Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University Medical Center, Durham, North Carolina.
Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University Medical Center, Durham, North Carolina.
J Am Coll Cardiol. 2017 Jun 27;69(25):3029-3039. doi: 10.1016/j.jacc.2017.04.043.
It is unclear how patients hospitalized for acute heart failure (HF) who are long-term chronic HF survivors differ from those with more recent HF diagnoses.
The goal of this study was to evaluate the influence of HF chronicity on acute HF patient profiles and outcomes.
The ASCEND-HF (Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure) trial randomized 7,141 hospitalized patients with acute HF with reduced or preserved ejection fraction (EF) to receive nesiritide or placebo in addition to standard care. The present analysis compared patients according to duration of HF diagnosis before index hospitalization by using pre-specified cutoffs (0 to 1 month [i.e., "recently diagnosed"], >1 to 12 months, >12 to 60 months, and >60 months).
Overall, 5,741 (80.4%) patients had documentation of duration of HF diagnosis (recently diagnosed, n = 1,536; >1 to 12 months, n = 1,020; >12 to 60 months, n = 1,653; and >60 months, n = 1,532). Across HF duration groups, mean age ranged from 64 to 66 years, and mean ejection fraction ranged from 29% to 32%. Compared with patients with longer HF duration, recently diagnosed patients were more likely to be women with nonischemic HF etiology, higher baseline blood pressure, better baseline renal function, and fewer comorbidities. After adjustment, compared with recently diagnosed patients, patients with longer HF duration were associated with more persistent dyspnea at 24 h (>1 to 12 months, odds ratio [OR]: 1.20; 95% confidence interval [CI]: 0.97 to 1.48; >12 to 60 months, OR: 1.34; 95% CI: 1.11 to 1.62; and >60 months, OR: 1.31; 95% CI: 1.08 to 1.60) and increased 180-day mortality (>1 to 12 months, hazard ratio [HR]: 1.89; 95% CI: 1.35 to 2.65; >12 to 60 months, HR: 1.82; 95% CI: 1.33 to 2.48; and >60 months, HR: 2.02; 95% CI: 1.47 to 2.77). The influence of HF duration on mortality was potentially more pronounced among female patients (interaction p = 0.05), but did not differ according to age, race, prior ischemic heart disease, or ejection fraction (all interactions, p ≥ 0.23).
In this acute HF trial, patient profile differed according to duration of the HF diagnosis. A diagnosis of HF for ≤1 month before hospitalization was independently associated with greater early dyspnea relief and improved post-discharge survival compared to patients with chronic HF diagnoses. The distinction between de novo or recently diagnosed HF and worsening chronic HF should be considered in the design of future acute HF trials. (A Study Testing the Effectiveness of Nesiritide in Patients With Acute Decompensated Heart Failure; NCT00475852).
尚不清楚因急性心力衰竭（HF）住院且为慢性 HF 幸存者的患者与近期 HF 诊断患者有何不同。
本研究旨在评估 HF 慢性程度对急性 HF 患者特征和结局的影响。
ASCEND-HF（急性心力衰竭失代偿期奈西立肽临床疗效研究）试验将 7141 例射血分数降低或保留的急性 HF 住院患者随机分为奈西立肽组或安慰剂组，加用标准治疗。本分析根据指数住院前 HF 诊断持续时间（使用预先指定的时间间隔）比较患者，包括 0 至 1 个月（即“近期诊断”）、＞1 至 12 个月、＞12 至 60 个月和＞60 个月。
总体而言，5741 例（80.4%）患者有 HF 诊断持续时间的记录（近期诊断，n=1536；＞1 至 12 个月，n=1020；＞12 至 60 个月，n=1653；＞60 个月，n=1532）。在 HF 持续时间组中，平均年龄为 64 至 66 岁，平均射血分数为 29%至 32%。与 HF 持续时间较长的患者相比，近期诊断患者更可能为女性、HF 病因是非缺血性、基线血压较高、基线肾功能较好且合并症较少。调整后，与近期诊断患者相比，HF 持续时间较长的患者在 24 小时时持续呼吸困难的可能性更高（＞1 至 12 个月，比值比 [OR]：1.20；95%置信区间 [CI]：0.97 至 1.48；＞12 至 60 个月，OR：1.34；95%CI：1.11 至 1.62；＞60 个月，OR：1.31；95%CI：1.08 至 1.60），180 天死亡率也更高（＞1 至 12 个月，风险比 [HR]：1.89；95%CI：1.35 至 2.65；＞12 至 60 个月，HR：1.82；95%CI：1.33 至 2.48；＞60 个月，HR：2.02；95%CI：1.47 至 2.77）。HF 持续时间对死亡率的影响在女性患者中可能更为明显（交互作用 p=0.05），但在年龄、种族、既往缺血性心脏病或射血分数方面没有差异（所有交互作用，p≥0.23）。
在这项急性 HF 试验中，患者特征根据 HF 诊断的持续时间而有所不同。与慢性 HF 诊断患者相比，住院前 HF 诊断时间≤1 个月与早期呼吸困难缓解更大和出院后生存改善相关。在未来的急性 HF 试验设计中，应考虑新发或近期诊断 HF 与慢性 HF 恶化之间的区别。（急性失代偿性心力衰竭患者奈西立肽疗效测试研究；NCT00475852）。
