作者：李少杰，梁浩，苏康康，谷剑，陈淑霞

单位：

1.河北北方学院研究生院2.河北省人民医院心血管内科

Units：

1.GraduateSchoolofHebeiNorthUniversity,Zhangjiakou075000,China2.DepartmentofHeartCenter,HebeiGeneralHospital,Shijiazhuang050051,China

关键词：

心力衰竭; 左心室射血分数; 射血分数改善; 缺血性心肌病; 预后; 影响因素;

Keywords：

Heartfailure;Leftventricularejectionfraction;Improvedejectionfraction;Ischemiccardiomyopathy;Prognosis;Influencingfactors

CLC：

R541.62

DOI：

10.12114/j.issn.1008-5971.2023.00.033

Funds：

河北省重点研发计划项目( 22377783D?)； 2022年度河北省医学科学研究课题计划( 20220821?)

摘要：

目的 探讨缺血性心肌病（ICM）合并射血分数改善的心力衰竭（HFimpEF）患者的临床特征及预后。方法 选取2018年6月至2021年5月河北省人民医院心脏中心收治的ICM合并慢性心力衰竭（HF）患者425例。根据基线、复查左心室射血分数（LVEF）将其分为HFimpEF组（基线LVEF≤40%，复查LVEF>40%,n=95）、射血分数中间值的心力衰竭（HFmrEF）组（复查LVEF为41%～49%,n=84）、射血分数降低的心力衰竭（HFrEF）组（基线LVEF≤49%，复查LVEF≤40%,n=178）、射血分数保留的心力衰竭（HFpEF）组（基线LVEF及复查LVEF均≥50%,n=68）。比较四组一般资料、超声心动图检查指标、实验室检查指标、治疗情况、全因死亡率、全因再入院率。采用单因素、多因素Cox比例风险回归分析探讨ICM合并HFimpHF患者全因死亡、全因再入院的影响因素。结果 HFimpEF组年龄小于HFpEF组，收缩压（SBP）低于HFpEF组，舒张压（DBP）低于HFrEF组（P<0.05）;HFimpEF组基线左心室收缩末期内径（LVESD）、左心室舒张末期内径（LVEDD）小于HFrEF组，大于HFpEF组（P<0.05）;HFimpEF组血红蛋白、红细胞计数高于HFpEF组，血小板计数高于HFrEF组，N末端脑钠肽前体（NTproBNP）低于HFrEF组（P<0.05）;HFimpEF组使用血管紧张素受体脑啡肽酶抑制剂（ARNI）、醛固酮受体拮抗剂（MRA）、利尿剂、抗血小板药、重组人脑利钠肽者占比高于HFpEF组，使用钙通道阻滞剂（CCB）者占比低于HFpEF组（P<0.05）;HFimpEF组全因死亡率低于HFrEF组（P<0.05）;HFimpEF组全因再入院率低于HFmrEF组（P<0.05）。多因素Cox比例风险回归分析结果显示，合并心房颤动（AF）、贫血是ICM合并HFimpEF患者全因死亡的危险因素，BMI升高、基线LVEDD>55 mm是ICM合并HFimpEF患者全因再入院的危险因素，使用钠-葡萄糖协同转运蛋白2抑制剂（SGLT2i）是ICM合并HFimpEF患者全因再入院的保护因素（P<0.05）。结论 在ICM患者中，合并HFimpEF者年龄较小、血压较低、心室重构程度较轻、使用ARNI及MRA等药物的比例较高、全因死亡率和全因再入院率较低，而合并AF、贫血是ICM合并HFimpEF患者全因死亡的独立危险因素，BMI升高、基线LVEDD>55 mm是ICM合并HFimpEF患者全因再入院的独立危险因素，使用SGLT2i是ICM合并HFimpEF患者全因再入院的独立保护因素。

Abstract：

ObjectiveToinvestigatetheclinicalcharacteristicsandprognosisofpatientswithischemiccardiomyopathy(ICM)combinedwithheartfailurewithimprovedejectionfraction(HFimpEF).MethodsAtotalof425patientswithICMcomplicatedwithchronicheartfailure(HF)admittedtotheHeartCenterofHebeiGeneralHospitalfromJune2018toMay2021wereselected.Accordingtobaselineandreviewleftventricularejectionfraction(LVEF),thepatientsweredividedintoHFimpEFgroup(baselineLVEF≤ 40%,reviewLVEF>40%,n=95),heartfailurewithmid-rangeejectionfraction(HFmrEF)group(reviewLVEFwas41%-49%,n=84),heartfailurewithreducedejectionfraction(HFrEF)group(baselineLVEF≤ 49%,reviewLVEF≤ 40%,n=178),heartfailurewithpreservedejectionfraction(HFpEF)group(baselineLVEFandreviewLVEFwereboth≥50%,n=68).Thegeneraldata,echocardiogramindexes,laboratoryexaminationindexes,treatmentstatus,all-cauesmortalityandall-causereadmmisonratewerecomparedamongthefourgroups.UnivariateandmultivariateCoxproportionalriskregressionanalysiswasusedtoinvestigatetheinfluencingfactorsofall-causedeathandall-causereadmissioninICMpatients combinedwithHFimpEF.ResultsTheageofHFimpEFgroupwasyoungerthanthatofHFpEFgroup,andsystolicbloodpressure(SBP)waslowerthanthatofHFpEFgroup,diastolicbloodpressure(DBP)waslowerthanthatofHFrEFgroup(P<0.05).Baselineleftventricularendsystolicdiameter(LVESD)andleftventricularenddiastolicdiameter(LVEDD)inHFimpEFgroupwerelowerthanthoseinHFrEFgroup,buthigherthanthoseinHFpEFgroup(P<0.05).ThehemoglobinandredbloodcellcountofHFimpEFgroupwerehigherthanthoseofHFpEFgroup,plateletcountwashigherthanthatofHFrEFgroup,andtheN-terminalpro-brainnatriureticpeptide(NT-proBNP)waslowerthanthatofHFrEFgroup(P<0.05).Theproportionofpatientsusingangiotensinreceptorneprilysininhibitor(ARNI),mineralcorticoidreceptantagonist(MRA),diuretics,antiplateletdrugsandrecombinanthumannatriureticpeptideinHFimpEFgroupwashigherthanthatinHFpEFgroup,andtheproportionofpatientsusingcalciumchannelblocker(CCB)waslowerthanthatinHFpEFgroup(P<0.05).Theall-causemortalityofHFimpEFgroupwaslowerthanthatofHFrEFgroup(P<0.05).Theall-causereadmissionrateofHFimpEFgroupwaslowerthanthatofHFmrEFgroup(P<0.05).MultivariateCoxproportionalriskregressionanalysisshowedthatatrialfibrillation(AF)andanemiawereriskfactorsforall-causedeathinICMpatientscombinedwithHFimpEF,increasedBMIandbaselineLVEDD>55mmwereriskfactorsforall-causereadmissioninICMpatientscombinedwithHFimpEF,useofsodium-glucosecotransporter2inhibitor(SGLT2i)wasaprotectivefactorforall-causereadmissioninICMpatientscombinedwithHFimpEF(P<0.05).ConclusionAmongICMpatients,patientswithHFimpEFhaveyoungerage,lowerbloodpressure,lessdegreeofventricularremodeling,higherratesofuseofguide-recommendeddrugssuchasARNIandMRA,andlowerall-causemortalityandall-causereadmissionrates.AFandanemiaareindependentriskfactorsforall-causedeathinICMpatientscombinedwithHFimpEF.IncreasedBMIandbaselineLVEDD>55mmareindependentriskfactorsforall-causereadmissioninICMpatientscombinedwithHFimpEF.UseofSGLT2iisindependentprotectivefactorforall-causereadmissioninICMpatientscombinedwithHFimpEF.

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