.05). Multiple Cox regression analysis shows that NYHA(HR=1.814,95%CI=1.051-3.131),NT-proBNP(HR=1.076,95%CI=1.033-1.120),CHA₂DS₂-VASc score(HR=1.375,95%CI=1.022-1.851),HFrEF with AF(HR=5.822,95%CI=1.699-19.955),HFmrEF with AF(HR=5.023,95%CI=1.565-16.118) were the influencing factors of main adverse cardiovascular and cerebrovascular events(All P<0.05). Kaplan-Meier analysis showed that the difference was a statistically significant in the incidence of long-term major adverse cardiovascular and cerebrovascular events among the four groups (χ²=12.432, P=0.006). Conclusion The initial patients with (HFrEF) or heart failure with mid-range ejection fraction (HFmrEF) combined AF were associated with increased risk of main adverse cardiovascular and cerebrovascular events.

Key words: heart failure with reduced ejection fraction, heart failure with mid-range ejection fraction, atrial fibrillation, outcome

中图分类号:

章敬水, 徐亚男, 王钧, 杨毅, 姜海兵, 唐龙, 王贤平, 邵名亮. 新发的不同类型心力衰竭合并心房颤动的临床特点和远期预后分析[J]. 临床荟萃, 2022, 37(6): 504-509.

Zhang Jingshui, Xu Yanan, Wang Jun, Yang Yi, Jiang Haibing, Tang Long, Wang Xianping, Shao Mingliang. Clinical characteristics and long-term prognosis of initial patients with new onset different type of heart failure combined atrial fibrillation[J]. Clinical Focus, 2022, 37(6): 504-509.

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链接本文: https://huicui.hebmu.edu.cn/CN/10.3969/j.issn.1004-583X.2022.06.004

https://huicui.hebmu.edu.cn/CN/Y2022/V37/I6/504

图/表 3

参考文献 20

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项目	Group 1(n=35)	Group 2(n=59)	Group 3(n=58)	Group 4(n=41)	F/Z/χ²值	P值
男性[例(%)]	18(51.4)	35(59.3)	22(37.9)	26(63.4)	8.008	0.046
年龄(岁)	73.94±9.24	70.31±11.66	76.86±8.17	72.34±10.06	4.448	0.005
高血压[例(%)]	20(57.1)	25(42.4)	26(44.8)	20(48.8)	2.112	0.549
糖尿病[例(%)]	6(17.1)	6(10.2)	4(6.9)	6(14.6)	2.828	0.419
目前吸烟[例(%)]	3(8.6)	11(18.6)	4(6.9)	3(7.3)	4.979	0.173
吸烟年数(年)	33.33±5.77	30.00±17.32	30.79±17.04	29.00±24.75	0.081	0.969
每天吸烟数量(支)	16.67±5.77	16.36±4.52	20.00±8.17	20.00±10.00	0.504	0.684
BMI(kg/m²)	21.71±4.06	21.52±3.30	21.30±3.19	21.76±3.29	0.183	0.908
冠心病[例(%)]	10(28.6)	14(23.7)	7(12.1)	6(14.6)	5.219	0.156
既往PCI[例(%)]	1(2.9)	3(5.1)	0(0.0)	0(0.0)	3.828	0.150
NYHA分级[例(%)]
Ⅱ	6(17.1)	13(22.0)	3(5.2)	2(4.9)
Ⅲ	20(57.1)	34(57.6)	38(65.5)	20(48.8)	16.320	0.012
Ⅳ	9(25.7)	12(20.3)	17(29.3)	19(46.3)
肌酐(μmol/L)	96.20(71.80, 136.00)	91.80(71.00, 112.90)	86.10(68.95, 102.70)	93.30(77.30, 112.05)	2.776	0.427
尿素(mmol/L)	9.08±4.26	8.22±3.78	7.86±4.02	8.52±4.67	0.645	0.587
尿酸(μmol/L)	398.31±110.07	444.93±141.67	431.98±156.79	492.74±155.28	2.740	0.045
葡萄糖(mmol/L)	5.75±1.72	5.29±1.47	5.45±1.77	5.38±1.71	0.557	0.644
NT-proBNP (ng/L)	7399.00 (3131.00, 13266.00)	7688.00 (4629.00, 13954.00)	4132.50 (2771.75, 7173.50)	7188 (4714.50.00, 14705.00)	18.899	<0.01
左心室舒张末内径(mm)	59.29±7.20	65.12±8.33	53.06±7.43	59.92±6.93	20.440	<0.01
LAD(mm)	41.13±5.02	45.80±6.34	45.89±6.79	47.82±9.69	5.240	0.002
LVEF (%)	44(42, 48)	31(27, 36)	46(42, 48)	32(28, 37)	144.410	<0.01
CO	6.10±1.77	6.18±2.07	4.97±1.83	5.92±1.85	1.074	0.365
FS	19.91±3.53	15.32±3.06	19.88±3.45	15.66±3.32	28.662	<0.01
CHA₂DS₂-VAS评分	3.23±0.77	3.00±1.17	3.29±1.04	3.34±1.13	1.096	0.352
用药[例(%)]
β受体阻滞剂	10(28.6)	25(42.4)	56(96.6)	39(95.1)	77.555	<0.01
ARB/ACEI	20(57.1)	25(42.4)	26(44.8)	20(48.8)	2.112	0.549
利尿剂	22(62.9)	57(96.6)	47(81.0)	41(100.0)	32.575	<0.01
MACCEs[例(%)]	4(11.4)	8(13.6)	18(31.0)^*#	14(34.1)^*#	10.667	0.014

项目	Group 1(n=35)	Group 2(n=59)	Group 3(n=58)	Group 4(n=41)	F/Z/χ²值	P值
男性[例(%)]	18(51.4)	35(59.3)	22(37.9)	26(63.4)	8.008	0.046
年龄(岁)	73.94±9.24	70.31±11.66	76.86±8.17	72.34±10.06	4.448	0.005
高血压[例(%)]	20(57.1)	25(42.4)	26(44.8)	20(48.8)	2.112	0.549
糖尿病[例(%)]	6(17.1)	6(10.2)	4(6.9)	6(14.6)	2.828	0.419
目前吸烟[例(%)]	3(8.6)	11(18.6)	4(6.9)	3(7.3)	4.979	0.173
吸烟年数(年)	33.33±5.77	30.00±17.32	30.79±17.04	29.00±24.75	0.081	0.969
每天吸烟数量(支)	16.67±5.77	16.36±4.52	20.00±8.17	20.00±10.00	0.504	0.684
BMI(kg/m²)	21.71±4.06	21.52±3.30	21.30±3.19	21.76±3.29	0.183	0.908
冠心病[例(%)]	10(28.6)	14(23.7)	7(12.1)	6(14.6)	5.219	0.156
既往PCI[例(%)]	1(2.9)	3(5.1)	0(0.0)	0(0.0)	3.828	0.150
NYHA分级[例(%)]
Ⅱ	6(17.1)	13(22.0)	3(5.2)	2(4.9)
Ⅲ	20(57.1)	34(57.6)	38(65.5)	20(48.8)	16.320	0.012
Ⅳ	9(25.7)	12(20.3)	17(29.3)	19(46.3)
肌酐(μmol/L)	96.20(71.80, 136.00)	91.80(71.00, 112.90)	86.10(68.95, 102.70)	93.30(77.30, 112.05)	2.776	0.427
尿素(mmol/L)	9.08±4.26	8.22±3.78	7.86±4.02	8.52±4.67	0.645	0.587
尿酸(μmol/L)	398.31±110.07	444.93±141.67	431.98±156.79	492.74±155.28	2.740	0.045
葡萄糖(mmol/L)	5.75±1.72	5.29±1.47	5.45±1.77	5.38±1.71	0.557	0.644
NT-proBNP (ng/L)	7399.00 (3131.00, 13266.00)	7688.00 (4629.00, 13954.00)	4132.50 (2771.75, 7173.50)	7188 (4714.50.00, 14705.00)	18.899	<0.01
左心室舒张末内径(mm)	59.29±7.20	65.12±8.33	53.06±7.43	59.92±6.93	20.440	<0.01
LAD(mm)	41.13±5.02	45.80±6.34	45.89±6.79	47.82±9.69	5.240	0.002
LVEF (%)	44(42, 48)	31(27, 36)	46(42, 48)	32(28, 37)	144.410	<0.01
CO	6.10±1.77	6.18±2.07	4.97±1.83	5.92±1.85	1.074	0.365
FS	19.91±3.53	15.32±3.06	19.88±3.45	15.66±3.32	28.662	<0.01
CHA₂DS₂-VAS评分	3.23±0.77	3.00±1.17	3.29±1.04	3.34±1.13	1.096	0.352
用药[例(%)]
β受体阻滞剂	10(28.6)	25(42.4)	56(96.6)	39(95.1)	77.555	<0.01
ARB/ACEI	20(57.1)	25(42.4)	26(44.8)	20(48.8)	2.112	0.549
利尿剂	22(62.9)	57(96.6)	47(81.0)	41(100.0)	32.575	<0.01
MACCEs[例(%)]	4(11.4)	8(13.6)	18(31.0)^*#	14(34.1)^*#	10.667	0.014

指标	单因素分析			多因素分析
指标	HR	95%CI	P	HR	95%CI	P
性别(女)	0.711	0.390-1.296	0.265
年龄(岁)	0.991	0.964-1.018	0.518
高血压	1.033	0.572-1.866	0.915
糖尿病	0.535	0.166-1.729	0.296
目前吸烟	1.062	0.419-2.695	0.899
BMI	1.013	0.931-1.103	0.758
冠心病	1.090	0.524-2.268	0.817
既往PCI	0.989	0.136-7.185	0.991
NYHA分级	2.023	1.229-3.330	0.006	1.814	1.051-3.131	0.033
肌酐(μmol/L)	1.037	1.003-1.072	0.035	1.036	0.993-1.081	0.105
尿酸(μmol/L)	1.001	0.999-1.003	0.540
NT-proBNP (ng/L)	1.036	1.001-1.072	0.046	1.076	1.033-1.120	<0.01
LVEDD(mm)	0.993	0.958-1.029	0.692
LAD(mm)	1.009	0.968-1.052	0.667
CO	0.892	0.651-1.222	0.476
FS	1.085	1.008-1.169	0.030	1.073	0.988-1.165	0.096
CHA₂DS₂-VASc评分	1.705	1.268-2.293	<0.01	1.375	1.022-1.851	0.036
β受体阻滞剂	1.641	0.829-3.248	0.155
ARB/ACEI	1.033	0.572-1.866	0.915
利尿剂	1.648	0.589-4.607	0.341
临床分组
Group2 vs Group1	1.207	0.363-4.007	0.759	1.910	0.536-6.810	0.318
Group3 vs Group1	3.199	1.082-9.457	0.035	5.023	1.565-16.118	0.007
Group4 vs Group1	3.818	1.256-11.603	0.018	5.822	1.699-19.955	0.005

指标	单因素分析			多因素分析
指标	HR	95%CI	P	HR	95%CI	P
性别(女)	0.711	0.390-1.296	0.265
年龄(岁)	0.991	0.964-1.018	0.518
高血压	1.033	0.572-1.866	0.915
糖尿病	0.535	0.166-1.729	0.296
目前吸烟	1.062	0.419-2.695	0.899
BMI	1.013	0.931-1.103	0.758
冠心病	1.090	0.524-2.268	0.817
既往PCI	0.989	0.136-7.185	0.991
NYHA分级	2.023	1.229-3.330	0.006	1.814	1.051-3.131	0.033
肌酐(μmol/L)	1.037	1.003-1.072	0.035	1.036	0.993-1.081	0.105
尿酸(μmol/L)	1.001	0.999-1.003	0.540
NT-proBNP (ng/L)	1.036	1.001-1.072	0.046	1.076	1.033-1.120	<0.01
LVEDD(mm)	0.993	0.958-1.029	0.692
LAD(mm)	1.009	0.968-1.052	0.667
CO	0.892	0.651-1.222	0.476
FS	1.085	1.008-1.169	0.030	1.073	0.988-1.165	0.096
CHA₂DS₂-VASc评分	1.705	1.268-2.293	<0.01	1.375	1.022-1.851	0.036
β受体阻滞剂	1.641	0.829-3.248	0.155
ARB/ACEI	1.033	0.572-1.866	0.915
利尿剂	1.648	0.589-4.607	0.341
临床分组
Group2 vs Group1	1.207	0.363-4.007	0.759	1.910	0.536-6.810	0.318
Group3 vs Group1	3.199	1.082-9.457	0.035	5.023	1.565-16.118	0.007
Group4 vs Group1	3.818	1.256-11.603	0.018	5.822	1.699-19.955	0.005