Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria.
Department of Medicine IV, Kaiser Franz Josef Spital, Kundratstraße 3, 1100 Wien, Vienna, Austira.
Eur Heart J. 2018 Jan 1;39(1):39-46. doi: 10.1093/eurheartj/ehx402.
Significant efforts are currently undertaken to reduce functional mitral regurgitation (FMR) in patients with chronic heart failure in the hope to improve prognosis. We aimed to assess the prognostic impact of FMR in heart failure with reduced ejection fraction (HFrEF) under optimal medical therapy (OMT) and various conditions of HFrEF. We further intended to identify a heart failure phenotype, where FMR is most likely a driving force and not a mere bystander of the disease.
We prospectively included 576 consecutive HFrEF patients into our long-term observational study. Functional [i.e. New York Heart Association (NYHA) class], echocardiographic, invasive haemodynamic, and biochemical (i.e. NT-proBNP, MR-proANP, MR-proADM, CT-proET-1, copeptin) measurements were performed at baseline. During a median follow-up of 62 months (interquartile range 52-76), 47% of patients died. Severe FMR was a significant predictor of mortality [hazard ratio (HR) 1.76, 95% confidence interval (CI) 1.34-2.30; P < 0.001], independent of clinical (adjusted HR 1.61, 95% CI 1.22-2.12; P = 0.001), and echocardiographic (adjusted HR 1.46, 95% CI 1.09-1.94; P = 0.01) confounders, OMT (adjusted HR 1.81, 95% CI 1.25-2.63; P = 0.002), and neurohumoral activation (adjusted HR 1.38, 95% CI 1.03-1.84; P = 0.03). Subanalysis revealed that severe FMR was associated with poor outcome in an intermediate-failure phenotype of HFrEF i.e. patients with NYHA class II (adjusted HR 2.17, 95% CI 1.07-4.44; P = 0.03) and III (adjusted HR 1.80, 95% CI 1.17-2.77; P = 0.008), moderately reduced left ventricular function (adjusted HR 2.37, 95% CI 1.36-4.12; P = 0.002), and within the second quartile (871-2360 pg/mL) of NT-proBNP (adjusted HR 2.16, 95% CI 1.22-3.86; P = 0.009).
In a patient cohort under OMT, the adverse prognostic impact of FMR is given predominantly in a sub-cohort of a specific intermediate-failure phenotype-well-defined functionally, haemodynamically, biochemically, and morphologically.
目前正在进行大量努力以减少慢性心力衰竭患者的功能性二尖瓣反流（FMR），希望改善预后。我们旨在评估在最佳药物治疗（OMT）和各种射血分数降低的心力衰竭（HFrEF）条件下，FMR 对心力衰竭的预后影响。我们还旨在确定心力衰竭表型，其中 FMR 最有可能是疾病的驱动因素，而不仅仅是旁观者。
我们前瞻性地将 576 例连续的 HFrEF 患者纳入我们的长期观察性研究。在基线时进行了功能[即纽约心脏协会（NYHA）分级]、超声心动图、有创血流动力学和生化（即 NT-proBNP、MR-proANP、MR-proADM、CT-proET-1、copeptin）测量。在中位数为 62 个月（四分位距 52-76）的随访期间，47%的患者死亡。严重的 FMR 是死亡率的显著预测因素[风险比（HR）1.76，95%置信区间（CI）1.34-2.30；P<0.001]，独立于临床（调整后的 HR 1.61，95%CI 1.22-2.12；P=0.001）和超声心动图（调整后的 HR 1.46，95%CI 1.09-1.94；P=0.01）混杂因素、OMT（调整后的 HR 1.81，95%CI 1.25-2.63；P=0.002）和神经激素激活（调整后的 HR 1.38，95%CI 1.03-1.84；P=0.03）。亚分析表明，在 HFrEF 的中间衰竭表型（即 NYHA 分级 II（调整后的 HR 2.17，95%CI 1.07-4.44；P=0.03）和 III（调整后的 HR 1.80，95%CI 1.17-2.77；P=0.008）、左心室功能中度降低（调整后的 HR 2.37，95%CI 1.36-4.12；P=0.002）和 NT-proBNP 的第二个四分位数（871-2360 pg/mL）内（调整后的 HR 2.16，95%CI 1.22-3.86；P=0.009），严重的 FMR 与不良预后相关。
在接受 OMT 的患者队列中，FMR 的不良预后影响主要存在于特定中间衰竭表型的亚组中-功能、血流动力学、生化和形态学上明确界定。
