Lip Gregory Y H, Rasmussen Lars Hvilsted, Skjøth Flemming, Overvad Kim, Larsen Torben Bjerregaard
Centre for Cardiovascular Sciences, University of Birmingham, City Hospital, Birmingham, UK.
BMJ Open. 2012 Jul 7;2(4). doi: 10.1136/bmjopen-2012-000975. Print 2012.
The objective was to test the hypothesis that the risk of stroke, death and the composite of 'stroke and death' would be increased among patients with incident heart failure (HF). While HF increases the risk of mortality, stroke and thromboembolism in general, the 'extreme high-risk' nature of incident HF is perhaps under-recognised in everyday clinical practice.
Prospective cohort study.
Large Danish prospective epidemiological cohort.
Subjects in the Diet, Cancer and Health study.
Stroke, death and the composite of 'stroke and death' among patients with incident cases of HF, without concomitant atrial fibrillation.
From the original cohort, 1239 patients with incident HF were identified. Incidence rates show a higher incidence in the initial period following the diagnosis of HF, with a markedly higher rate of death and stroke (ischaemic or haemorrhagic) in the initial 30 days following the diagnosis of incident HF. While lower than the risk at 0-30 days, the higher risk did not return to normal at 6+ months after the diagnosis of incident HF. This risk increase was apparent for the end points of stroke (ischaemic or haemorrhagic or both) whether or not a vitamin K antagonist (VKA) was used. With VKA use, there was a lower adjusted HR for death and the composite of 'death or stroke' compared to non-VKA use at the three time intervals following diagnosis of HF, whether 0-30 days, 30 days to 6 months and 6+ months. On multivariate analysis, previous stroke/transient ischaemic attack/thromboembolism was a predictor of higher risk of stroke, death and the composite of 'stroke and death', while VKA treatment was a highly significant predictor of a lower risk for death (adjusted HR 0.46, 95% CI 0.28 to 0.74, p<0.001) and the combined end point of death or stroke (adjusted HR 0.64, 95% CI 0.43 to 0.96, p=0.003).
Based on relative hazards, incident HF is clearly a major risk factor for stroke, death and the composite of 'stroke and death', especially in the initial 30 days following initial diagnosis. The use of VKA therapy was associated with a lower risk of these end points. These findings would have major implications for the approach to management of patients presenting with incident HF, given the high risk of this population for death and stroke, which may be ameliorated by VKA therapy.
本研究旨在验证以下假设：新发心力衰竭（HF）患者发生卒中、死亡及“卒中与死亡”复合事件的风险会增加。虽然一般而言，HF会增加死亡率、卒中和血栓栓塞的风险，但新发HF的“极高风险”性质在日常临床实践中可能未得到充分认识。
前瞻性队列研究。
丹麦大型前瞻性流行病学队列。
饮食、癌症与健康研究中的受试者。
新发HF患者（无合并房颤）的卒中、死亡及“卒中与死亡”复合事件。
从原始队列中，共识别出1239例新发HF患者。发病率显示，在HF诊断后的初始阶段发病率较高，在新发HF诊断后的最初30天内，死亡和卒中（缺血性或出血性）发生率显著更高。虽然低于0至30天的风险，但在新发HF诊断后6个月以上，较高的风险并未恢复正常。无论是否使用维生素K拮抗剂（VKA），卒中（缺血性或出血性或两者皆有）的终点风险均有增加。使用VKA时，在HF诊断后的三个时间间隔（0至30天、30天至6个月和6个月以上），与未使用VKA相比，死亡及“死亡或卒中”复合事件的校正风险比更低。多因素分析显示，既往卒中/短暂性脑缺血发作/血栓栓塞是卒中、死亡及“卒中与死亡”复合事件风险增加的预测因素，而VKA治疗是死亡风险降低的高度显著预测因素（校正风险比0.46，95%可信区间0.28至0.74，p<0.001）以及死亡或卒中联合终点的预测因素（校正风险比0.64，95%可信区间0.43至0.96，p=0.003）。
基于相对风险，新发HF显然是卒中、死亡及“卒中与死亡”复合事件的主要危险因素，尤其是在初次诊断后的最初30天内。VKA治疗与这些终点事件风险降低相关。鉴于该人群死亡和卒中风险较高，而VKA治疗可能改善这种情况，这些发现将对新发HF患者的管理方法产生重大影响。
