一项关于心力衰竭患者纽约心脏协会心功能分级和自然病史终点的倾向匹配研究

众所周知，较高的纽约心脏协会（NYHA）心功能分级与心力衰竭（HF）预后不良有关。但是，尚不清楚这种相关性在多大程度上受到年龄、疾病严重性和共病负荷等协变因素的混杂影响。洋地黄研究组（DIG）试验中入选的7788例慢性HF患者中有2441例为NYHA心功能Ⅲ级或Ⅳ级。计算每例患者的NYHA分级为Ⅲ级或Ⅳ级的倾向性评分，进而将1863例NYHA分级Ⅲ级或Ⅳ级患者与1863例NYHA分级Ⅰ级或Ⅱ级患者匹配。应用Kaplan-Meier和匹配Cox回归分析，估计NYHA分级Ⅲ级或Ⅳ级与中位时间37个月的随访期内死亡及住院之间的关系。

心力衰竭、慢性利尿剂应用与死亡率及住院率升高:应用倾向性评分方法的观察研究

Aims: Non-potassium-sparing diuretics are commonly used in heart failure(HF). They activate the neurohormonal system,and are potentially harmful. Yet, the long-term effects of chronic diuretic use in HF are largely unknown. We retrospectively analysed the Digitalis Investigation Group(DIG) data to determine the effects of diuretics on HF outcomes. Methods and results: Propensity scores for diuretic use were calculated for each of the 7788 DIG participants using a non-parsimonious multivariable logistic regression model, and were used to match 1391(81%) no-diuretic patients with 1391 diuretic patients. Effects of diuretics on mortality and hospitalization at 40 months of median follow-up were assessed using matched Cox regression models. All-cause mortality was 21%for nodiuretic patients and 29%for diuretic patients[hazard ratio(HR) 1.31; 95%confidence interval(CI) 1.11-1.55; P=0.002]. HF hospitalizations occurred in 18%of no-diuretic patients and 23%of diuretic patients(HR 1.37; 95%CI 1.13-1.65; P=0.001). Conclusion: Chronic diuretic use was associated with increased long-term mortality and hospitalizations in a wide spectrum of ambulatory chronic systolic and diastolic HF patients. The findings of the current study challenge the wisdom of routine chronic use of diuretics in HF patients who are asymptomatic or minimally symptomatic without fluid retention, and are on complete neurohormonal blockade. These findings, based on a non-randomized design, need to be further studied in randomized trials.

纽约心脏协会心功能分级增高与左心室功能尚存的心力衰竭患者死亡率和入院率增加的关系

Background: The association between higher New York Heart Association(NYHA) class and outcomes in patients with heart failure and preserved systolic function is not well known. Methods: We performed a retrospective follow- up study of 988 patients with heart failure with ejection fraction >45% who participated in the DIG trial. Using Cox proportional hazard models, we estimated risks of all- cause mortality, heart failure mortality, all- cause hospitalization, and hospitalization due to worsening heart failure during a median follow- up of 38.5 months. Results: Patients had a median age of 68 years; 41.2% were women and 13.9% , nonwhites. Overall, 23.4% of patients died, and 19.9% were hospitalized because of worsening heart failure. Proportion of patients with NYHA classes I, II, III, and IV were 19.9% , 58.0% , 20.9% , and 1.2% , respectively, and 14.7% , 21.1% , 35.9% , and 58.3% , respectively, died of all causes(P< .001 for trend). Respective rates for heart failure related hospitalizations were 14.2% , 17.1% , 32.5% , and 33.3% (P< .001 for trend). Compared with NYHA class I patients, adjusted hazard ratios(HRs) for all- cause mortality for class II, III, and IV patients were 1.54(95% CI 1.02- 2.32, P=.042), 2.56(95% CI 1.64- 24.01, P< .001), and 8.46(95% CI 3.57- 20.03, P< .001), respectively. Respective adjusted HRs(95% CI) for hospitalization due to heart failure for class II, III, and IV patients were 1.16(0.76- 1.77)(P=.502), 2.27(1.45- 3.56)(P< .001), and 3.71(1.25- 11.02)(P=.018). New York Heart Association classes II through IV were also associated with higher risk of all- cause hospitalization. Conclusion: Higher NYHA classes were associated with poorer outcomes in patients with heart failure and preserved systolic function.

停用地高辛与低血药浓度继续应用地高辛对慢性心力衰竭的效果

停用地高辛可引起心力衰竭(HF)症状恶化。然而,停用地高辛治疗对HF患者死亡率及发病率的长期影响尚未很好地研究。在地高辛调查组试验的7788例参与者中,3365例患者在随机化之前已接受了地高辛治疗。在该试验中,1666例患者继续使用地高辛,1699例患者停用地高辛。利用多变量Cox回归分析,首次确定了停用地高辛对中位期为39.7个月的随访内死亡率和住院率的影响。