心房颤动合并心力衰竭患者的临床特点及治疗现状分析的多中心研究

Clinical Characteristics and Treatment of Atrial Fibrillation and Heart Failure:a Multicenter Survey

背景心房颤动为临床上常见的快速型心律失常,患病率高,且易导致脑卒中,同时与心力衰竭互为因果。近年来,随着新型药物的出现,治疗策略发生了变化,目前关于心房颤动抗凝治疗的调查较多,但心房颤动合并心力衰竭患者的相关多中心调查研究较为缺乏。目的调查重庆地区心房颤动合并心力衰竭患者的临床特征及治疗现状。方法纳入重庆市21家医院出院日期在2018年的4011例心房颤动合并心力衰竭患者。从电子病历系统采集患者的数据包括性别、年龄、合并基础疾病、心房颤动类型、心功能分级(NYHA分级)、栓塞史、出血史、心脏彩超结果、心力衰竭类型以及药物使用情况〔包括抗栓药物、节律/心室率控制药物、血管紧张素转换酶抑制剂/血管紧张素受体Ⅱ拮抗剂(ACEI/ARB)类药物、强心药等〕。计算纳入患者入院时的脑卒中风险评分(CHA2DS2-VASc评分)和出血风险评分(HAS-BLED评分),确定血栓栓塞及出血风险。按年龄不同分为<65岁组、65~75岁组、>75岁组,按医院等级分为二级医院组、三级医院组,比较分析各组患者的性别、合并基础疾病、是否为瓣膜性心房颤动、心房颤动类型、NYHA分级、CHA2DS2-VASc评分、HAS-BLED评分、左心房内径(LAD)、左心室舒张末期内径(LVIDd)、左心室射血分数(LVEF)、终点事件(血栓栓塞及出血事件)发生率、心力衰竭类型、用药方案之间的差异。结果临床特点方面,4011例心房颤动合并心力衰竭患者平均年龄(74.0±10.6)岁,2279例(56.8%)为女性,合并基础疾病前三位主要为冠心病2610例(65.1%)、高血压2047例(51.0%)和糖尿病700例(17.5%);非瓣膜性心房颤动(NVAF)患者3346例(83.4%),持续性心房颤动2243例(55.9%),心功能分级为Ⅲ级、Ⅳ级患者3059例(76.3%),发生栓塞事件患者531例(13.2%),发生出血事件患者176例(4.4%);心脏彩超结果方面,平均LAD为(44.12±9.21)mm,平均LVIDd为(48.45±10.06)mm,平均LVEF为(54.23±11.94)%;射血分数保留型心力衰竭(HFpEF)患者2656例(66.2%);平均CHA2DS2-VASc评分为(3.9±1.5)分,纳入患者CHA2DS2-VASc评分与年龄呈正相关(r=0.589,P<0.001),平均HAS-BLED评分为(1.7±1.0)分;血栓栓塞高危患者3641例(90.8%),出血风险高危患者723例(18.0%)。治疗现状方面,患者总体抗凝率为47.1%,其中以华法林抗凝治疗为主(37.8%),采用新型口服抗凝药(NOAC)抗凝率仅为9.3%;抗血小板率为44.6%,其中以单抗血小板为主(13.2%);<65岁组、65~75岁组和>75组的抗凝率随年龄增长而下降(χ2趋势=136.502,P<0.001),但抗血小板率随年龄增长而上升(χ2趋势=135.730,P<0.001),并且二级医院总体抗凝率以及华法林和NOAC的使用率低于三级医院(P<0.001);3162例(78.8%)心房颤动患者进行心室率控制,其中使用β-受体阻滞剂占总患者的61.6%,地高辛为17.6%,ACEI/ARB类药物总使用率为59.7%。结论重庆市心房颤动合并心力衰竭患者多数为老年人,女性占比较高,HFpEF是心房颤动的主要类型,NYHA分级以Ⅲ级、Ⅳ级为主,大部分为血栓栓塞高危患者,而出血风险高危患者不足1/4,各年龄段、各级医院抗凝治疗、抗血小板治疗比例仍不理想,改善心力衰竭的治疗现状与指南推荐差距较大,各级医院医师应需进一步提高认识,规范诊疗。

Background Atrial fibrillation(AF)is a common clinical tachyarrhythmia with high prevalence,and a predisposing factor of stroke.In addition,it has a causal relationship with heart failure(HF).Treatment options for AF have changed recently owing to the emergence of new drugs.Many investigations are focused on anticoagulant therapies for AF,but relevant multicenter investigations on AF and HF are rare.Objective To investigate the clinical characteristics and treatment of patients with AF combined with HF in Chongqing,China.Methods A total of 4011 patients with AF and HF who were discharged from 21 hospitals in Chongqing in 2018 were included.Data were collected through the electronic medical record system of the hospitals,including sex,age,basic comorbid conditions,type of AF,NYHA class,thromboembolism history,bleeding history,Color Doppler echocardiography results,HF type and use of drugs(including antithrombotic drugs,rhythm/ventricular rate-control drugs,ACEIs/ARBs,cardiotonic drugs).The risk of thromboembolism and bleeding were assessed using admission CHA2DS2-VASc score and HAS-BLED score.Sex,basic comorbid conditions,AF type,NYHA class,admission CHA2DS2-VASc score and HAS-BLED score,left atrial diameter,left ventricular end-diastolic diameter,left ventricular ejection fraction,endpoint events(thromboembolism and bleeding),HF type,and treatment options were compared across three age groups(<65,65-75,>75)and across patients by the level of hospitalized hospital(secondary and tertiary).Results In terms of clinical characteristics,the patients had an average age of(74.0±10.6)years,2279(56.8%)were female.The top three prevalent basic comorbid conditions were coronary heart disease(65.1%),hypertension(51.0%),and diabetes(17.5%).3346(83.4%)patients with nonvalvular atrial fibrillation(NVAF).NYHA class wasⅢandⅣin 3059 patients(76.3%),thromboembolism events occurred in 531 patients(13.2%),and bleeding events occurred in 176 patients(4.4%).In Color Doppler echocardiography results,The average left atrial diameter was(44.12±9.21)mm.The average left ventricular end-diastolic diameter was(48.45±10.06)mm.The average left ventricular ejection fraction was(54.23±11.94)mm.The main type of HF was HF with preserved ejection fraction,accounting for 66.2%.The average CHA2DS2-VASc score was(3.9±1.5)points,and the admission CHA2DS2-VASc score was positively correlated with age(r=0.589,P<0.001).The average HAS-BLED score was(1.7±1.0)points.3641(90.8%)patients were at high risk of thromboembolism and 723(18.0%)patients were at high risk of bleeding.In terms of antithrombotic treatment,the overall prevalence of anticoagulation treatment was 47.1%,warfarin was the main anticoagulant(37.8%),the prevalence of use of the new oral anticoagulant was only 9.3%.The overall prevalence of antiplatelet treatment was 44.6%,most of them were monoclonal antiplatelet agents(13.2%).The prevalence of anticoagulation treatment decreased with age(χ2 trend=136.502,P<0.001),but that of antiplatelet treatment increased with age(χ2 trend=135.730,P<0.001).The prevalence of anticoagulation treatment,and use of warfarin and new oral anticoagulants in secondary hospitals was significantly lower than that in tertiary hospitals(P<0.001).A total of 3162(78.8%)patients with atrial fibrillation received ventricular rate control.The prevalence of use of betablockers,digoxin and ACEIs/ARBs was 61.6%,17.6%,and 59.7%,respectively.Conclusion The majority of patients with AF complicated with HF in Chongqing are elderly,and the proportion of women is relatively high.HFpEF is the main type of atrial fibrillation,and the NYHA classification is mainly classⅢandⅣ.Most were at high risk for thromboembolism,but less than 1/4 were at high risk of bleeding.The prevalence of antithrombotic treatmentin all ages and levels of hospitals was unsatisfactory,and there was a large gap between current treatment and guideline recommendations in improving HF.In view of this,hospitalphysicians should increase their awareness and capability of standardized diagnosis and treatmentregarding AF with HF.