慢性收缩性心力衰竭患者右房室瓣收缩期位移与肾功能状态的关系研究

The Association between Tricuspid Annular Plane Systolic Excursion and Renal Function in Patients with Chronic Systolic Heart Failure

目的探讨慢性收缩性心力衰竭患者右房室瓣收缩期位移(TAPSE)与肾功能状态的关系。方法选取经超声心动图证实的左室射血分数(LVEF)≤45%的慢性收缩性心力衰竭(CHF)患者98例,M型超声测定其TAPSE,以TAPSE<16 mm定义为右室功能不全,将所有入选者分为两组:右室功能不全组(TAPSE<16 mm)和右室功能正常组(TAPSE≥16 mm)。对两组入选者抽血测定常规肾功能指标及N端B型钠尿肽前体(NT-proBNP),用改良MDRD公式计算肾小球滤过率(eGFR),测定平均动脉压(MAP),超声心动图测定左室舒张末内径(LVDd)、右室舒张末内径(RVDd)、肺动脉收缩压(PASP)、LVEF,分别比较两组上述指标有无差别。同时比较两组患者静脉袢利尿剂的使用情况。结果两组患者的年龄、性别构成、心功能分级、心力衰竭病因及心房纤颤发生率间差异均无统计学意义(P>0.05)。两组患者LVDd、PASP、LVEF及MAP比较,差异均无统计学意义(P>0.05);RVDd水平比较,差异有统计学意义(P<0.05)。两组患者NT-proBNP水平间差异无统计学意义(P>0.05)。右室功能不全组患者发生肾功能不全的比例(73%)明显高于右室功能正常组(30%),差异有统计学意义(P<0.05)。右室功能不全组患者eGFR〔(70±21)ml.min-1.(1.73 m2)-1〕明显小于右室功能正常组〔(106±29)ml.min-1.(1.73m2)-1〕,差异有统计学意义(P<0.05)。以所有患者的肾功能状态为因变量,以LVDd、RVDd、PASP、LVEF、MAP、TAPSE及NT-proBNP作为备选自变量进行二分类Logistic回归分析,结果显示只有TAPSE降低为CHF患者发生肾功能不全的危险因素,TAPSE每下降1 mm,CHF患者发生肾功能不全的危险性增加1.78倍。在纠正心力衰竭过程中右室功能不全组患者静脉大剂量袢利尿剂使用率(85%)明显高于右室功能正常组(39%),差异有统计学意义(P<0.05)。结论伴右室功能不全的CHF患者更易发生肾功能不全。TAPSE下降是CHF患者发生肾功能不全的危险因素,可用来预测CHF患者肾功能不全的发生。伴右室功能不全的CHF患者在纠正心力衰竭过程中所需静脉袢利尿剂剂量较右室功能正常者为大。

Objective To explore the association between tricuspid annular plane systolic excursion （TAPSE） and re- nal function in patients with chronic systolic heart failure （CHF）. Methods Ninety - eight inpatients with CHF who had left ventricular ejection fraction （LVEF） ≤45% on ecbocardiogram were enrolled. M -mode Doppler ecbocardiograpby was per- formed in all patients. The patients were divided into two groups according to the level of TAPSE ： group with dysfunction of right ventricle （DFRV） （ TAPSE 〈 16 mm） and group with normal function of right ventricle （NFRV） （ TAPSE ≥ 16 nun）. We con- ducted blood test to determine routine renal function indices and NT - proBNP; Used simplified Modification of Diet in Renal Dis- ease （MDRD） formula to calculate glomerular filtration rate （eGFR） ; And applied echocardiography to determine left ventricu]ar end diastolic diameter （ LVDd）, right vcntricular end diastolic diameter （ RVDd）, pulmonary arterial systolic pressure （ PASP）, and LVEF; Mean arterial pressure was also measured. The above indices and the equivalent daily dosage of intravenous loop diu- retics were compared between the two groups. Results No significant differences were observed between the two groups in age,sex, renal function grading, cause of heart failure, and incidence of atrial fibrillation （P 〉 0.05）. Significant differences were not observed between the two groups in LYDd, PASP, LVEF, or MAP （ P 〉 0. 05）, but in RVDd （ P 〈 O. 05）. The differ- ences of NT - proBNP level between the two groups was not statistically significant （P 〉 0. 05）. The incidence of renal dysfunc- tion in the DFRV group （73%） was significantly higher than that in the NFRV group （30%） （P 〈0. 05）. The eGFR of DFRV group [ （70 ± 21 ） ml · min-1 （ 1.73 m2 ） was significantly lower than that of NFRV group [ （ 106± 29） ml · min-1 （1.73 m2） -1 （P 〈0.05 ）. Binary Logistic regression analysis was conducted with renal function as the dependent variable, LVDd, RVDd, PASP, LVEF, MAP, TAPSE, and NT- proBNP as the independent variables. Analysis results showed that TAPSE decrease was the only risk factor for renal dysfunction in CHF patients. For 1 mm decrease of TAPSE, the risk of renal dysfunction in CI-IF patients increased 1.78 times. The use rate of intravenous loop diuretics in the DFRV group （85%） during correction of cardiac failure was significantly higher than that in the NFRV group （39%） （ P 〈 0.05 ）. Conclusion CHF pa- tients with DFRV have higher incidence of renal dysfunction. TAPSE decrease is a risk factor and might be a predictor of renal dysfunction. CHF patients with DFRV usually need more intravenous loop diuretics.