Keele Cardiovascular Research Group, Institute of Applied Clinical Sciences and Centre for Prognosis Research, Keele University, Stoke on Trent, UK.
Department of Academic Cardiology, University of Hull, Kingston upon Hull, UK.
Clin Res Cardiol. 2019 May;108(5):510-519. doi: 10.1007/s00392-018-1380-6. Epub 2018 Oct 25.
Heart failure is heterogeneous in aetiology, pathophysiology, and presentation. Despite this diversity, clinical trials of patients hospitalized for HF deal with this problem as a single entity, which may be one reason for repeated failures.
The first EuroHeart Failure Survey screened consecutive deaths and discharges of patients with suspected heart failure during 2000-2001. Patients were sorted into seven mutually exclusive hierarchical presentations: (1) with cardiac arrest/ventricular arrhythmia; (2) with acute coronary syndrome; (3) with rapid atrial fibrillation; (4) with acute breathlessness; (5) with other symptoms/signs such as peripheral oedema; (6) with stable symptoms; and (7) others in whom the contribution of HF to admission was not clear.
The 10,701 patients enrolled were classified into the above seven presentations as follows: 260 (2%), 560 (5%), 799 (8%), 2479 (24%), 1040 (10%), 703 (7%), and 4691 (45%) for which index-admission mortality was 26%, 20%, 10%, 8%, 6%, 6%, and 4%, respectively. Compared to those in group 7, the hazard ratios for death during the index admission were 4.9 (p ≤ 0.001), 4.0 (p < 0.001), 2.2 (p < 0.001), 2.1 (p < 0.001), 1.4 (p < 0.04) and 1.4 (p = 0.04), respectively. These differences were no longer statistically significant by 12 weeks.
There is great diversity in the presentation of heart failure that is associated with very different short-term outcomes. Only a minority of hospitalizations associated with suspected heart failure are associated with acute breathlessness. This should be taken into account in the design of future clinical trials.
心力衰竭在病因、病理生理学和临床表现上存在异质性。尽管存在这种多样性，但临床试验中对因心力衰竭住院的患者均作为单一实体进行处理，这可能是导致临床试验反复失败的原因之一。
第一份《欧洲心力衰竭调查》在 2000 年至 2001 年期间对疑似心力衰竭患者的连续死亡和出院病例进行了筛查。患者被分为 7 个互斥的层次表现：（1）心搏骤停/室性心律失常；（2）急性冠状动脉综合征；（3）快速心房颤动；（4）急性呼吸困难；（5）其他症状/体征，如外周水肿；（6）稳定症状；（7）心力衰竭对入院的贡献不明确的其他情况。
纳入的 10701 例患者被归入上述 7 个表现如下：260 例（2%）、560 例（5%）、799 例（8%）、2479 例（24%）、1040 例（10%）、703 例（7%）和 4691 例（45%），其入院死亡率分别为 26%、20%、10%、8%、6%、6%和 4%。与第 7 组相比，入院期间死亡的风险比分别为 4.9（p≤0.001）、4.0（p<0.001）、2.2（p<0.001）、2.1（p<0.001）、1.4（p<0.04）和 1.4（p=0.04）。这些差异在 12 周时不再具有统计学意义。
心力衰竭的临床表现存在很大差异，与不同的短期预后相关。只有少数疑似心力衰竭相关的住院治疗与急性呼吸困难相关。这在未来临床试验的设计中应予以考虑。
