超声心动图无创评估左心室充盈压指导慢性心力衰竭患者利尿剂的使用

Value of Non-invasive Echocardiographic Assessment of Left Ventricular Filling Pressure in Guiding the Rational Diuretic Use in Patients With Chronic Heart Failure

目的:评价超声心动图无创评估左心室充盈压(LVFP)指导慢性心力衰竭(CHF)患者利尿剂的合理使用及改善预后。方法:入选2019年10月至2020年10月就诊于我院急诊危重症中心门诊的CHF患者127例,随机分为超声评估组(n=64)和常规评估组(n=63),超声评估组根据常规临床查体、化验和超声心动图无创评估的LVFP结果制定利尿剂治疗方案,常规评估组仅依据常规临床查体和化验结果制定利尿剂治疗方案。随访时间为入组后14 d、30 d和90 d。主要终点是因心力衰竭(HF)紧急就诊或再入院复合终点事件;次要终点是因HF紧急就诊、因HF再入院、全因死亡和N末端B型利钠肽原(NT-proBNP)水平;安全性终点为肾功能恶化(WRF)。结果:排除未获得有效超声心动图参数及随访资料不全患者6例,最终121例纳入研究,超声评估组58例和常规评估组63例。基线时充血阳性体征的患者不足1/4,而LVFP升高的比例约占一半。随访期间超声评估组袢利尿剂使用人数和剂量调整频次较常规评估组更多(P均<0.05),平均剂量和WRF患者比例差异无统计学意义(P均>0.05)。在基线LVFP升高患者的随访中,与常规评估组比,超声评估组袢利尿剂平均剂量更大(P<0.05),但其WRF患者比例未增加(P>0.05)。次要终点NT-proBNP水平在两组间差异无统计学意义(P>0.05)。采用生存分析进一步证实,因HF紧急就诊或再入院发生率超声评估组明显低于常规评估组(HR=0.402,95%CI:0.174~0.929,P=0.033),且其差异主要来自因HF紧急就诊发生率(HR=0.324,95%CI:0.114~0.925,P=0.035)。结论:超声心动图评估LVFP指导CHF患者利尿剂的使用,能显著降低因HF紧急就诊或再入院的复合终点事件。在无创评估LVFP指导下,LVFP升高患者袢利尿剂使用剂量更大,但未增加WRF风险。

Objectives:To evaluate the value of non-invasive echocardiographic assessment of left ventricular filling pressures(LVFP)in guiding the rational use of diuretic and improve outcomes in patients with chronic heart failure(CHF).Methods:A total of 127 CHF patients admitted to our outpatient clinic of emergency critical care center from October 2019 to October 2020 were enrolled in this study,and patients were randomized into echo-guided group(n=64)and usual care group(n=63),the echo-guided group formulated diuretic treatment plan based on routine clinical examination,laboratory test and non-invasive evaluation of LVFP,while the usual care group formulated diuretic treatment plan based on routine clinical examination and laboratory test.The follow-up was 14,30 and 90 days after enrollment.The primary composite end point was urgent visits or re-hospitalization for heart failure,and the secondary end points were urgent visits for heart failure,rehospitalization for heart failure,all cause death and N-terminal pro-brain natriuretic peptide(NT-proBNP)level,and the safety end point was worsening renal function(WRF).Results:After excluding 6 patients without valid echocardiographic parameters and complete follow-up data,121patients were included in the final analysis,including 58 patients in the echo-guided group and 63 patients in the usual care group.At baseline,less than a quarter of patients had positive signs of congestion but LVFP was elevated in about half of them.During follow-up,patients in echo-guided group had higher loop diuretic use and dose adjustment frequency(P<0.05),average dose and WRF were similar between the two groups.In patients with elevated baseline LVFP,loop diuretic dose was higher in echo-guided group during follow-up(P<0.05),but the rate of WRF was not increased in this group.No difference was found in secondary end point of NT-proBNP levels between the two groups.Survival analysis showed that the incidence of primary endpoint was lower in echo-guided group(HR=0.402,95%CI:0.174-0.929,P=0.033),mainly due to the reduction of urgent visits due to HF(HR=0.324,95%CI:0.114-0.925,P=0.035).Conclusions:Guiding diuretic therapy by the assessment of LVFP with echocardiography could significantly reduce the urgent visits and readmission due to heart failure in CHF patients.Under the noninvasive guidance of LVFP,the doses of loop diuretics used are significantly higher in patients with elevated LVFP,but this is not related to increased risk of WRF.