慢性心力衰竭患者入院时血压水平对近期预后的判断价值

发布时间：2018-05-11 00:22

本文选题：慢性心力衰竭 + 入院收缩压　；参考：《河北医科大学》2017年硕士论文

【摘要】：目的:慢性心力衰竭(Chronic Heart Failure,CHF)是多种器质性心脏病发展的终末期表现及最主要的死因。其发病率高,病情复杂,预后不佳。近年来我国每年新发慢性心力衰竭患者呈不断上升趋势,严重威胁着患者的生活质量及生存期,早期对其进行危险分层,尽早的给予有效合理的治疗措施可改善心衰预后。心力衰竭多伴有神经体液因素的改变,血压作为一项综合反映全身血流动力学的指标,测量简便、无创、可重复操作,而且同样受到神经体液的调节,提示血压在心力衰竭的病情发展过程中具有一定的意义。本研究对119例慢性心力衰竭患者进行入院时血压测量及随访,探讨慢性心力衰竭患者入院时血压水平对预后的判断价值。方法:连续入选2015年01月至2015年12月就诊于河北医科大学第二附属医院心血管内三科的慢性心力衰竭患者共119人。入选标准:临床诊断为心力衰竭,有明确的基础心脏病病史,病史均在半年以上,年龄大于18岁。以收缩功能障碍为主,符合NYHA心功能Ⅱ~Ⅳ级分级标准,N端前脑钠肽(NT-proBNP)2000ng/L。排除标准:存在认知障碍、意识不清者;肥厚性梗阻性心肌病、心脏瓣膜病、心包缩窄、心包积液、心肌炎、先天性心脏病等;急性心肌梗死、急性心力衰竭;合并恶性心律失常;继发性高血压、贫血、脑卒中、大量胸腔积液、肺炎、慢性阻塞性肺病等;伴有严重肝肾功能不全者;伴有其他影响预后的严重疾病(如恶性肿瘤等)。所有入选患者入院时均严格遵循中国血压测量指南测量、记录血压,并记录患者年龄、性别、体重、身高,依据纽约心脏病协会心功能分级标准对患者进行心功能分级;完善心脏超声检查测定左室射血分数(LVEF)、左室舒张末径(LVEDD);入院24小时内检测NT-proBNP、总胆红素、白蛋白、血脂、肌酐等生化指标。入院后按照中国心力衰竭防治指南给予相应治疗。出院后定期电话随访,以入院日为起始随访时间,以心源性死亡(包括心衰加重死亡及猝死)为随访终点,随访日期截止至2016-6,随访时间至少6月。依据患者入院血压,以不同血压水平分组,用Kaplan-meier法绘制生存曲线并对其进行log-rank统计检验。将影响预后的因素依次进行cox风险比例单因素分析,将单因素分析有意义的指标进行cox风险比例多因素分析,探讨入院血压对慢性心力衰竭患者预后的判断价值。用spss21.0软件进行数据处理及分析。计量资料结果用“均数±标准差((?)±s)”或“中位数(第一四分位数,第三四分位数)[m(q1,q3)]”表示,计数资料采用“例数(百分比)”表示。首先对计量资料进行正态及方差齐性检验,不满足正态分布的计量资料如果对数转换后符合正态分布,则使用计量资料的自然对数值,组间比较采用“t检验”或“非参数mann-whitneyu检验”。计数资料组间比较采用“χ2检验”或“fish确切概率法”。相关分析采用“pearson相关系数”或“spearman相关系数”。三组间单因素分析用“kaplan-meier生存曲线”,组间比较采用“log-rank检验”。对发生终点事件的危险因素分别采用“cox比例风险模型”进行单变量和多变量生存分析。所有统计均是双侧检验,以p0.05为差异有统计学意义。结果:共入选慢性心力衰竭患者119例,其中男性77例,女性42例,年龄44~90(67.3±10.0)岁,bmi23.8±2.6kg/m2。病因:缺血性心肌病(冠心)79例,扩张性心肌病(扩心)26例,高血压心脏病(高心)14例。根据纽约心脏病协会(nyha)心功能分级:Ⅱ级51例,Ⅲ级47例,Ⅳ级21例。1心源性死亡组与非死亡组临床资料比较所有入选患者共119例,其中心源性死亡22例。以心源性死亡为随访终点,将入选患者分为死亡组与非死亡组。两组在年龄,性别比例,体重指数(bmi),病因构成比,血清白蛋白、血清肌酐、血钾、总胆固醇、低密度脂蛋白胆固醇、入院时心率差异均无明显统计学意义(p0.05)。死亡组心功能Ⅳ级的患者明显多于非死亡组(68.2%vs6.2%),心功能Ⅱ级的患者明显少于非死亡组(4.5%vs51.5%),差异有统计学意义(p0.01)。死亡组患者nt-probnp[9750(7805,10980)vs3210(2022,5068)]、lnnt-probnp(9.15±9.16vs8.03±8.03)、tbil(21.8±10.5vs12.2±5.0)明显高于非死亡组,差异有统计学意义(p0.01)。死亡组患者lvef(27.4±5.0vs42.1±9.1)、入院sbp(108.4±10.5vs122.5±8.9)、入院dbp(65.5±5.4vs72.4±7.7)、入院pp(42.9±12.3vs50.2±9.3)明显低于非死亡组,差异有统计学意义(p0.01)。2将入院血压与上述2组临床资料比较有差异的因素进行相关性分析经pearson相关或spearman相关分析显示:入院sbp与nt-probnp呈负相关(rs=㧟0.266,p0.01),与lvef呈正相关(rs=0.352,p0.01),与lvedd呈负相关(rs=㧟0.225,p0.05),与nyha分级呈负相关(rs=㧟0.201,p0.05),与tbil呈负相关(rs=㧟0.232,p0.05)。入院dbp与nt-probnp呈负相关(rs=㧟0.227,p0.05),与lvef呈正相关(r=0.188,p0.05),与lvedd呈负相关(r=㧟0.202,p0.05),与nyha分级呈负相关(rs=㧟0.219,p0.05),与tbil呈负相关(r=㧟0.202,p0.05)。3用kaplan-meier法对不同血压水平分组绘制生存曲线并对其进行log-rank统计检验依据入院sbp,将入院sbp分为100mmhg,100~130mmhg,130mmhg三组。用kaplan-meier法绘制生存曲线,经log-rank检验3组间生存率存在差异(χ2=33.935,p0.01)。对其进行两两比较,入院sbp100mmhg的慢性心力衰竭患者生存率明显低于入院sbp在100~130mmhg、入院sbp130mmhg的慢性心力衰竭患者(χ2分别为27.659,17.922,p均0.01);而入院sbp在100~130mmhg的慢性心力衰竭患者生存率与sbp130mmhg的慢性心力衰竭患者的生存率差别无统计学意义(χ2=1.561,p0.05)。依据入院dbp,将入院dbp分为60mmhg,60~80mmhg,80mmhg三组。用kaplan-meier法绘制生存曲线,经log-rank检验3组间生存率不存在差异(χ2=3.324,p=0.190)。依据入院pp,将入院pp分为35mmhg,35~55mmhg,55mmhg三组。用kaplan-meier法绘制生存曲线,经log-rank检验3组间生存率存在差异(χ2=26.834,p0.01)。对其进行两两比较,入院pp35mmhg的慢性心力衰竭患者生存率明显低于入院pp在35~55mmhg、入院pp55mmHg的慢性心力衰竭患者(χ2分别为22.279,16.022,P均0.01);而入院PP在35~55mmHg的慢性心力衰竭患者生存率与入院PP55mmHg的慢性心力衰竭患者的生存率差别无统计学意义(χ2=0.367,P0.05)。4慢性心衰患者心源性死亡的单因素Cox比例风险回归分析以心源性死亡为因变量,以年龄、病因构成比、NYHA分级、lnNT-proBNP、TBIL、Alb、SCr、TG、LDL-c、LVEF、LVEDD、入院心率、入院SBP、入院PP为自变量,逐个引入Cox回归模型,经Wald检验,显示NYHA分级(RR=8.938,95%CI 4.135~19.324),lnNT-pro BNP(RR=38.591,95%CI 11.129~133.822),TBIL(RR=1.159,95%CI 1.105~1.215),LVEF(RR=0.825,95%CI 0.776~0.878),LVEDD(RR=1.107,95%CI 1.059~1.156),入院SBP(RR=0.866,95%CI 0.823~0.910),入院PP(RR=0.935,95%CI 0.898~0.973)对慢性心力衰竭预后具有显著性作用(P0.01)。而年龄、病因构成比、Alb、SCr、TG、LDL-c、入院心率逐个引入Cox回归模型,经Wald检验后,显示均无统计学意义(P0.05)。5慢性心衰患者心源性死亡的多因素Cox比例风险回归分析将上述慢性心力衰竭患者预后单因素Cox比例风险模型分析有意义的影响因素(NYHA分级、lnNT-proBNP、TBIL、LVEF、LVEDD、入院SBP、入院PP)进行多因素Cox比例风险模型分析(Enter法),结果显示只有lnNT-proBNP(RR=12.921,95%CI 2.373~70.353,P0.01)、入院SBP(RR=0.891,95%CI 0.828~0.958,P0.01)是判断慢性力衰竭患者预后的独立预测因素。结论:1入院时SBP100mmHg,PP35mmHg的慢性心力衰竭患者生存率明显降低。2慢性心力衰竭患者入院时低收缩压预后较差,是判断慢性心力衰竭患者预后的独立预测因素。
[Abstract]:Objective: Chronic Heart Failure (CHF) is the end stage manifestation of the development of various organic heart diseases and the most important cause of death. Its incidence is high, the disease is complicated, and the prognosis is poor. In recent years, the new chronic heart failure patients in China have been increasing in recent years, which seriously threaten the quality of life and life of the patients. The risk stratification and effective and reasonable treatment as early as possible can improve the prognosis of heart failure. Heart failure is often accompanied by changes in neurohumoral factors. Blood pressure is a comprehensive indicator of systemic hemodynamics. It is easy to measure, noninvasive, repeatable, and the same pattern is regulated by neurohumoral, suggesting blood pressure in heart failure. The blood pressure of 119 patients with chronic heart failure was measured and followed up to explore the value of the blood pressure level on the prognosis of the patients with chronic heart failure. Methods: from 01 months to December 2015 2015, the blood pressure of the patients with chronic heart failure was examined in the Second Affiliated Hospital of Hebei Medical University. A total of 119 patients with chronic heart failure in the three families. Criteria: clinical diagnosis of heart failure and a clear history of basic heart disease, with a history of more than half a year, age more than 18 years old. Contractile dysfunction is the main criterion for NYHA cardiac function II to IV grading, and N terminal natriuretic peptide (NT-proBNP) 2000ng/L. exclusion criteria: Cognition Obstacles, poor awareness, hypertrophic obstructive cardiomyopathy, valvular heart disease, pericardial constriction, pericardial effusion, myocarditis, congenital heart disease, acute myocardial infarction, acute heart failure, combined malignant arrhythmia, secondary hypertension, anemia, stroke, large amount of pleural effusion, pneumonia, chronic obstructive pulmonary disease, and so on; accompanied by severe liver and kidney function All the patients with serious prognosis (such as malignant tumor, etc.). All the selected patients strictly follow the Chinese blood pressure measurement guide, record blood pressure, record the age, sex, weight, height of the patients, and classify the heart function according to the New York Heart Association's heart function classification standard; perfect the cardiac ultrasound examination. The left ventricular ejection fraction (LVEF) and left ventricular end diastolic diameter (LVEDD) were measured and the biochemical indexes such as NT-proBNP, total bilirubin, albumin, blood lipid and creatinine were detected within 24 hours. After admission, the treatment was given in accordance with the guidelines for the prevention and treatment of heart failure in China. Death and sudden death were followed up to 2016-6, the follow-up time was at least 2016-6, and the follow-up time was at least in June. According to the blood pressure of the patients, the survival curves were plotted and the log-rank statistical test was made by the Kaplan-meier method. The factors affecting the prognosis were analyzed by the single factor analysis of the risk ratio of the Cox, and the single factor was divided. The value of Cox risk ratio analysis was analyzed to evaluate the value of admission blood pressure to the prognosis of patients with chronic heart failure. Data processing and analysis were carried out by spss21.0 software. The results of measurement data were "mean + standard deviation ((?) + s" or "median (14 quantiles, three or four digits) [m (Q1, Q3)]" The number of data is represented by the "number of cases (percentage)". First, the measurement data are tested with normal and variance homogeneity. If the normal distribution is not satisfied after the logarithmic conversion, the natural pair value of the measured data is used, and the "t test" or "non parametric mann-whitneyu test" is used for the comparison between the groups. The "x 2 test" or "fish exact probability method" were used among the groups. The correlation analysis used "Pearson correlation coefficient" or "Spearman correlation coefficient". The "Kaplan-Meier survival curve" was used for the single factor analysis among the three groups, and the "log-rank test" was used among groups. The risk factors for the endpoint events were respectively used "Cox proportion risk". Model "single variable and multivariable survival analysis. All statistics were bilateral tests, and P0.05 was statistically significant. Results: 119 patients with chronic heart failure were selected, including 77 males, 42 females, age 44~90 (67.3 + 10) years, bmi23.8 + 2.6kg/m2.: ischemic cardiomyopathy (coronary heart) 79 cases, dilated cardiomyopathy (expansion). 26 cases, 14 cases of hypertension and heart disease (Gao Xin). According to the heart function classification of New York heart disease association (NYHA), 51 cases of grade II, 47 cases of grade III, 21 cases of.1 cardiac death and non death group were compared with all the patients in the non death group, including 22 cases of cardiogenic death. The cardiac death was the end point of the follow-up, and the selected patients were divided into death group. There was no significant difference in age, sex ratio, body mass index (BMI), serum albumin, serum creatinine, serum potassium, total cholesterol, low density lipoprotein cholesterol, and heart rate difference at admission (P0.05). The heart function of the death group was significantly more than that in the non death group (68.2%vs6.2%) and the heart function grade II. The patients were significantly less than the non death group (4.5%vs51.5%), the difference was statistically significant (P0.01). The patients in the death group were nt-probnp[9750 (780510980) vs3210 (20225068)], lnnt-probnp (9.15 + 9.16vs8.03 + 8.03), TBIL (21.8 + 10.5vs12.2 + 5) were significantly higher than those in the non death group, and the difference was statistically significant (P0.01). The mortality group was LVEF (27.4 + 5.0vs42.1 + 9.1). The admission of SBP (108.4 + 10.5vs122.5 + 8.9), admission to hospital DBP (65.5 + 5.4vs72.4 + 7.7), PP (42.9 + 12.3vs50.2 + 9.3) in hospital was significantly lower than that of non death group. The difference was statistically significant (P0.01) and the correlation analysis between the admission blood pressure and the above 2 groups of clinical data was analyzed by Pearson related or Spearman correlation analysis: admission SBP Negative correlation with NT-proBNP (rs=? 0.266, P0.01), positive correlation with LVEF (rs=0.352, P0.01), negative correlation with LVEDd (rs=? 0.225, P0.05), negative correlation with NYHA classification (rs=? 0.201, P0.05), negative correlation (0.232, 0.227). (r=? 0.202, P0.05), negative correlation with NYHA classification (rs=? 0.219, P0.05), negative correlation with TBIL (r=? 0.202, P0.05).3 (r=? 0.202, P0.05).3 using Kaplan-Meier method to plot the survival curve of different blood pressure levels and carry out log-rank statistical test based on admission SBP, which will be divided into three groups. The survival rates of the 3 groups were different between the 3 groups (x 2=33.935, P0.01). The survival rate of the patients with chronic heart failure in sbp100mmhg was significantly lower than that of SBP in 100~130mmhg, and the patients with chronic heart failure admitted to sbp130mmhg (27.659,17.922, P, respectively 0.01) were admitted to sbp130mmhg, while SBP in 100~130mmhg was in the chronic heart. There was no significant difference between the survival rate of the patients with stress failure and the survival rate of chronic heart failure patients with sbp130mmhg (x 2=1.561, P0.05). According to the admission DBP, the admission DBP was divided into groups of 60mmhg, 60~80mmhg, 80mmHg three. The survival curves were plotted by Kaplan-Meier method, and the survival rate between the 3 groups was tested by log-rank (x 2=3.324, p=0.190). PP, the hospitalized PP was divided into 35mmhg, 35~55mmhg, 55mmhg three groups. The survival curves were plotted by Kaplan-Meier, and the survival rates of the 3 groups were different by log-rank test (x 2=26.834, P0.01). The survival rate of the patients with chronic heart failure in the hospitalized pp35mmhg was significantly lower than that of PP in 35~55mmhg, and the chronic heart failure patients admitted to hospital. The rate of survival of patients with chronic heart failure in 35~55mmHg and the survival rate of chronic heart failure in PP55mmHg was not statistically significant (x 2=0.367, P0.05), and the 22.279,16.022.4 chronic heart failure patients had no statistical difference (x 2=0.367, P0.05).4 chronic heart failure patients with cardiac death, the single factor Cox proportional risk regression analysis was based on cardiac death as a cause of change. NYHA classification, lnNT-proBNP, TBIL, Alb, SCr, TG, LDL-c, LVEF, LVEDD, admission heart rate, admission SBP, and PP as independent variables. F (RR=0.825,95%CI 0.776~0.878), LVEDD (RR=1.107,95%CI 1.059~1.156), admission to SBP (RR=0.866,95%CI 0.823~0.910), admission PP (RR=0.935,95%CI 0.898~0.973) have a significant effect on the prognosis of chronic heart failure. Multiple factor Cox proportional risk regression analysis of cardiac death in chronic heart failure patients with no statistical significance (P0.05).5 analysis of the prognostic factors of the prognostic single factor Cox proportional risk model for the patients with chronic heart failure (NYHA classification, lnNT-proBNP, TBIL, LVEF, LVEDD, admission SBP, admission PP) to carry out a multi factor Cox proportional risk model The analysis (Enter method) showed that only lnNT-proBNP (RR=12.921,95%CI 2.373~70.353, P0.01) and admission SBP (RR=0.891,95%CI 0.828~0.958, P0.01) were independent predictors for predicting the prognosis of patients with chronic stress failure. Conclusion: 1 at admission, SBP100mmHg, PP35mmHg chronic heart failure patients significantly reduced the incidence of chronic congestive heart failure. Poor prognosis in patients with low systolic blood pressure is an independent predictor of prognosis in patients with chronic heart failure.

【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R541.6

【参考文献】