“专科-全科”一体化联合管理在老年非瓣膜性房颤合并心衰患者中的应用:一项倾向性评分匹配研究

Application of"specialty-general practice"integrated management in elderly patients with nonvalvular atrial fibrillation and heart failure:a propensity score matching study

目的探讨“专科-全科”一体化联合管理模式对非瓣膜性房颤(NVAF)合并非左心室射血分数保留心衰(HFpEF)患者的疗效。方法选取2019年12月~2021年12月期间在苏州大学附属苏州九院心内科门诊或住院明确诊断为NVAF且合并非HFpEF患者184名,其中规范化组为心内科传统诊疗与随访模式下的心衰患者(141例);一体化组为心内科专科传统模式联合社区全科医师团队进行一体化联合管理的心衰患者(43例)。运用倾向评分匹配(PSM)分析方法,将2组患者的性别、年龄、吸烟、2型糖尿病、高脂血症、高血压病、冠心病、慢性阻塞性肺疾病、LVEF以及标准化药物(抗凝药、ARNI/ACEI/ARB、β受体阻滞剂、利尿剂、螺内酯、地高辛)使用情况按照1∶1进行倾向性评分匹配,进而比较2组疗效。结果倾向性评分匹配成功41对病例,PSM后,较规范化组相比,一体化组在6分钟步行试验(6MWT)、NT-proBNP、不规则停药、明尼苏达心功能不全生命质量量表(MLHFQ)评分、多次心衰再入院率、1年主要心血管不良事件(MACE)明显改善(P<0.05);两组患者在心室率、LVEF值、器械治疗(ICD、CRT、CRT-D、射频消融、左心耳封堵)方面无明显差异(P>0.05)。结论心血管专科联合社区全科医师团队,对老年NVAF合并非HFpEF患者进行一体化联合管理,在提高患者依从性、改善患者生活质量的同时,可以明显降低患者心衰住院次数以及MACE事件的发生。

Objective To evaluate the efficacy of the"specialty-general practice"integrated management model in patients with non-valvular atrial fibrillation(NVAF)complicated with non-heart failure with preserved left ventricular ejection fraction(HFpEF).Methods A total of 184 patients who were diagnosed as having NVAF with non-HFpEF at the Suzhou Ninth Hospital Affiliated to Soochow University from December 2019 to December 2021 were retrospectively enrolled in the study.The patients were divided into either a standardized group consisting of heart failure patients(141 cases)managed using the traditional mode of diagnosis and treatment and follow-up of cardiology department,or an integrated management group consisting of heart failure patients(43 cases)who were managed using the traditional mode of cardiology specialist combined with the community general practitioner team.Gender,age,smoking,type 2 diabetes mellitus,hyperlipidemia,hypertension,coronary heart disease,chronic obstructive pulmonary disease,LVEF,and standardized drugs(anticoagulants,ARNI/ACEI/ARB,beta-blockers,diuretics,spironolactone,digoxin,etc.)were matched with a 1∶1 propensity score,and then the therapeutic effects of the two groups were compared.Results Propensity score matching was successful for 41 pairs of cases.After propensity score matching,compared with the standardized group,the integrated management group had significant improvements in 6-minute walk test(6MWT),NT-proBNP,irregular drug withdrawal,Minnesota Heart Insufficiency Quality of Life Scale(MLHFQ)score,multiple heart failure readmission rate,and 1-year major adverse cardiovascular events(MACE)(P<0.05).There was no significant difference in ventricular rate,LVEF value,or device therapy(ICD,CRT,CRT-D,catheter radiofrequency ablation,and left atrial appendage closure)between the two groups(P>0.05).Conclusion Cardiovascular specialists combined with community general practitioner team to carry out integrated joint management of elderly patients with NVAF complicated with non-HFpEF can significantly reduce the number of heart failure hospitalizations and the occurrence of MACE events while improving patient compliance and quality of life.