心力衰竭972例患者临床特征、治疗现状及预后分析

发布时间：2018-06-28 04:01

本文选题：心力衰竭 + 治疗　；参考：《北京协和医学院》2017年硕士论文

【摘要】：目的:我国心力衰竭(心衰)住院患者的治疗和预后情况以往有所报道,但门诊心衰患者的情况尚不了解,本研究旨在了解真实世界中我国心衰患者的临床特征,治疗情况及预后。方法:采用前瞻性、多中心注册研究,连续入选2012年12月至2014年11月在我国不同地区、不同级别的24家医院门诊或住院的972例心衰患者,收集患者的人口学和临床资料以及治疗情况。在1年时进行随访,采用配对卡方分析比较患者的药物治疗情况。观察的终点事件为全因死亡、因心衰再住院以及全因死亡/因心衰再住院的联合终点,分别应用单变量和多变量Cox和logistic回归模型分析评价终点事件的影响因素。结果:患者平均年龄65.6±13.0岁,男性557例(57.3%),门诊患者610例(62.8%)。合并高血压、糖尿病、心肌梗死或行血运重建术、卒中史的患者分别占59.1%、21.7%、25.2%和16.9%,纽约心脏病协会(NYHA)Ⅲ/Ⅳ级者占58%,其中住院患者明显高于门诊患者(70.4%vs 50.8%,P0.001)。无论住院或门诊就诊以及左室射血分数(LVEF)50%或≥50%,走坡路时呼吸困难的心衰患者均占90%以上,而走平路时呼吸困难、夜间阵发性呼吸困难和休息时呼吸困难在住院的心衰患者(72.1%vs 56.9%,49.3%vs 31.3%,29.6%vs 15.1%,均 P0.001)和 LVEF50%的患者(67.5%vs 56.6,P0.005,;43.3%vs 35.1%,P0.05;27.9%vs 15.0%,P0.001)更多。入选时心电图显示房颤或房扑者227例(25.7%),53.4%的患者超声心动图LVEF50%。缺血性心脏病是心衰的首要病因(52.2%),其次是高血压性心脏病(16.9%)、扩张型心肌病(14.1%)和瓣膜性心脏病(9.5%)。入选时心衰的药物治疗中血管紧张素阻滞剂(ABs)(血管紧张素转换酶抑制剂(ACEI)或血管紧张素受体阻滞剂(ARB))的使用率为65.7%(ACEI 34.3%,ARB 32.0%),其次为阿司匹林、利尿剂和β-受体阻滞剂,分别为62.6%、60.5%和60.0%。超过一半的患者使用了醛固酮受体拮抗剂,硝酸酯类药和地高辛的使用分别为36.2%和26.1%。门诊患者中β-受体阻滞剂的应用多于住院患者(63.1%vs 54.7%,P0.05),LVEF50%的患者β 受体阻滞剂(66.5%vs 60.5%,P0.05)、ACEI(45.4%vs 29.7%,P0.001)和醛固酮受体拮抗剂(70.5%vs 47.0%,P0.001)的使用均明显多于LVEF≥500%的患者。随着入选时NYHA心功能级别增加,ACEI和醛固酮受体拮抗剂的使用逐渐增多。入选时β-受体阻滞剂、ACEI、ARB剂量达标率分别为5.2%、29.9%、10.6%,其中门诊患者β-受体阻滞剂(6.5%vs 2.5%,P0.05)、ACEI(34.0%vs 25.1%)的剂量达标率高于住院患者(P0.05)。与入选时相比,一年随访时除抗凝剂的应用率有所增加外(11.6%vs9.9%,P0.05),β-受体阻滞剂和ACEI使用率无变化,而ARB(30.2%vs32.7%,P0.05)和醛固酮受体拮抗剂(47.5%vs 53.6%,P0.001)的使用率有所减少。ARB使用率降低主要见于门诊患者,而醛固酮受体拮抗剂使用率降低主要见于住院患者。一年随访时仅ACEI的剂量达标率高于入选时(36.6%vs29.9%,P0.05)。一年随访时,NHYAⅢ/Ⅳ级的患者比例明显低于入选时(29.1%vs 56.5%,P0.001),患者的全因死亡率为7.9%,因心衰再住院率和联合终点发生率分别为30.2%,和33.9%,其中住院患者因心衰再住院率(37.2%vs 26.00%,P0.001)以及联合终点发生率(42.0%vs 29.1%,P0.001)均明显高于门诊患者。多因素Cox回归分析显示糖尿病、吸烟,双侧胸腔积液和硝酸酯类药物应用是心衰患者一年全因死亡的独立危险因素;多因素Logistic回归分析显示一年随访时因心衰再住院和联合终点的独立危险因素均为NYHA心功能Ⅲ/Ⅳ级、糖尿病,X线心/胸比0.5和慢性阻塞性肺疾病(COPD)。结论:首先,缺血性心脏病是我国心衰患者的主要病因,扩张型心肌病导致的心衰已明显超过风湿性心脏瓣膜病。其次,心衰患者的规范化药物治疗有待于提高,不仅体现在有改善预后意义的抗心衰药物使用率低,依从性差,更体现在β-受体阻滞剂、ACEI和ARB的剂量达标率低。第三,无论从心衰患者的症状,NYHA心功能分级,药物治疗和预后方面,住院和门诊的心衰患者均存在差异,因此,未来应更加重视对全部心衰患者的评估,更全面地了解我国心衰患者的真实情况。
[Abstract]:Objective: the treatment and prognosis of patients with heart failure (heart failure) in our country have been reported in the past, but the situation of patients with heart failure is not yet understood. The purpose of this study is to understand the clinical characteristics, treatment and prognosis of heart failure patients in the real world. Methods: a forward-looking, multi center registration study and continuous selection from December 2012 to 2014. The demographic and clinical data and treatment of 972 patients with heart failure in 24 hospitals of different levels and in 24 hospitals of different levels were collected and compared with the patient's drug treatment at 1 years. The end point of the observation was all cause death, heart failure hospitalization and all causes. The combined endpoints of death / heart failure and rehospitalization were analyzed with univariate and multivariate Cox and logistic regression models respectively. Results: the average age of the patients was 65.6 + 13 years, 557 men (57.3%), 610 outpatients (62.8%). Combined with high blood pressure, diabetes, myocardial infarction, or revascularization, stroke history The patients accounted for 59.1%, 21.7%, 25.2% and 16.9% respectively, and the New York Heart Association (NYHA) class III / IV was 58%, and the hospitalized patients were significantly higher than the outpatients (70.4%vs 50.8%, P0.001). No matter the hospitalization or outpatient clinic and the left ventricular ejection fraction (LVEF) 50% or more 50%, the patients with dyspnea were more than 90% in the walk road, while the breathing was on the flat road. Difficulties, nocturnal paroxysmal dyspnea, and breathing difficulties during rest in hospitalized heart failure patients (72.1%vs 56.9%, 49.3%vs 31.3%, 29.6%vs 15.1%, P0.001) and LVEF50% patients (67.5%vs 56.6, P0.005, 43.3%vs 35.1%, P0.05; 27.9%vs 15%, P0.001). 227 cases (25.7%), 53.4% of patients with atrial fibrillation or atrial flutter (25.7%) were selected at the time of entry. Acoustic cardiogram LVEF50%. ischemic heart disease is the primary cause of heart failure (52.2%), followed by hypertensive heart disease (16.9%), dilated cardiomyopathy (14.1%) and valvular heart disease (9.5%). Angiotensin blocker (ABs) (angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (AR) in the drug treatment of heart failure at the time of selection (AR) B)) use of 65.7% (ACEI 34.3%, ARB 32%), followed by aspirin, diuretics and beta blockers, 62.6%, 60.5%, and more than half of the patients with aldosterone receptor antagonists, nitrate and digoxin used in 36.2% and 26.1%. outpatients for beta blockers more than hospitalized patients. Patients (63.1%vs 54.7%, P0.05), LVEF50% patients with beta blockers (66.5%vs 60.5%, P0.05), ACEI (45.4%vs 29.7%, P0.001) and aldosterone receptor antagonists (70.5%vs 47%, P0.001) were significantly more used in patients with LVEF than 500%. With the increase in the grade of NYHA cardiac power, the use of the antagonists and aldosterone receptor antagonists increased gradually. The dose rate of beta blocker, ACEI, and ARB was 5.2%, 29.9%, 10.6%, respectively. The rate of beta blocker (6.5%vs 2.5%, P0.05), ACEI (34.0%vs 25.1%) was higher than that of hospitalized patients (P0.05). The rate of anticoagulant application was increased (11.6%vs9.9%, P0.05) and beta receptor resistance at one year follow-up. The use of hysteresis and ACEI was not changed, while the use of ARB (30.2%vs32.7%, P0.05) and aldosterone receptor antagonists (47.5%vs 53.6%, P0.001) decreased the.ARB use rate and decreased mainly in outpatients, while the reduction of aldosterone receptor antagonists was mainly in hospitalized patients. The rate of only ACEI at one year follow-up was higher than that of the admission (3 6.6%vs29.9%, P0.05). At a one-year follow-up, the proportion of patients with NHYA III / IV was significantly lower than that of the admission (29.1%vs 56.5%, P0.001). The total cause mortality was 7.9%, the rate of rehospitalization and the joint endpoint of heart failure were 30.2%, and 33.9% respectively, and the rate of hospitalization for heart failure (37.2%vs 26%, P0.001) and the incidence of joint endpoints were in the hospital. 42.0%vs 29.1%, P0.001) were significantly higher than outpatients. Multifactor Cox regression analysis showed that diabetes, smoking, bilateral pleural effusion, and nitroester use were independent risk factors for one year all cause death in patients with heart failure; multiple factor Logistic regression analysis showed an independent risk of heart failure rehospitalization and joint endpoint at one year's follow-up. NYHA cardiac function was grade III / IV, diabetes, X-ray cardiac / thoracic ratio 0.5 and chronic obstructive pulmonary disease (COPD). Conclusion: first, ischemic heart disease is the main cause of heart failure in China. Dilated cardiomyopathy is obviously more than rheumatic valvular heart failure. The drug use rate is low, the compliance is poor, and the dose rate of ACEI and ARB is low. Third, there are differences in the symptoms of heart failure, the classification of NYHA heart function, the drug treatment and the prognosis in both hospitalized and outpatient heart failure patients, therefore, the future should be more aggravated. All patients with heart failure can be assessed for a more comprehensive understanding of the real situation of patients with heart failure in China.
【学位授予单位】：北京协和医学院
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R541.6

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