衰弱对老年慢性心力衰竭患者长期心血管事件的影响

The effect of frailty on adverse cardiovascular events during long-term follow-up in elderly patients with preserved ejection fraction and chronic heart failure

目的:观察合并衰弱的老年射血分数保留慢性心力衰竭(preserved ejection fraction chronic heart failure,HFpEF)患者随访3年发生主要不良心血管事件(major adverse cardiovascular events,MACE)的风险,并分析影响MACE的危险因素。方法:本研究为回顾性队列研究,连续纳入2017年1月至2019年1月,在我院诊治的老年HFpEF患者。依据是否合并衰弱,选择合并衰弱的140例患者为衰弱组;按照1:1比例选择同期入院、年龄、BMI和心功能(LVEF)类似的未合并衰弱的140例患者为对照组。随访3年期间22例失访,最终衰弱组和对照组分别纳入130例和128例。记录MACE发生情况(全因死亡、心肌梗死、心力衰竭入院和卒中的复合事件)。应用Kaplan-Meier生存分析和Log-rank检验比较组间的MACE发生情况。应用单因素和多因素Cox比例风险回归模型检测MACE的危险因素。结果:258例老年HFpEF患者中,平均年龄(70.5±11.1)岁。与对照组相比,衰弱组的HGB更低,空腹血糖和血肌酐更高,利尿剂应用率更高,ACEI/ARB应用率更低,醛固酮受体拮抗剂应用率更高,差异均有统计学意义(P <0.05)。中位随访时间(38.3±2.2)个月期间,共发生86例(33.3%)不良心血管事件,包括11例(4.3%)全因死亡,24例(9.3%)心肌梗死,39例(15.1%)因心力衰竭再入院,12例(4.7%)卒中。Kaplan-Meier生存分析和Log-rank检验结果提示,衰弱组的心力衰竭入院(16.9%vs.13.3%,HR=1.293,95%CI:1.053~1.589,P=0.014)和MACE(36.9%vs. 29.7%,HR=1.242,95%CI:1.025~1.506,P=0.027)发生风险均明显增加,但两组间的全因死亡(4.6%vs. 3.9%,HR=1.174,95%CI:0.950~1.451,P=0.138)、心肌梗死(10.0%vs. 8.6%,HR=1.171,95%CI:0.984~1.397,P=0.075)和卒中(5.4%vs. 3.9%,HR=1.382,95%CI:0.911~2.098,P=0.128)的发生风险无明显差异。采用多因素Cox比例风险回归模型显示,年龄(HR=1.446)、HGB(HR=0.953)、血肌酐(HR=1.566)、BNP(HR=1.423)、衰弱(HR=1.242)和ACEI/ARB(HR=0.931)是MACE的相关因素(均为P <0.05)。结论:衰弱可显著增加老年HFpEF患者随访3年发生心力衰竭再入院和MACE的发生风险。

Objective:To observe the risk of major adverse cardiovascular events(MACE)in elderly patients with heart failure with preserved ejection fraction(HFpEF)who have concomitant frailty and to analyze the risk factors influencing MACE.Methods:This was a retrospective cohort study that included consecutive elderly HFpEF patients treated at our hospital from January 2017 to January 2019.Based on the presence or absence of frailty,140 patients with frailty were selected as the frailty group,and 140 patients without frailty,matched for hospitalization period,age,BMI,and LVEF,were selected as the control group in a 1:1 ratio.During a 3-year follow-up period,22 patients were lost to follow-up,resulting in a final inclusion of 130 patients in the frailty group and 128 patients in the control group.The occurrence of MACE(composite events including all-cause death,myocardial infarction,heart failure hospitalization,and stroke)was recorded.Kaplan-Meier survival analysis and log-rank test were used to compare the occurrence of MACE between the two groups.Univariate and multivariate Cox proportional hazards regression models were used to identify the risk factors for MACE.Results:Among the 258 elderly HFpEF patients,the mean age was(70.5±11.1)years.Compared to the control group,the frailty group had lower levels of HGB,higher levels of fasting blood glucose and serum creatinine,higher usage of diuretics,lower usage of ACEI/ARB,and higher usage of aldosterone receptor antagonists,with all differences being statistically significant(P<0.05).During a median follow-up period of(38.3±2.2)months,a total of 86 cases(33.3%)experienced MACE,including 11 cases(4.3%)of all-cause death,24 cases(9.3%)of myocardial infarction,39 cases(15.1%)of heart failure hospitalization,and 12 cases(4.7%)of stroke.Kaplan-Meier survival analysis and log-rank test results indicated that the frailty group had a significantly increased risk of heart failure hospitalization(16.9%vs.13.3%,HR=1.293,95%CI:1.053-1.589,P=0.014)and MACE(36.9%vs.29.7%,HR=1.242,95%CI:1.025-1.506,P=0.027).However,there were no significant differences between the two groups in terms of all-cause death(4.6%vs.3.9%,HR=1.174,95%CI:0.950-1.451,P=0.138),myocardial infarction(10.0%vs.8.6%,HR=1.171,95%CI:0.984-1.397,P=0.075),and stroke(5.4%vs.3.9%,HR=1.382,95%CI:0.911-2.098,P=0.128).Multivariate Cox proportional hazards regression analysis showed that age(HR=1.446),HGB(HR=0.953),serum creatinine(HR=1.566),BNP(HR=1.423),frailty(HR=1.242),and ACEI/ARB(HR=0.931)were associated with MACE(all P<0.05).Conclusions:Frailty significantly increases the risk of heart failure hospitalization and MACE in elderly patients with HFpEF during a 3-year follow-up period.