Liniado Guillermo E, Beck Martín A, Gimeno Graciela M, González Ana L, Cianciulli Tomás F, Castiello Gustavo G, Gagliardi Juan A
Hospital General de Agudos Dr. Cosme Argerich, Buenos Aires, Argentina. E-mail:
Hospital General de Agudos Dr. Cosme Argerich, Buenos Aires, Argentina.
Medicina (B Aires). 2018;78(3):163-170.
Congestion in heart failure patients with reduced ejection fraction (HFrEF) is relevant and closely linked to the clinical course. Bedside blood pressure measurement during the Valsalva maneuver (Val) added to clinical examination may improve the assessment of congestion when compared to NT-proBNP levels and left atrial pressure (LAP) estimation by Doppler echocardiography, as surrogate markers of congestion in HFrEF. A clinical examination, LAP and blood tests were performed in 69 HFrEF ambulatory patients with left ventricular ejection fraction ≤ 40% and sinus rhythm. Framingham Heart Failure Score (HFS) was used to evaluate clinical congestion; Val was classified as normal or abnormal, NT-proBNP was classified as low (< 1000 pg/ml) or high (≥ 1000 pg/ml) and the ratio between Doppler early mitral inflow and tissue diastolic velocity was used to estimate LAP and was classified as low (E/e'< 15) or high (E/e' ≥ 15). A total of 69 patients with HFrEF were included; 27 had a HFS ≥ 2 and 13 of them had high NT-proBNP. HFS ≥ 2 had a 62% sensitivity, 70% specificity and a positive likelihood ratio of 2.08 (p=0.01) to detect congestion. When Val was added to clinical examination, the presence of a HFS ≥ 2 and abnormal Val showed a 100% sensitivity, 64% specificity and a positive likelihood ratio of 2.8 (p = 0.0004). Compared with LAP, the presence of HFS = 2 and abnormal Val had 86% sensitivity, 54% specificity and a positive likelihood ratio of 1.86 (p = 0.03). In conclusion, an integrated clinical examination with the addition Valsalva maneuver may improve the assessment of congestion in patients with HFrEF.
射血分数降低的心力衰竭患者（HFrEF）的充血情况很重要，且与临床病程密切相关。与作为HFrEF充血替代标志物的NT-proBNP水平及通过多普勒超声心动图估计的左心房压力（LAP）相比，在临床检查基础上增加Valsalva动作（Val）时的床边血压测量，可能会改善对充血情况的评估。对69例左心室射血分数≤40%且为窦性心律的HFrEF门诊患者进行了临床检查、LAP测定及血液检测。采用Framingham心力衰竭评分（HFS）评估临床充血情况；Val分为正常或异常，NT-proBNP分为低（<1000 pg/ml）或高（≥1000 pg/ml），并使用二尖瓣舒张早期血流与组织舒张速度之比来估计LAP，分为低（E/e'<15）或高（E/e'≥15）。共纳入69例HFrEF患者；27例HFS≥2，其中13例NT-proBNP高。HFS≥2检测充血的灵敏度为62%，特异度为70%，阳性似然比为2.08（p=0.01）。当在临床检查基础上增加Val时，HFS≥2且Val异常检测充血的灵敏度为100%，特异度为64%，阳性似然比为2.8（p = 0.0004）。与LAP相比，HFS = 2且Val异常检测充血的灵敏度为86%，特异度为54%，阳性似然比为1.86（p = 0.03）。总之，综合临床检查并增加Valsalva动作可能会改善对HFrEF患者充血情况的评估。
