射血分数改善型心力衰竭的临床特点及预后研究

doi:10.12114/j.issn.1007-9572.2021.01.050

摘要/Abstract

摘要： 背景左心室射血分数（LVEF）常被用来对心力衰竭（HF）进行分型，但部分HF患者经治疗后射血分数会发生改善，因此产生了射血分数改善型心力衰竭（HFimpEF）这一概念。然而目前HFimpEF相关研究多集中于欧美国家，我国关于此类人群的临床特点及预后分析鲜有报道。目的分析我国HFimpEF患者临床特点、预后及预后的预测因素。方法纳入于2018年6月至2020年5月在河北省人民医院心内科住院治疗的慢性心力衰竭（CHF）患者，从电子病历中获取患者的人口学数据和基线临床信息，根据基线及复查时的LVEF分为射血分数保留（HFpEF）组、射血分数中间值（HFmrEF）组、射血分数降低（HFrEF）组、射血分数改善（HFimpEF）组。自最后一次复查超声心动图开始，通过电子病历、门诊及电话进行随访，终点事件为全因死亡及全因再住院，随访时间截至2021-06-01。采用二元Logistic回归分析探讨LVEF改善的影响因素，采用Kaplan-Meier法绘制全因死亡和全因住院的生存曲线，采用Cox比例风险回归模型分析全因死亡和全因再入院的危险因素。结果最终纳入患者530例，HFpEF组245例（占46.2%），HFmrEF组55例（占10.4%），HFrEF组133例（占25.1%），HFimpEF组97例（占18.3%）。HFimpEF组死亡率低于HFpEF组（P=0.014）和HFrEF组（P<0.001）。HFimpEF组再住院率低于HFpEF组（P=0.011）和HFmrEF组（P=0.001）。基线时收缩压较高〔OR=1.036，95%CI（1.019，1.053），P<0.001〕、左心室收缩末内径（LVESD）≤37 mm〔OR=0.245，95%CI（0.118，0.507），P<0.001〕、应用β-受体阻滞剂〔OR=2.868，95%CI（1.304，6.305），P=0.009〕和醛固酮受体拮抗剂〔OR=2.691，95%CI（1.316，5.503），P=0.007〕是LVEF改善的影响因素。HFrEF、年龄较大、合并心脏瓣膜病、慢性肾脏病、贫血、未应用β-受体阻滞剂及口服抗凝药是CHF患者全因死亡的独立风险因素（P<0.05），HFpEF、HFmrEF、慢性肾脏病是CHF患者全因再入院的独立风险因素（P<0.05）。合并心脏瓣膜病〔HR=6.499，95%CI（1.504，28.089），P=0.012〕、贫血〔HR=4.884，95%CI（1.242，19.208），P=0.023〕是HFimpEF患者死亡的风险因素。结论HFimpEF是一组独立的HF表型，此类患者临床表现较轻、心室重构程度较小、预后较好，收缩压较高、LVESD≤37 mm、应用β-受体阻滞剂和醛固酮受体拮抗剂是LVEF改善的独立预测因子，而合并心脏瓣膜疾病、贫血是HFimpEF患者全因死亡的风险因素。

关键词: 心力衰竭, 心血管疾病, 左心室射血分数, 心室重构, 射血分数改善, 疾病特征, 预后, 影响因素分析, 生存分析

Abstract: Background

Left ventricular ejection fraction (LVEF) is often used to classify heart failure (HF) . Some HF patients were observed to have improved ejection fraction after treatment, thus giving rise to the concept of HF with improved EF (HFimpEF) . However, most relevant studies have focused on European countries and the US, and there are few reports on the clinical characteristics and diagnosis of this population in China.

Objective

To analyze the clinical characteristics, prognosis and prognostic predictors in Chinese HFimpEF patients.

Methods

Participants included in this case-control study were chronic HF inpatients who were recruited from Department of Heart Center, Hebei General Hospital from June 1, 2018, to May 1, 2020. Demographic data and baseline clinical information were obtained from the electronic medical record, in particular, clinical phenotypes of HF classified by baseline and follow-up LVEF included four: HF with preserved EF (HFpEF) , HF with mid-range EF (HFmrEF) , HF with reduced EF (HFrEF) and HFimpEF. Follow-up was conducted via electronic medical record review, outpatient department and telephone since the last reexamination with echocardiography. The follow-up continued through 2021-06-01, with all-cause death and all-cause readmission as endpoint events. Predictors of HFimpEF were explored by binary Logistic regression. Kaplan-Meier estimator was used to describe the survival of patients with all-cause death and all-cause readmission. Cox regression model was used to identify risk factors for all-cause death and all-cause readmission.

Results

A total of 530 cases were included, including 245 (46.2%) with HFpEF, 55 (10.4%) with HFmrEF, 133 (25.1%) with HFrEF, and 97 (18.3%) with HFimpEF. HFimpEF patients had lower mortality than did HFpEF patients (P=0.014) and HFmrEF patients (P<0.001) . The readmission rate was lower in HFimpEF patients than that of HFpEF (P=0.011) or HFmrEF patients (P=0.001) . Elevated systolic blood pressure〔OR=1.036, 95%CI (1.019, 1.053) , P<0.001〕, and left ventricular end-systolic diameter (LVESD) ≤37 mm〔OR=0.245, 95%CI (0.118, 0.507) , P<0.001〕 at baseline, and treatments with beta-blockers〔OR=2.868, 95%CI (1.304, 6.305) , P=0.009〕 and aldosterone antagonists〔OR=2.691, 95%CI (1.316, 5.503) , P=0.007〕 were associated with increased probability of LVEF improvement. HFrEF, older age, heart valve disease, chronic kidney disease, anemia, non-use of beta-blockers and oral anticoagulants were independently associated with increased risk of all-cause death in HF patients (P<0.05) . HFpEF, HFmrEF and chronic kidney disease were independently associated with increased risk of all-cause readmission in HF patients (P<0.05) . Concomitant valvular heart disease〔HR=6.499, 95%CI (1.504, 28.089) , P=0.012〕and anemia〔HR=4.884, 95%CI (1.242, 19.208) , P=0.023〕were independently associated with increased risk of all-cause death in HFimpEF patients. The use of beta-blockers〔HR=2.868, 95%CI (1.304, 6.305) P=0.009〕 and aldosterone antagonists〔HR=2.691, 95%CI (1.316, 5.503) , P=0.007〕 were associated with increased probability of LVEF improvement.

Conclusion

We consider that HFimpEF is a clinical phenotype of HF manifested as milder clinical symptoms, less ventricular remodelling and a better prognosis. Elevated systolic blood pressure, LVESD≤37 mm and treatments with beta-blockers and aldosterone receptor antagonists may be independent predictors of improved LVEF, while valvular heart disease and anaemia may be risk factors for all-cause death in HFimpEF patients.

Key words: Heart failure, Cardiovascular diseases, Left ventricular ejection fraction, Ventricular remodeling, Improved ejection fraction, Disease attributes, Prognosis, Root cause analysis, Survival analysis

中图分类号:

R541.62

苏康康,王岩,王立立,等. 射血分数改善型心力衰竭的临床特点及预后研究[J]. 中国全科医学, 2022, 25(05): 568-576. DOI: 10.12114/j.issn.1007-9572.2021.01.050.

SU Kangkang, WANG Yan, WANG Lili, CHEN Shuxia, GU Jian.

Characteristics and Prognosis of Herat Failure with Improved Ejection Fraction [J]. Chinese General Practice, 2022, 25(05): 568-576.

图/表 7

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组别	例数	年龄（±s，岁）	男〔n（%）〕	BMI （±s，kg/m²）	血压（±s，mm Hg）		心率（次/min）	NYHAⅢ/Ⅳ级〔n（%）〕	吸烟史〔n（%）〕
组别	例数	年龄（±s，岁）	男〔n（%）〕	BMI （±s，kg/m²）	收缩压	舒张压	心率（次/min）	NYHAⅢ/Ⅳ级〔n（%）〕	吸烟史〔n（%）〕
HFpEF组	245	73.5±12.5	119（48.6）	25.13±5.08	139±24	78±15	79±18	189（77.1）^c	48（19.6）
HFmrEF组	55	69.3±14.3^a	38（69.1）^a	25.41±4.67	138±24^c	80±15	80±19	43（78.2）^c	9（16.4）
HFrEF组	133	65.9±13.2^a	102（76.7）^a	24.31±4.78	118±20^ab	77±17	87±21^ab	125（94.0）	26（19.5）
HFimpEF组	97	65.8±14.3^a	66（68.0）^a	25.20±4.84	132±23^ac	82±17	88±23^ab	80（82.5）^c	30（30.9）
检验统计量值		13.709^d	33.286^e	1.091^d	25.847^d	2.072^d	7.668^d	16.693^e	6.828^e
P值		<0.001	<0.001	0.353	<0.001	0.103	<0.001	0.001	0.078

组别	例数	年龄（±s，岁）	男〔n（%）〕	BMI （±s，kg/m²）	血压（±s，mm Hg）		心率（次/min）	NYHAⅢ/Ⅳ级〔n（%）〕	吸烟史〔n（%）〕
组别	例数	年龄（±s，岁）	男〔n（%）〕	BMI （±s，kg/m²）	收缩压	舒张压	心率（次/min）	NYHAⅢ/Ⅳ级〔n（%）〕	吸烟史〔n（%）〕
HFpEF组	245	73.5±12.5	119（48.6）	25.13±5.08	139±24	78±15	79±18	189（77.1）^c	48（19.6）
HFmrEF组	55	69.3±14.3^a	38（69.1）^a	25.41±4.67	138±24^c	80±15	80±19	43（78.2）^c	9（16.4）
HFrEF组	133	65.9±13.2^a	102（76.7）^a	24.31±4.78	118±20^ab	77±17	87±21^ab	125（94.0）	26（19.5）
HFimpEF组	97	65.8±14.3^a	66（68.0）^a	25.20±4.84	132±23^ac	82±17	88±23^ab	80（82.5）^c	30（30.9）
检验统计量值		13.709^d	33.286^e	1.091^d	25.847^d	2.072^d	7.668^d	16.693^e	6.828^e
P值		<0.001	<0.001	0.353	<0.001	0.103	<0.001	0.001	0.078

项目	单因素		多因素
项目	P值	OR（95%CI）	β	SE	Wald χ²值	P值	OR（95%CI）
收缩压	<0.001	1.035（1.021，1.049）	0.036	0.008	18.195	<0.001	1.036（1.019，1.053）
NYHAⅢ/Ⅳ级	0.008	0.301（0.124，0.730）
LVESD≤37 mm	<0.001	0.203（0.103，0.401）	-1.406	0.371	14.357	<0.001	0.245（0.118，0.507）
LVEDD≤55 mm	<0.001	0.318（0.171，0.593）
ACEI/ARB	0.042	0.557（0.316，0.980）
β-受体阻滞剂	0.006	2.523（1.303，4.885）	1.053	0.402	6.869	0.009	2.868（1.304，6.305）
醛固酮受体拮抗剂	0.003	2.572（1.366，4.842）	0.990	0.365	7.361	0.007	2.691（1.316，5.503）

项目	单因素		多因素
项目	P值	OR（95%CI）	β	SE	Wald χ²值	P值	OR（95%CI）
收缩压	<0.001	1.035（1.021，1.049）	0.036	0.008	18.195	<0.001	1.036（1.019，1.053）
NYHAⅢ/Ⅳ级	0.008	0.301（0.124，0.730）
LVESD≤37 mm	<0.001	0.203（0.103，0.401）	-1.406	0.371	14.357	<0.001	0.245（0.118，0.507）
LVEDD≤55 mm	<0.001	0.318（0.171，0.593）
ACEI/ARB	0.042	0.557（0.316，0.980）
β-受体阻滞剂	0.006	2.523（1.303，4.885）	1.053	0.402	6.869	0.009	2.868（1.304，6.305）
醛固酮受体拮抗剂	0.003	2.572（1.366，4.842）	0.990	0.365	7.361	0.007	2.691（1.316，5.503）

项目	单因素		多因素
项目	P值	HR（95%CI）	β	SE	Wald χ²值	P值	HR（95%CI）
HFimpEF	-	1	-	-	-	-	1
HFpEF	0.017	2.376（1.717，4.821）	0.607	0.368	2.714	0.099	1.835（0.891，3.778）
HFmrEF	0.232	1.756（0.697，4.425）	0.407	0.477	0.729	0.393	1.503（0.590，3.825）
HFrEF	<0.001	4.408（2.157，9.008）	1.489	0.367	16.452	<0.001	4.431（2.158，9.097）
年龄	<0.001	1.035（1.019，1.051）	0.033	0.008	16.122	<0.001	1.033（1.017，1.050）
合并心脏瓣膜病	0.001	1.819（1.263，2.621）	0.527	0.190	7.675	0.006	1.695（1.167，2.461）
PCI	0.031	0.491（0.256，0.938）
肾病	<0.001	2.061（1.461，3.000）	0.604	0.196	9.502	0.002	1.829（1.246，2.685）
低蛋白	0.001	2.300（1.563，3.384）
贫血	0.001	1.955（1.339，2.856）	0.627	0.202	9.656	0.014	1.684（1.112，2.549）
ACEI/ARB	0.014	0.594（0.391，0.901）
β-受体阻滞剂	0.003	0.567（0.390，0.823）	-0.473	0.194	5.926	0.015	0.623（0.426，0.912）
醛固酮受体拮抗剂	0.006	0.596（0.413，0.859）
口服抗凝药	0.017	0.494（0.277，0.880）	-0.632	0.302	4.372	0.037	0.531（0.294，0.961）