住院扩张型心肌病患者入院收缩压与院内及院外病死率的关系

Association of systolic blood pressure on admission with in-hospital and post-discharge mortality in patients hospitalized with dilated cardiomyopathy

目的 分析住院扩张型心肌病(DCM)患者入院收缩压水平与其院内及院外病死率的关系.方法 入选2009年1月至2013年12月期间在阜外医院心力衰竭病房住院的成人DCM患者,存活出院患者随访至2015年12月或死亡或心脏移植.定义心力衰竭恶化、猝死或脑卒中导致的死亡为心血管原因死亡.主要终点为心血管原因死亡或心脏移植.危险因素判定采用多变量Cox回归分析方法 .结果 793例患者纳入分析,35例发生院内死亡.多变量分析显示,入院收缩压每升高10 mmHg(1 mmHg=0.133 kPa),院内病死率降低33.4%(风险比HR=0.666,95%可信区间CI0.501~0.886,P<0.01).701例出院患者中位随访34(18,51)个月后,137例死亡,其中126例为心血管原因死亡,另有16例行心脏移植.入院收缩压每升高10 mmHg,院外主要终点发生风险降低24.0%(HR=0.760,95%CI0.669~0.864,P<0.01).根据患者入院收缩压水平分为4组:<100 mmHg(144例),100~109mmHg(159例),110~119 mmHg(150例)和≥120 mmHg(248例),四组患者随访期间主要终点发生率有明显差别(分别为43.8%、20.1%、16.7%和8.9%,P<0.01).多变量Cox回归分析显示,入院收缩压<100 mmHg患者主要终点风险是收缩压≥120 mmHg患者的近4倍(HR=3.953,95%CI2.374~6.582,P<0.01).根据患者入院时左室射血分数(LVEF)水平分2个亚组:LVEF<30%(369例)和LVEF≥30%(332例),前者入院收缩压水平与主要终点事件发生率之间呈线性关系,后者呈非线性关系.结论 住院DCM患者入院收缩压水平越低,院内病死率越高,院外心血管原因死亡或心脏移植发生风险也越高.不同收缩功能水平患者入院收缩压水平与预后的关系模式不同.

Objective To investigate the association of systolic blood pressure(SBP)on admission with in-hospital and post-discharge mortality in hospitalized patients with dilated cardiomyopathy(DCM).Methods Adult patients hospitalized with DCM in Heart Failure Care Unit,Fuwai Hospital from January 2009 to December 2013 were enrolled and those discharged alive from hospital were followed to December 2015 or until death or heart transplantation(HTx).Cardiovascular mortality(CVM)was defined as death from worsening heart failure,sudden death,or stroke.Primary endpoint was CVM or HTx.Multivariate Cox regression analysis was used to identify predictors.Results A total of 793 patients were enrolled and 35 died during hospitalization,thus in-hospital mortality rate was 4.4%.Odds of in-hospital mortality decreased 33.4%for each 10 mmHg(1 mmHg=0.133 kPa)increase in admission SBP[hazard ratio(HR)=0.666,95%confidence interval(CO 0.501-0.886,P<0.01].During a median period of 34(18,51)months for 701 patients with follow-up after discharge,137 died(126 died of CVM),and other 16 underwent HTx.Risk of post-discharge CVM/HTx decreased 24.0%for per 10 mmHg increase in SBP(HR=0.760,95%CI 0.669-0.864,P<0.01).Patients were grouped into 4 categories according to admission SBP:<100 mmHg(n=144),100-109 mmHg(n=159),110-119 mmHg(n=150)and≥120 mmHg(n=248).There was significant difference in the occurrence of primary endpoint among different SBP categories(43.8%,20.1%,16.7%,8.9%,P<0.01).Multivariate Cox analysis demonstrated that relative risk of CVM/HTx among patients with SBP<100 mmHg was almost 4 times higher than those with SBP≥120 mmHg(HR=3.953,95%CI 2.374-6.582,P<0.01).When the cohort was divided into two subgroups based on left ventricular ejection fraction(LVEF),there was a linear relationship of SBP with primary endpoint among patients with LVEF<30%(n=369)despite a non-linear relation among those with LVEF≥30%(n=332).Conclusion Lower SBP on admission was associated with higher in-hospital and post-discharge mortality in patients hospitalized with DCM.There was different relationship pattern of admission SBP with post-discharge mortality among patients with different systolic dysfunction.