射血分数保留的心力衰竭不同诊断方法在维持性血液透析患者中的应用

Application of different diagnostic methods for heart failure with preserved ejection fraction in maintenance hemodialysis patients

目的分析射血分数保留的心力衰竭(heart failure with preserved ejection fraction,HFpEF)不同诊断方法在维持性血液透析(maintenance hemodialysis,MHD)患者中的临床应用。方法该研究为单中心回顾性队列研究,纳入2020年7月至2021年6月在上海交通大学医学院附属瑞金医院接受血液透析的尿毒症患者,收集患者人口学资料、实验室指标及超声心动图结果。分别对患者应用2016年欧洲心脏病学会(European Society of Cardiology,ESC)标准、H2FPEF评分[基于超重(H)、高血压(H)、房颤(F)、肺动脉高压(P)、高龄(E)、充盈压(F)的加权分数构建的复合分数]和心力衰竭协会(Heart Failure Association,HFA)-PEFF[包括检查前评估(P)、超声心动图和利钠肽评分(E)、功能测试(F)和最终病因学(F)]评分诊断HFpEF,比较3种诊断方法的差异,并分析不同方法诊断HFpEF与患者不良预后(全因死亡、心血管相关死亡)的关系。结果共纳入160例MHD患者,年龄(58.5±13.4)岁,男性92例(57.5%),中位透析龄5.0(2.3,9.6)年,中位H2FPEF评分2(1,3)分,中位HFA-PEFF评分4(3,5)分。这些患者中,118例(73.8%)患者符合ESC标准诊断HFpEF,4例(2.5%)符合H2FPEF评分诊断HFpEF,56例(35.0%)符合HFA-PEFF评分诊断HFpEF。三种评分诊断HFpEF的一致性差,两两比较的κ值分别为0.018(ESC标准和H2FPEF评分)、0.322(ESC标准和HFA-PEFF评分)和0.056(H2FPEF评分和HFA-PEFF评分)。中位随访2.6年后,20例(12.5%)患者死亡。Kaplan-Meier生存分析结果显示使用H2FPEF评分确诊HFpEF和无HFpEF患者预后差异有统计学意义(Log-rank检验,χ^(2)=6.95,P=0.008)。在校正了人口统计学和临床参数后,多因素Cox回归分析提示HFA-PEFF评分诊断的HFpEF与全因死亡(HR=2.73,95%CI 1.07~6.98,P=0.036)和心血管相关死亡(HR=4.77,95%CI 1.31~17.30,P=0.018)相关。结论2016年ESC标准、H2FPEF评分和HFA-PEFF评分诊断MHD患者HFpEF的异质性大,一致性差。三种诊断方法中,仅HFA-PEFF评分与血液透析患者预后相关。HFA-PEFF评分更适用于MHD患者HFpEF风险评估,今后尚需更多的临床研究进一步验证。

Objective To analyze the clinical application of different diagnostic methods for heart failure with preserved ejection fraction(HFpEF)in maintenance hemodialysis(MHD)patients.Methods It was a single-center retrospective cohort study.Uremia patients who underwent hemodialysis at Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine from July 2020 to June 2021 were enrolled.The demographic characteristics,laboratory indicators,and echocardiography parameters were collected.The 2016 European Society of Cardiology(ESC)criteria,H2FPEF score[composite score based on weighted scores of heavy(H),hypertensive(H),atrial fibrillation(F),pulmonary hypertension(P),elder(E),and filling pressure(F)],and Heart Failure Association(HFA)-PEFF score[including pre-test assessment(P),echocardiography and natriuretic peptide score(E),functional testing(F)and final aetiology(F)]were used to diagnose HFpEF,respectively,and the difference of three diagnostic methods was compared.The association between HFpEF diagnosed by the three methods and poor outcomes(all-cause death,cardiovascular death)was analyzed.Results A total of 160 MHD patients were included,whose age was(58.5±13.4)years,median dialysis age was 5.0(2.3,9.6)years,median H2FPEF score was 2(1,3),median HFA⁃PEFF score was 4(3,5),and 92(57.5%)were males.Of these patients,118 patients(73.8%)met the 2016 ESC criteria for diagnosis of HFpEF,4(2.5%)met H2FPEF score for diagnosis of HFpEF,and 56(35.0%)met HFA⁃PEFF score for diagnosis of HFpEF.The consistency of three methods in diagnosing HFpEF was poor withκvalues of 0.018 between ESC criteria and H2FPEF score,0.322 between ESC criteria and HFA⁃PEFF score,and 0.056 between H2FPEF score and HFA⁃PEFF score.After a median follow-up of 2.6 years,20(12.5%)of the 160 MHD patients died.The Kaplan⁃Meier survival analysis showed a significant difference in mortality between patients diagnosed with HFpEF and those without using the H2FPEF score(Log⁃rank test,χ^(2)=6.95,P=0.008).After adjusting for demographic and clinical parameters,multivariate Cox regression analysis showed that HFpEF diagnosed by HFA⁃PEFF score was associated with all-cause mortality(HR=2.73,95%CI 1.07-6.98,P=0.036)and cardiovascular mortality(HR=4.77,95%CI 1.31-17.30,P=0.018).Conclusions The 2016 ESC criteria,H2FPEF score,and HFA⁃PEFF score have high heterogeneity and poor consistency in diagnosing HFpEF in MHD patients.Among the three diagnostic methods,only the diagnosis based on HFA⁃PEFF score is associated with the prognosis of MHD patients.The HFA⁃PEFF score can be used to assess the risk of HFpEF in MHD patients,and more clinical studies are needed to further verify it in the future.