Department of Internal Medicine and Program of Applied Translational Research, Yale University School of Medicine, New Haven, CT 06510, USA.
J Am Coll Cardiol. 2013 Aug 6;62(6):516-24. doi: 10.1016/j.jacc.2013.05.027. Epub 2013 Jun 7.
This study sought to determine if the timing of hemoconcentration influences associated survival.
Indicating a reduction in intravascular volume, hemoconcentration during the treatment of decompensated heart failure has been associated with reduced mortality. However, it is unclear if this survival advantage stems from the improved intravascular volume or if healthier patients are simply more responsive to diuretics. Rapid diuresis early in the hospitalization should similarly identify diuretic responsiveness, but hemoconcentration this early would not indicate euvolemia if extravascular fluid has not yet equilibrated.
Consecutive admissions at a single center with a primary discharge diagnosis of heart failure were reviewed (N = 845). Hemoconcentration was defined as an increase in both hemoglobin and hematocrit levels, then further dichotomized into early or late hemoconcentration by using the midway point of the hospitalization.
Hemoconcentration occurred in 422 (49.9%) patients (41.5% early and 58.5% late). Patients with late versus early hemoconcentration had similar baseline characteristics, cumulative in-hospital loop diuretic administered, and worsening of renal function. However, patients with late hemoconcentration versus early hemoconcentration had higher average daily loop diuretic doses (p = 0.001), greater weight loss (p < 0.001), later transition to oral diuretics (p = 0.03), and shorter length of stay (p < 0.001). Late hemoconcentration conferred a significant survival advantage (hazard ratio: 0.74 [95% confidence interval: 0.59 to 0.93]; p = 0.009), whereas early hemoconcentration offered no significant mortality benefit (hazard ratio: 1.0 [95% confidence interval: 0.80 to 1.3]; p = 0.93) over no hemoconcentration.
Only hemoconcentration occurring late in the hospitalization was associated with improved survival. These results provide further support for the importance of achieving sustained decongestion during treatment of decompensated heart failure.
本研究旨在确定血液浓缩发生的时间是否会影响相关生存率。
在失代偿性心力衰竭的治疗过程中，血液浓缩表明血管内容积减少，与死亡率降低有关。然而，尚不清楚这种生存优势是源于血管内容积的改善，还是健康状况较好的患者对利尿剂的反应更为敏感。住院早期快速利尿同样可以识别利尿剂的反应性，但如果细胞外液尚未达到平衡，早期的血液浓缩并不能表明血容量正常。
回顾性分析了单一中心连续收治的以心力衰竭为主要出院诊断的患者（N=845）。血液浓缩定义为血红蛋白和血细胞比容水平均升高，然后根据住院期间的中点进一步分为早期或晚期血液浓缩。
422 例（49.9%）患者发生血液浓缩（41.5%为早期，58.5%为晚期）。与早期血液浓缩相比，晚期血液浓缩的患者具有相似的基线特征、累积住院期间使用的袢利尿剂以及肾功能恶化。然而，晚期血液浓缩患者与早期血液浓缩患者的平均日剂量袢利尿剂更高（p=0.001）、体重减轻更多（p<0.001）、更晚过渡到口服利尿剂（p=0.03）以及住院时间更短（p<0.001）。晚期血液浓缩患者的生存优势显著（风险比：0.74[95%置信区间：0.59 至 0.93]；p=0.009），而早期血液浓缩患者的死亡率无显著改善（风险比：1.0[95%置信区间：0.80 至 1.3]；p=0.93）。
只有在住院晚期发生的血液浓缩与生存率提高相关。这些结果进一步支持了在治疗失代偿性心力衰竭时实现持续去充血的重要性。
