Philbin E F, Rocco T A, Lindenmuth N W, Ulrich K, Jenkins P L
Section of Heart Failure and Cardiac Transplantation (EFP), Henry Ford Hospital, Detroit, Michigan, USA.
Am J Med. 2000 Dec 1;109(8):605-13. doi: 10.1016/s0002-9343(00)00601-x.
Among patients with heart failure, there is controversy about whether there are clinical features and laboratory tests that can differentiate patients who have low ejection fractions from those with normal ejection fractions. The usefulness of angiotensin-converting enzyme (ACE) inhibitors among heart failure patients who have normal left ventricular ejection fractions is also not known.
From a registry of 2,906 unselected consecutive patients with heart failure who were admitted to 10 acute-care community hospitals during 1995 and 1997, we identified 1291 who had a quantitative measurement of their left ventricular ejection fraction. Patients were separated into three groups based on ejection fraction: < or =0.39 (n = 741, 57%), 0.40 to 0.49 (n = 238, 18%), and > or =0.50 (n = 312, 24%). In-hospital mortality, prescription of ACE inhibitors at discharge, subsequent rehospitalization, quality of life, and survival were measured; survivors were observed for at least 6 months after hospitalization.
The mean (+/- SD) age of the sample was 75+/-11 years; the majority (55%) of patients were women. In multivariate models, age >75 years, female sex, weight >72.7 kg, and a valvular etiology for heart failure were associated with an increased probability of having an ejection fraction > or =0.50; a prior history of heart failure, an ischemic or idiopathic cause of heart failure, and radiographic cardiomegaly were associated with a lower probability of having an ejection fraction > or =0.50. Total mortality was lower in patients with an ejection fraction > or =0.50 than in those with an ejection fraction < or =0.39 (odds ratio [OR] = 0.69, 95% confidence interval [CI 0.49 to 0.98, P = 0.04). Among hospital survivors with an ejection fraction of 0.40 to 0.49, the 65% who were prescribed ACE inhibitors at discharge had better mean adjusted quality-of-life scores (7.0 versus 6.2, P = 0.02), and lower adjusted mortality (OR = 0.34, 95% CI: 0.17 to 0.70, P = 0.01) during follow-up than those who were not prescribed ACE inhibitors. Among hospital survivors with an ejection fraction > or =0.50, the 45% who were prescribed ACE inhibitors at discharge had better (lower) adjusted New York Heart Association (NYHA) functional class (2.1 versus 2.4, P = 0.04) although there was no significant improvement in survival.
Among patients treated for heart failure in community hospitals, 42% of those whose ejection fraction was measured had a relatively normal systolic function (ejection fraction > or 0.40). The clinical characteristics and mortality of these patients differed from those in patients with low ejection fractions. Among the patients with ejection fractions > or =0.40, the prescription of ACE inhibitors at discharge was associated favorable effects.
在心力衰竭患者中，对于是否存在能够区分射血分数降低的患者和射血分数正常的患者的临床特征及实验室检查存在争议。血管紧张素转换酶（ACE）抑制剂在左心室射血分数正常的心力衰竭患者中的作用也尚不清楚。
从1995年至1997年期间入住10家急症社区医院的2906例未经选择的连续心力衰竭患者登记册中，我们确定了1291例进行了左心室射血分数定量测量的患者。根据射血分数将患者分为三组：≤0.39（n = 741，57%）、0.40至0.49（n = 238，18%）和≥0.50（n = 312，24%）。测量住院死亡率、出院时ACE抑制剂的处方情况、随后的再住院情况、生活质量和生存率；对幸存者在出院后至少观察6个月。
样本的平均（±标准差）年龄为75±11岁；大多数（55%）患者为女性。在多变量模型中，年龄>75岁、女性、体重>72.7 kg以及心力衰竭的瓣膜病因与射血分数≥0.50的可能性增加相关；心力衰竭的既往病史、缺血性或特发性心力衰竭病因以及影像学心脏扩大与射血分数≥0.50的可能性降低相关。射血分数≥0.50的患者的总死亡率低于射血分数≤0.39的患者（比值比[OR]=0.69，95%置信区间[CI 0.49至0.98，P = 0.04]）。在射血分数为0.40至0.49的住院幸存者中，出院时开具ACE抑制剂的65%患者在随访期间的平均调整后生活质量评分更好（7.0对6.2，P = 0.02），且调整后死亡率更低（OR = 0.34，95% CI：0.17至0.70，P = 0.01），高于未开具ACE抑制剂的患者。在射血分数≥0.50的住院幸存者中，出院时开具ACE抑制剂的45%患者的调整后纽约心脏协会（NYHA）功能分级更好（更低）（2.1对2.4，P = 0.04），尽管生存率没有显著改善。
在社区医院接受心力衰竭治疗的患者中，42%测量了射血分数的患者具有相对正常的收缩功能（射血分数>或0.40）。这些患者的临床特征和死亡率与射血分数降低的患者不同。在射血分数≥0.40的患者中，出院时开具ACE抑制剂具有有益效果。
