心力衰竭患者入院收缩压水平与院内死亡的相关性研究

The correlation between admission systolic blood pressure and hospital mortality in patients with heart failure

目的:研究心力衰竭患者入院收缩压水平与院内死亡率的相关性,总结不同梯度血压与院内死亡相关性的特点,为改善心力衰竭患者的短期预后提供更多临床证据支持。方法:纳入心力衰竭住院的患者1667例。分析收缩压低、中、高三组患者临床指标、超声心动参数差异;绘制平滑曲线描述入院收缩压与院内死亡的趋势;采用GAM模型进行阈值计算;构建分段Logistic回归模型探讨入院收缩压院内死亡的影响因素。结果:高收缩压组患者年龄更大(P=0.034),糖尿病(P=0.003)及高血压病患病率(P<0.001)更高,TC及TG水平更高(P<0.001;P<0.001),室间隔厚度及后壁厚度更大(P<0.001;P<0.001);低收缩压组血肌酐水平(P<0.001)显著高于中、高收缩压组,LVESD(P=0.014)及E/a比值(P<0.001)更大,LVEF更低(P<0.001)。整体心力衰竭患者院内死亡率为7.4%,其中低收缩压组(13.7%)显著高于中、高收缩压组(P<0.001)。绘制平滑曲线发现入院SBP与院内死亡率为“L”型曲线,采用GAM模型计算阈值为119mmHg。根据阈值进行两段Logistic回归分析,在入院收缩压<119mmHg的心力衰竭患者中,入院收缩压越低(OR=0.977,95%CI:0.956~0.997,P=0.028)、年龄越大、合并高血压、空腹血糖越高、LVEF越低增加院内死亡风险;在入院收缩压≥119mmHg的心力衰竭患者中,合并高脂血症,血肌酐水平越高,空腹血糖越高增加院内死亡风险。结论:以119mmHg为阈值分组,两组患者的入院收缩压与院内死亡相关性有差异:小于阈值时,入院收缩压与院内死亡呈现明显负相关;而大于阈值时,入院收缩压与院内死亡未呈现明显相关性。在临床实践中应根据入院收缩压对心力衰竭患者进行准确的危险分层,制定个体化、规范化的干预方式。

Objective:To study the correlation between admission systolic blood pressure and hospital mortality in patients with heart failure,and to summarize the characteristics of the correlation between different gradient admission systolic blood pressure and hospital mortality,so as to provide more clinical evidence support for improving the short-term prognosis of patients with heart failure.Methods:A total of 1667 hospitalized patients with heart failure were included.Three groups were divided according to the blood pressure at admission:systolic depression group(SBP≤104mmHg;Group A),middle systolic blood pressure group(104mmHg<SBP≤124mmHg;Group B)and high systolic blood pressure(SBP>124mmHg;Group C).The differences of clinical indexes and echocardiography parameters among the three groups were analyzed.A smooth curve was drawn to describe the trend of admission systolic blood pressure and hospital mortality.GAM model was used to calculate the threshold value.Finally,a piecewise Logistic regression model was established to investigate the influencing factors of hospital mortality due to admission systolic blood pressure.Results:Patients in Group C were older(P=0.034),had higher rates of diabetes(P=0.003)and hypertension(P<0.001),and had higher levels of total cholesterol and triglycerides(P<0.001;P<0.001),the thickness of interventricular septum and posterior wall was larger(P<0.001;P<0.001);The serum creatinine level(P<0.001),LVESD(P=0.014)and E/A ratio(P<0.001)of A group were significantly higher than those of other groups(P<0.001),LVEF was lower(P<0.001).The overall hospital mortality was 7.38%,of which group A(13.7%)was significantly higher than group B(4.4%)and GROUP C(4.2%)(P<0.001).The smooth curve was drawn and it was found that the admission systolic blood pressure and hospital mortality were L-shaped curves.Then the GAM model was used to calculate the threshold,which was 119mmHg.Two Logistic regression analyses were conducted as the threshold point of 119mmHg.In heart failure patients with admission systolic pressure<119mmHg,lower admission systolic pressure(OR=0.977,95%CI:0.956-0.997,P=0.028),older(OR=1.067,95%CI:1.032-1.103,P<0.001),hypertension(OR=2.347,95%CI:1.162~4.738,P=0.017),the higher fasting blood glucose(OR=1.084,95%CI:1.004-1.169,P=0.039)and lower ejection fraction(OR=0.946,95%CI:0.919-0.973,P<0.001)increase the risk of in-hospital death.In patients with admission systolic pressure≥119mmHg,hyperlipidemia(OR=6.042,95%CI:2.332-15.652,P<0.001),the higher serum creatinine level(OR=1.011,95%CI:1.004-1.019,P=0.004)and the higher fasting blood glucose(OR=1.152,95%CI:1.037-1.280,P=0.008)increase the risk of in-hospital death.Conclusions:Our study found that with 119mmHg as the threshold,the correlation between admission systolic blood pressure and hospital mortality of patients with high systolic blood pressure and low systolic blood pressure was different:when the threshold was lower,admission systolic blood pressure was significantly negatively correlated with hospital mortality;However,there was no significant correlation between admission systolic blood pressure and hospital death when it was greater than the threshold.In clinical practice,patients with heart failure should be accurately stratified according to admission systolic blood pressure,and individualized and standardized intervention methods should be formulated.