Omar H R, Guglin M
Internal Medicine Department, Mercy Medical Center, Clinton, IA, USA.
Division of Cardiovascular Medicine, Linda and Jack Gill Heart Institute, University of Kentucky, Lexington, KY, USA.
Herz. 2018 Dec;43(8):752-758. doi: 10.1007/s00059-017-4623-9. Epub 2017 Oct 9.
We aimed to identify the best tools from history and physical examination that predict severity of heart failure (HF) exacerbation among patients with an ejection fraction (EF) ≤ 30%.
Patients enrolled in the ESCAPE trial were divided into tertiles according to the combined value of pulmonary capillary wedge pressure (PCWP) and right atrial pressure (RAP) which we used as a marker of volume loading of both pulmonary and systemic compartments. Variables of congestion from history and physical examination were examined across tertiles.
There were significant differences across tertiles (tertile 1: PCWP + RAP < 31 mm Hg, tertile 2: PCWP + RAP 31-42 mm Hg and tertile 3: PCWP + RAP > 42 mm Hg) with respect to baseline B‑type natriuretic peptide (P = 0.016), blood urea nitrogen (P = 0.022), sodium (P = 0.015), left ventricular ejection fraction (P = 0.005), and inferior vena cava diameter during inspiration (P < 0.001) and expiration (P < 0.001). With respect to variables of congestion from history and physical examination, we found significant differences across tertiles predominantly in signs of right sided failure, specifically, the frequency of jugular venous distension (JVD, P < 0.001) and JVD > 12 cmHO (p < 0.001), lower extremity edema (P = 0.001) and lower extremity edema of at least grade 2 + (P = 0.029), and positive hepatojugular reflux (HJR, P = 0.022) but no differences in patients' symptoms such as degree of dyspnea, orthopnea or fatigue. With regards to post-discharge outcomes, there was a significant difference across tertiles in all-cause mortality (P = 0.029) and rehospitalization for HF (P = 0.031) at 6 months following randomization. Receiver operator characteristic curves showed that admission PCWP + RAP had an area under the curve of 0.623 (P = 0.0075) and 0.617 (P = 0.0048), respectively, in predicting 6‑month all-cause mortality and rehospitalization for HF.
The presence and extent of JVD and lower extremity edema, and a positive HJR are better than other signs and symptoms in identifying severity of HF exacerbation among patients with EF ≤ 30%.
我们旨在从病史和体格检查中找出预测射血分数（EF）≤30%的心力衰竭（HF）加重患者病情严重程度的最佳方法。
根据肺毛细血管楔压（PCWP）和右心房压力（RAP）的综合值，将参与ESCAPE试验的患者分为三个三分位数组，我们将该综合值用作肺和体循环容量负荷的指标。在三分位数组中检查病史和体格检查中的充血变量。
三分位数组之间存在显著差异（三分位数1：PCWP + RAP < 31 mmHg，三分位数2：PCWP + RAP 31 - 42 mmHg，三分位数3：PCWP + RAP > 42 mmHg），在基线B型利钠肽（P = 0.016）、血尿素氮（P = 0.022）、钠（P = 0.015）、左心室射血分数（P = 0.005）以及吸气（P < 0.001）和呼气（P < 0.001）时的下腔静脉直径方面。关于病史和体格检查中的充血变量，我们发现三分位数组之间存在显著差异，主要体现在右侧心力衰竭的体征上，具体而言，颈静脉扩张（JVD，P < 0.001）和JVD > 12 cmH₂O（P < 0.001）的频率、下肢水肿（P = 0.001）和至少2 +级的下肢水肿（P = 0.029）以及肝颈静脉反流阳性（HJR，P = 0.022），但在患者症状如呼吸困难程度、端坐呼吸或疲劳方面没有差异。关于出院后结局，随机分组后6个月时，三分位数组在全因死亡率（P = 0.029）和因HF再次住院率（P = 0.031）方面存在显著差异。受试者工作特征曲线显示，入院时的PCWP + RAP在预测6个月全因死亡率和因HF再次住院方面，曲线下面积分别为0.623（P = 0.0075）和0.617（P = 0.0048）。
JVD和下肢水肿的存在及程度，以及HJR阳性在识别EF≤30%的HF加重患者病情严重程度方面优于其他体征和症状。
