Okada Atsushi, Sugano Yasuo, Nagai Toshiyuki, Honda Yasuyuki, Iwakami Naotsugu, Nakano Hiroki, Takashio Seiji, Honda Satoshi, Asaumi Yasuhide, Aiba Takeshi, Noguchi Teruo, Kusano Kengo, Yasuda Satoshi, Anzai Toshihisa
Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan; Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.
Am J Cardiol. 2017 Jun 15;119(12):2035-2041. doi: 10.1016/j.amjcard.2017.03.033. Epub 2017 Mar 29.
Abnormal liver function test results are often observed in acute decompensated heart failure (ADHF). However, the prognostic value of bilirubin fractionation has not been elucidated. The prognostic value of direct bilirubin (DB), in comparison with total bilirubin (TB), was examined in 556 consecutive patients with ADHF. Patients with elevated DB showed mostly similar patient characteristics including signs of elevated right-sided pressure (frequent hepatomegaly, jugular venous distention, dilated inferior vena cava, and elevated gamma-glutamyltransferase) and decreased cardiac output (cold extremities, decreased pulse pressure, and lower blood pressure) and other parameters of heart failure (HF) severity (increased plasma renin activity, decreased sodium, total cholesterol, and ejection fraction) to elevated TB; however, only patients with elevated DB showed a significant difference in the frequency of HF history and alkaline phosphatase value. Kaplan-Meier analysis showed that patients with elevated DB had a significantly higher rate of the composite end point of all-cause mortality or HF readmission (p = 0.021) compared with those with normal DB, whereas patients with elevated TB did not show a statistically significant difference compared with those with normal TB (NS). A multivariate Cox hazards model showed that DB was an independent predictor of adverse events (adjusted hazard ratio 1.052, 95% confidence interval 1.001 to 1.099, p = 0.034), whereas TB was not (adjusted hazard ratio 1.017, 95% confidence interval 0.985 to 1.046, p = 0.27). Adding DB to existing prognostic variables resulted in higher C-statistics than adding TB (C-statistics: 0.670 to 0.675, 0.670 to 0.674, respectively). In conclusion, elevated DB in ADHF was an independent prognostic predictor that was superior to TB. DB may be useful for further risk stratification in ADHF.
急性失代偿性心力衰竭（ADHF）患者常出现肝功能检查结果异常。然而，胆红素分级的预后价值尚未阐明。我们对556例连续的ADHF患者进行了研究，比较直接胆红素（DB）与总胆红素（TB）的预后价值。DB升高的患者大多具有相似的患者特征，包括右侧压力升高的体征（常见肝肿大、颈静脉扩张、下腔静脉扩张和γ-谷氨酰转移酶升高）、心输出量降低（四肢冰冷、脉压降低和血压降低）以及其他心力衰竭（HF）严重程度参数（血浆肾素活性升高、钠降低、总胆固醇降低和射血分数降低），与TB升高的患者相似；然而，只有DB升高的患者在HF病史频率和碱性磷酸酶值方面存在显著差异。Kaplan-Meier分析显示，与DB正常的患者相比，DB升高的患者全因死亡率或HF再入院复合终点发生率显著更高（p = 0.021），而与TB正常的患者相比，TB升高的患者未显示出统计学显著差异（无显著性差异）。多变量Cox风险模型显示，DB是不良事件的独立预测因子（调整后风险比1.052，95%置信区间1.001至1.099，p = 0.034），而TB不是（调整后风险比1.017，95%置信区间0.985至1.046，p = 0.27）。将DB添加到现有的预后变量中比添加TB产生更高的C统计量（C统计量分别为：0.670至0.675，0.670至0.674）。总之，ADHF中DB升高是一个独立的预后预测因子，优于TB。DB可能有助于ADHF的进一步风险分层。
