Abstract: Background　Abnormal metabolism of thyroid hormones is involved in the pathological processes of chronic heart failure （CHF）.However，there are few studies on the long-term prognosis of CHF patients with euthyroid sick syndrome （ESS） in China.Objective　To study the effects of ESS on long-term prognosis of CHF patients.Methods　This study included 304 CHF patients，who were hospitalized in Department of Cardiology，Wusong Hospital of Zhongshan Hospital，Fudan University from January 2017 to June 2019.The general information and laboratory indicators were compared between those with T3 level<1.01 nmol/L and/or FT3 level<3.28 nmol/L（ESS group） and those with T3 level of 1.01-2.48 nmol/L and FT3 level of 3.28-6.47 nmol/L（normal thyroid function group）.Post-discharge follow-up was conducted until June 2020 with all-cause death （including death due to heart failure and non-cardiac death）as the primary endpoint，and readmission due to heart failure as the secondary endpoint.Thyroid hormones 〔T3，FT3，thyroxine （T4），free T4 （FT4），and thyroid stimulating hormone （TSH）〕，B-type natriuretic peptide （BNP），and left ventricular ejection fraction （LVEF）of the survivors were compared with those of the deceased due to all causes，the deceased due to heart failure，and the deceased due to noncardiac causes.The readmission rate due to heart failure，heart failure mortality rate，and all-cause mortality rate between the ESS and normal thyroid function groups were compared，and Kaplan-Meier survival curves were plotted.Cox regression analysis was used to identify the factors associated with heart failure death and all-cause death.Results　There were 164 patients in the ESS group and 140 patients in the normal thyroid function group.The distribution of NYHA class showed significant difference between the two groups （P<0.05）.The mean levels of T3，FT3，FT4，TSH，albumin，and hemoglobin，and LVEF were lower，and mean levels of BNP，C-reactive protein，and creatinine were higher in the ESS group （P<0.05）.In a median follow-up period of 25.7 （interquartile range 14.2） months，there were 46 all-cause deaths （32 due to heart failure，and 14 due to noncardiac causes） and 258 survivors（115 were readmitted at least once for heart failure）.The survivors showed higher mean levels of T3，FT3 and LVEF and lower mean level of BNP compared with the deceased due to all causes，or the deceased due to heart failure （P<0.05）.Those with ESS had higher heart failure readmission rate，heart failure mortality rate，and all-cause mortality rate than those with normal thyroid function（P<0.05）.Kaplan-Meier survival analysis showed that the heart failure mortality rate and all-cause mortality rate of the ESS group were higher than those in the normal thyroid function group （P<0.016）.Cox regression analysis showed that age 〔HR=1.056，95%CI（1.009，1.105）〕，FT3 〔HR=0.564，95%CI（0.325，0.976）〕，hemoglobin 〔HR=0.955，95%CI（0.932，0.980）〕，and LVEF〔HR=0.980，95%CI（0.961，1.000）〕 were associated with heart failure death in CHF patients （P<0.05），and age 〔HR=1.055，95%CI（1.019，1.093）〕，hemoglobin〔HR=0.964，95%CI（0.944，0.984）〕，and LVEF 〔HR=0.979，95%CI（0.963，0.994）〕 were associated with all-cause death （P<0.05）.Conclusion　CHF patients with ESS had poor renal and liver function.Their heart-failure mortality rate and all-cause mortality rate were higher，and their prognosis was poorer than those of CHF patients without ESS.T3 and FT3 levels reflected the severity and prognosis of CHF patients.

Key words: Heart failure, Euthyroid sick syndrome, Nonthyroidal illness syndrome, Low T3 syndrome, Prognosis

摘要： 背景　甲状腺激素的代谢异常参与了慢性心力衰竭（CHF）的病理过程，而目前国内对伴正常甲状腺病态综合征（ESS）的CHF患者的远期预后研究甚少。目的　探讨ESS对CHF患者远期预后的影响。方法　选取2017年1月—2019年6月于复旦大学附属中山医院吴淞医院心内科住院的CHF患者304例。将三碘甲状腺原氨酸（T3）<1.01 nmol/L和/或游离三碘甲状腺原氨酸（FT3）<3.28 nmol/L的患者纳入ESS组，T3为1.01~2.48 nmol/L及FT3为3.28~6.47 nmol/L的患者纳入甲功正常组。比较两组患者一般资料及实验室检查指标。出院后对所有患者进行随访，随访截至2020年6月，观察主要终点是全因死亡（包括因心力衰竭死亡和非心源性死亡），次要终点是因心力衰竭再入院。依据患者存活情况将患者分为存活组与全因死亡组，再将全因死亡组分为心力衰竭死亡亚组和非心源性死亡亚组。比较存活组与全因死亡组、存活组与心力衰竭死亡亚组和非心源性死亡亚组甲状腺激素〔T3、FT3、甲状腺素（T4）、游离甲状腺素（FT4）、促甲状腺激素（TSH）〕、B型脑钠肽（BNP）、左心室射血分数（LVEF）。比较ESS组和甲功正常组患者心力衰竭再入院率、心力衰竭死亡率、全因死亡率，并绘制生存分析曲线；采用Cox回归分析探究CHF患者发生心力衰竭死亡、全因死亡的影响因素。结果　CHF患者中ESS组164例，甲功正常组140例。两组患者美国纽约心脏病协会（NYHA）分级比较，差异有统计学意义（P<0.05）；ESS组患者T3、FT3、FT4、TSH、ALB、Hb水平及LVEF低于甲功正常组，BNP、C反应蛋白（CRP）、肌酐水平高于甲功正常组（P<0.05）。中位随访时间25.7（14.2）月，发现全因死亡46例（因心力衰竭死亡32例、非心源性死亡14例），存活258例（出现至少1次因心力衰竭再入院115例）。全因死亡组及心力衰竭死亡亚组患者T3、FT3水平及LVEF低于存活组，BNP水平高于存活组（P<0.05）。ESS组患者心力衰竭再入院率、心力衰竭死亡率、全因死亡率高于甲功正常组（P<0.05）。经Kaplan-Meier法分析结果显示：ESS组心力衰竭死亡率、全因死亡率均高于甲功正常组（P<0.016）。Cox回归分析结果显示，年龄〔HR=1.056，95%CI（1.009，1.105）〕、FT3〔HR=0.564，95%CI（0.325，0.976）〕、Hb〔HR=0.955，95%CI（0.932，0.980）〕、LVEF〔HR=0.980，95%CI（0.961，1.000）〕是CHF患者发生心力衰竭死亡的影响因素（P<0.05）；年龄〔HR=1.055，95%CI（1.019，1.093）〕、Hb〔HR=0.964，95%CI（0.944，0.984）〕、LVEF〔HR=0.979，95%CI（0.963，0.994）〕是CHF患者发生全因死亡的影响因素（P<0.05）。结论　CHF伴ESS患者肾功能、肝功能情况较差，且心力衰竭死亡率、全因死亡率高于单纯CHF患者，远期预后较差，而T3、FT3可以反映CHF患者病情严重程度及预后情况。

关键词: 心力衰竭, 正常甲状腺病态综合征, 非甲状腺疾病综合征, 低T3综合征, 预后