McAlister Finlay A, Ezekowitz Justin, Tonelli Marcello, Armstrong Paul W
Division of General Internal Medicine, University of Alberta, Edmonton, Canada.
Circulation. 2004 Mar 2;109(8):1004-9. doi: 10.1161/01.CIR.0000116764.53225.A9. Epub 2004 Feb 9.
The prevalence, prognostic import, and impact of renal insufficiency on the benefits of ACE inhibitors and beta-blockers in community-dwelling patients with heart failure are uncertain.
We analyzed data from a prospective cohort of 754 patients with heart failure who had ejection fraction, serum creatinine, and weight measured at baseline. Median age was 69 years, and 43% had an ejection fraction > or =35%. By the Cockcroft-Gault equation, 118 patients (16%) had creatinine clearances < or =30 mL/min and 301 (40%) had creatinine clearances between 30 and 59 mL/min. During follow-up (median 926 days), 385 patients (37%) died. Even after adjustment for all other prognostic factors, survival was significantly associated with renal function (P=0.002) in patients with either systolic or diastolic dysfunction; patients exhibited a 1% increase in mortality for each 1-mL/min decrease in creatinine clearance. The associations with 1-year mortality reductions were similar for ACE inhibitors (OR 0.46 [95% CI 0.26 to 0.82] versus OR 0.28 [95% CI 0.11 to 0.70]) and beta-blockers (OR 0.40 [95% CI 0.23 to 0.70] versus OR 0.41 [95% CI 0.19 to 0.85]) in patients with creatinine clearances <60 mL/min versus > or =60 mL/min, although these drugs were used less frequently in patients with renal insufficiency.
Renal insufficiency is more prevalent in patients with heart failure than previously reported and is an independent prognostic factor in diastolic and systolic dysfunction. ACE inhibitors and beta-blockers were associated with similar reductions in mortality in patients with and without renal insufficiency.
在社区居住的心力衰竭患者中，肾功能不全的患病率、预后意义以及对血管紧张素转换酶抑制剂（ACE抑制剂）和β受体阻滞剂疗效的影响尚不确定。
我们分析了一个前瞻性队列中754例心力衰竭患者的数据，这些患者在基线时测量了射血分数、血清肌酐和体重。中位年龄为69岁，43%的患者射血分数≥35%。根据Cockcroft - Gault公式，118例患者（16%）肌酐清除率≤30 mL/分钟，301例患者（40%）肌酐清除率在30至59 mL/分钟之间。在随访期间（中位时间926天），385例患者（37%）死亡。即使在对所有其他预后因素进行调整后，无论是收缩功能障碍还是舒张功能障碍患者，生存率都与肾功能显著相关（P = 0.002）；肌酐清除率每降低1 mL/分钟，患者死亡率增加1%。对于肌酐清除率<60 mL/分钟与≥60 mL/分钟的患者，ACE抑制剂（比值比[OR] 0.46 [95%可信区间（CI）0.26至0.82] 对比OR 0.28 [95% CI 0.11至0.70]）和β受体阻滞剂（OR 0.40 [95% CI 0.23至0.70] 对比OR 0.41 [95% CI 0.19至0.85]）与1年死亡率降低的关联相似，尽管肾功能不全患者使用这些药物的频率较低。
心力衰竭患者中肾功能不全的患病率比之前报道的更高，并且是舒张功能障碍和收缩功能障碍的独立预后因素。ACE抑制剂和β受体阻滞剂在有或没有肾功能不全的患者中与死亡率降低的关联相似。
