Institute of Population Health, University of Manchester, Manchester, UK.
Institute of Population Health, University of Manchester, Manchester, UK.
Lancet. 2015 Feb 26;385 Suppl 1:S11. doi: 10.1016/S0140-6736(15)60326-9.
Heart failure contributes to 5% of all hospital admissions, and mortality is more than 50% at 4 years. 54% of patients with a left ventricular ejection fraction of less than 40% have renal artery stenosis. The potential benefit of revascularisation for heart failure is not established. We aimed to compare clinical outcomes for renal artery revascularisation with medical therapy for renal artery stenosis associated with heart failure as the first step towards validating revascularisation as a therapeutic option in heart failure.
In a prospective, longitudinal observational study at a single UK nephrology centre, we recruited patients with atherosclerotic renal artery stenosis (>50% as judged by CT, MR, or direct angiography). Endpoints were all-cause mortality and hospital admission for heart failure. Survival analyses were performed with Cox proportional hazard model adjusted for age, estimated glomerular filtration rate (eGFR), and cardiovascular comorbidities. Ethics approval was granted by South Manchester Research Ethics Committe.
611 patients (152 [25%] with and 459 [75%] without heart failure) were recruited. Mean age was 70 years (SD 9), 348 (57%) were men, 183 (30%) had diabetes, and mean eGFR was 33 mL/min per 1·73 m(2) (SD 19). Patients with and without heart failure were similar with to sex, diabetes, and eGFR. 367 participants (60%) died over a follow-up of a mean of 4·3 years (SD 3·6). 87 patients without heart failure (19%) underwent revascularisation compared with 47 with heart failure (31%). The adjusted hazard ratio (HR) for death in heart failure compared with no heart failure was 1·9 (95% CI 1·5-2·5, p<0·0001). For patients without heart failure, the adjusted HR for death in revascularisation compared with receiving medical therapy was 0·8 (0·5-1·1, p=0·16). For heart failure, the HR was 0·6 (0·3-0·9, p=0·01). The HR for hospital admission for heart failure in revascularised patients was 0·2 (0·0-1·1, p=0·06).
Revascularisation of renal artery stenosis in heart failure is associated with a substantial reduction in all-cause mortality and hospital admission, although such observational data might be complicated by hidden confounders. These findings are encouraging for the development of a randomised trial of renal artery revascularisation versus medical therapy in heart failure, and suggest that investigation for renal artery stenosis should be considered more frequently in heart failure clinics.
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心力衰竭导致 5%的住院病例，4 年后死亡率超过 50%。左心室射血分数低于 40%的患者中，有 54%存在肾动脉狭窄。对于心力衰竭患者，血运重建的潜在获益尚未确定。我们旨在比较肾动脉血运重建与肾动脉狭窄相关的心力衰竭的药物治疗的临床结果，以此作为验证心力衰竭血运重建治疗选择的第一步。
在英国单肾病中心进行的前瞻性、纵向观察性研究中，我们招募了经 CT、MR 或直接血管造影判断存在动脉粥样硬化性肾动脉狭窄（>50%）的患者。主要终点为全因死亡率和心力衰竭住院。采用 Cox 比例风险模型进行生存分析，调整年龄、估算肾小球滤过率（eGFR）和心血管合并症。研究获得了南曼彻斯特研究伦理委员会的批准。
共纳入 611 例患者（152 例[25%]合并心力衰竭，459 例[75%]无心力衰竭）。平均年龄为 70 岁（标准差 9），348 例（57%）为男性，183 例（30%）患有糖尿病，平均 eGFR 为 33ml/min/1.73m2（标准差 19）。合并和不合并心力衰竭的患者在性别、糖尿病和 eGFR 方面相似。随访平均 4.3 年（标准差 3.6）后，367 例（60%）患者死亡。87 例无心力衰竭患者（19%）接受了血运重建，而 47 例合并心力衰竭患者（31%）接受了血运重建。与无心力衰竭相比，心力衰竭患者的死亡调整风险比（HR）为 1.9（95%CI 1.5-2.5，p<0.0001）。对于无心力衰竭患者，与接受药物治疗相比，血运重建的死亡调整 HR 为 0.8（0.5-1.1，p=0.16）。对于心力衰竭患者，HR 为 0.6（0.3-0.9，p=0.01）。血运重建患者因心力衰竭住院的 HR 为 0.2（0.0-1.1，p=0.06）。
心力衰竭患者肾动脉狭窄血运重建与全因死亡率和心力衰竭住院显著降低相关，尽管这种观察性数据可能因潜在混杂因素而变得复杂。这些发现令人鼓舞，为心力衰竭患者的肾动脉血运重建与药物治疗的随机试验提供了依据，并提示在心力衰竭诊所中应更频繁地考虑肾动脉狭窄的检查。
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