Abstract: Background　Chronic heart failure （CHF） is the terminal stage of all cardiovascular diseases，and its incidence，hospitalization rate and mortality rate increased gradually.Compared with traditional diuretics，tolvaptan has less effect on electrolyte balance，which in turn can achieve better therapeutic effects，but there is also a risk of elevating plasma osmotic pressure.Objective　To investigate the predictive effect of elevated plasma osmotic pressure （POP） induced by tolvaptan on the prognosis of patients with CHF．Methods　We enrolled 83 patients with CHF from Department of Cardiology，the Affiliated Hospital of Southwest Medical University from January 2015 to January 2017.All of them received combination treatment with tolvaptan based on their own conditions and an outpatient follow-up of 12-months （started since the initiating of the standardized treatment）．We collected their clinical data，laboratory findings and echocardiographic results.Kaplan-Meier method was used to perform the survival analysis.Univariate and multivariate Cox proportional hazard models were adopted to investigate the factors affecting the prognosis of these patients and the values of them were examined by ROC analysis.Results　Except for 6 drop outs，other 77 completed the follow-up.Among them，25 with endpoint events and 52 without were found with poor prognosis，good prognosis，respectively.The 2-，4-，and 6-month survival rates for them were 93.8%，84.2%，77.0%，respectively.The analysis with multivariate Cox proportional hazard models identified that troponin T （cTnT）〔RR=1.373，95%CI（1.005，1.876）〕，left ventricular ejection fraction （LVEF） 〔RR=1.463，95%CI（1.036，2.066）〕，N-terminal brain natriuretic peptide （NT-proBNP） 〔RR=1.051，95%CI（1.015，1.166）〕，increased POP 〔RR=1.638，95%CI（1.206，2.224）〕were independent factors for the prognosis of CHF patients with tolvaptan treatment （P<0.05）．For predicting the prognosis of CHF treated by tolvaptan，the area under the ROC curve （AUC） of cTnT，LVEF，NT-proBNP，increased POP，NT-proBNP combined with increased POP was 0.74，0.67，0.80，0.83，0.87，respectively.NT-proBNP combined with POP had a larger AUC than NT-proBNP （Z=2.706，P=0.048） and POP （Z=3.124，P=0.032） alone.Conclusion　cTnT，LVEF，NT-proBNP and increased POP could independently predict the prognosis of patients with CHF treated by tolvaptan，in particular，NT-proBNP combined with increased POP has a higher predictive value.

Key words: Heart failure, Tolvaptan, Osmotic pressure, Prognosis

摘要： 背景　慢性心力衰竭（CHF）是所有心血管疾病的终末阶段，其发病率、住院率及病死率呈逐年上升的趋势。相对于传统利尿剂，托伐普坦对电解质平衡影响较小，进而能获得更好的治疗效果，但亦有血浆渗透压升高的风险。目的　探讨服用托伐普坦治疗引起的血浆渗透压升高对CHF患者预后的预测作用。方法　选取2015年1月—2017年1月西南医科大学附属医院心内科收治的需服用托伐普坦治疗的CHF患者83例为研究对象，均根据病情服用托伐普坦治疗，自规范化治疗即日起进行为期1年的门诊随访，记录患者一般临床资料、实验室检查指标及超声心动图检查结果。采用Kaplan-Meier法绘制生存曲线，采用单因素及多因素Cox比例风险回归模型分析服用托伐普坦治疗的CHF患者预后影响因素，绘制受试者工作特征（ROC）曲线。结果　83例患者参与随访，失访6例，余77例患者完成随访。依据有无终点事件将患者分为预后不良25例和预后良好52例。服用托伐普坦治疗的CHF患者2个月生存率为93.8%，4个月生存率为84.2%，6个月生存率为77.0%。多因素Cox比例风险回归模型结果显示，肌钙蛋白T（cTnT）〔RR=1.373，95%CI（1.005，1.876）〕、左心室射血分数（LVEF）〔RR=1.463，95%CI（1.036，2.066）〕、N末端脑钠肽前体（NT-proBNP）〔RR=1.051，95%CI（1.015，1.166）〕、血浆渗透压〔RR=1.638，95%CI（1.206，2.224）〕为服用托伐普坦治疗的CHF患者预后的独立影响因素（P<0.05）。cTnT、LVEF、NT-proBNP、血浆渗透压预测服用托伐普坦治疗的CHF患者预后的ROC曲线下面积（AUC）分别为0.74、0.67、0.80、0.83。NT-proBNP联合血浆渗透压预测服用托伐普坦治疗的CHF患者预后的AUC为0.87，高于NT-proBNP（Z=2.706，P=0.048）及血浆渗透压（Z=3.124，P=0.032）的AUC。结论　cTnT、LVEF、NT-proBNP、血浆渗透压为服用托伐普坦治疗的CHF患者预后的影响因素，NT-proBNP联合血浆渗透压具有更高的预测价值。

关键词: 心力衰竭, 托伐普坦, 渗透压, 预后