慢性心力衰竭患者住院期间血压水平及变化对全因死亡的影响

Influence of blood pressure and its change during hospitalization on all-cause mortality in patients with chronic heart failure

目的探讨慢性心力衰竭患者住院期间血压水平及其变化对全因死亡的预测价值。方法收集2014年3月—2019年2月于山西省三所医院住院,明确诊断为慢性心力衰竭的患者共3928例,测量其入院、出院血压并计算出院血压变化率。以全因死亡为研究终点,截止随访时间为2022年3月1日。采用单因素Cox及多因素Cox比例风险回归模型分析死亡的危险因素,并绘制限制性立方样条图,分析不同年龄人群中血压对全因死亡的影响。结果患者平均入院血压为(131±20)/(78±12)mmHg,平均出院血压为(122±15)/(73±9)mmHg。中位随访时间为5.17年,共504例(12.8%)患者发生全因死亡。与血压较低组(入院收缩压<90 mmHg和/或入院舒张压<60 mmHg)相比,血压正常组(入院收缩压90~<140和入院舒张压60~<90 mmHg)及血压较高组(入院收缩压≥140 mmHg和/或舒张压≥90 mmHg)患者全因死亡发生率更低(12.1%、13.1%比23.3%,χ^(2)=11.230,P=0.004)。单因素Cox回归分析显示,出院收缩压和舒张压、入院舒张压、出院收缩压变化率是慢性心力衰竭患者全因死亡的预测因素(均P<0.05)。多因素Cox回归分析显示,入院舒张压(HR=0.989;95%CI 0.981~0.997)、出院收缩压变化率(HR=0.987;95%CI 0.981~0.994)是慢性心力衰竭患者全因死亡的独立预测因素。调整后的限制性立方样条图表明,入院舒张压<75 mmHg、出院收缩压较入院降低超过14.8%可增加患者的全因死亡风险。分层分析显示,出院收缩压变化率(HR=0.987;95%CI 0.979~0.994)、入院舒张压(HR=0.989;95%CI 0.981~0.998)是老年(年龄≥65岁)患者发生全因死亡的独立预测因素,入院舒张压(HR=0.982;95%CI 0.966~0.998)是中青年(年龄<65岁)患者发生全因死亡的独立预测因素。结论入院舒张压<75 mmHg、出院收缩压较入院降低超过14.8%的慢性心力衰竭患者全因死亡风险高。

Objective To investigate the predictive value of blood pressure and its changes during hospitalization on all-cause mortality in patients with chronic heart failure.Methods A total of 3928 patients with confirmed diagnosis of chronic heart failure were collected from three hospitals in Shanxi Province from March 2014 to February 2019.The admission and discharge blood pressures were measured and the change rates of discharge blood pressure were calculated.All-cause mortality was used as the study endpoint.The deadline for follow-up was March 1,2022.Univariate and multivariate Cox proportional risk regression models were used to analyze the risk factors for death,and restrictive cubic spline plots were used to analyze the effect of blood pressure on all-cause mortality in different age groups.Results The mean admission blood pressure was(131±20)/(78±12)mmHg and the mean discharge blood pressure was(122±15)/(73±9)mmHg.During a median follow-up of 5.17 years,all-cause mortality occurred in 504 patients,with an all-cause mortality rate of 12.8%.Compared with the low blood pressure group[admission systolic blood pressure(SBP)<90 mmHg and/or admission diastolic blood pressure(DBP)<60 mmHg],patients in the normal(admission SBP 90-<140 and DBP 60-<90 mmHg)and high blood pressure groups(admission SBP≥140 mmHg and/or DBP≥90 mmHg)had a lower all-cause motality rate(12.1%,13.1%vs 23.3%,χ^(2)=11.230;P=0.004).Univariate Cox regression analysis showed that discharge SBP and DBP,admission DBP,discharge SBP change rate were predictors of all-cause mortality in patients with chronic heart failure(all P<0.05).Multivariate Cox regression analysis showed that admission DBP(HR=0.989;95%CI 0.981-0.997)and discharge SBP change rate(HR=0.987;95%CI 0.981-0.994)were independent predictors of all-cause mortality in patients with chronic heart failure.The adjusted restricted cubic spline graph showed that patients with admission DBP<75 mmHg and discharge SBP decreased by more than 14.8% compared to admission could increase the risk of all-cause mortality.Layered analysis showed that the discharge SBP change rate(HR=0.987;95%CI 0.979-0.994)and admission DBP(HR=0.989;95%CI 0.981-0.998)were independent predictors for all-cause mortality in elderly patients(≥65 years old),while admission DBP(HR=0.982;95%CI 0.966-0.998)was an independent predictor for all-cause mortality in middle-aged and young patients(<65 years old).Conclusion Admission DBP<75 mmHg and discharge SBP decreased by more than 14.8% compared to admission are risk factors of all-cause mortality in patients with chronic heart failure.