Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, 565-8565, Japan.
Department of Cardiovascular Medicine, Ikuwakai Memorial Hospital, Osaka, Japan.
ESC Heart Fail. 2019 Apr;6(2):319-327. doi: 10.1002/ehf2.12391. Epub 2019 Jan 7.
Consensus-derived guidelines recommend renal stenting for patients with atherosclerotic renal artery disease (ARAD) and heart failure (HF). The aim of this prospective multi-centre observational study was to verify our hypothesis that changes in E/e', an echocardiographic correlate of left ventricular (LV) filling pressure, following renal stenting may differ between ARAD patients with and without HF.
This study enrolled de novo ARAD patients undergoing renal stenting at 14 institutions. The primary endpoint was the difference in E/e' change between ARAD patients with and without HF. Clinical and echocardiographic data were prospectively collected at baseline, the day following renal stenting, and 1 month and 6 months afterwards. ARAD patients with HF were defined as patients with New York Heart Association (NYHA) Class 2 and more, or a history of HF hospitalization. A total of 76 patients were included, and 39% were ARAD patients with HF. ARAD patients with HF had significantly lower estimated glomerular filtration rate (P = 0.028) and higher NYHA functional class (P < 0.001) and Minnesota Living with Heart Failure Questionnaire (MLHFQ) score (P = 0.001) than ARAD patients without HF. Also, ARAD patients with HF had significantly lower LV ejection fraction (P = 0.003) and e'-velocity (P = 0.003) and higher E/e' ratio (P = 0.001), left atrial volume index (LAVI) (P = 0.046), LV end-diastolic volume (LVEDV) (P = 0.001), LV end-systolic volume (LVESV) (P = 0.001), and LV mass index (P = 0.009) than ARAD patients without HF. All procedures were successful. In contrast to blood pressure and renal function, there was a significant interaction in E/e' (P < 0.001) between time and HF, and ARAD patients with HF showed a significant (P < 0.001) decrease in E/e' albeit those without HF. By the same token, there was a significant interaction in NYHA class (P < 0.001), MLHFQ score (P = 0.018), E-velocity (P = 0.002), LAVI (P = 0.001), LVEDV (P = 0.003), and LVESV (P = 0.001) between time and HF with a significant improvement in all these variables in ARAD patients with HF (NYHA class, P = 0.001; MLHFQ score, P = 0.002; E-velocity, P = 0.005; LAVI, P = 0.001; LVEDV, P = 0.017; and LVESV, P = 0.011).
Change in LV filling pressure after renal stenting differed between ARAD patients with and without HF, with a significant improvement in LV filling pressure in patients with HF-ARAD. These unique findings might support clinical cardiac benefits of renal stenting in ARAD patients with HF.
共识指南建议对患有动脉粥样硬化性肾动脉疾病（ARAD）和心力衰竭（HF）的患者进行肾动脉支架置入术。本前瞻性多中心观察性研究的目的是验证我们的假设，即肾动脉支架置入术后左心室（LV）充盈压的超声心动图相关指标 E/e'的变化在 ARAD 合并 HF 与不合并 HF 的患者中可能不同。
本研究纳入了在 14 个机构接受肾动脉支架置入术的新发 ARAD 患者。主要终点是 ARAD 合并 HF 与不合并 HF 患者 E/e'变化的差异。临床和超声心动图数据在基线、肾动脉支架置入后第 1 天、1 个月和 6 个月时前瞻性收集。HF 被定义为纽约心脏协会（NYHA）心功能分级 2 级及以上或有 HF 住院史的 ARAD 患者。共纳入 76 例患者，其中 39%为 ARAD 合并 HF 患者。与 ARAD 不合并 HF 患者相比，ARAD 合并 HF 患者的估算肾小球滤过率（P=0.028）更低，NYHA 心功能分级（P<0.001）和明尼苏达州心力衰竭生活质量问卷（MLHFQ）评分（P=0.001）更高。此外，ARAD 合并 HF 患者的左室射血分数（P=0.003）和 e'速度（P=0.003）更低，E/e'比值（P=0.001）、左心房容积指数（LAVI）（P=0.046）、LV 舒张末期容积（LVEDV）（P=0.001）、LV 收缩末期容积（LVESV）（P=0.001）和左室质量指数（P=0.009）更高。所有手术均成功完成。与血压和肾功能不同，E/e'在时间和 HF 之间存在显著的交互作用（P<0.001），并且 ARAD 合并 HF 患者的 E/e'显著降低（P<0.001），而 ARAD 不合并 HF 患者则没有。同样，在 NYHA 心功能分级（P<0.001）、MLHFQ 评分（P=0.018）、E-速度（P=0.002）、LAVI（P=0.001）、LVEDV（P=0.003）和 LVESV（P=0.001）之间也存在显著的时间与 HF 的交互作用，ARAD 合并 HF 患者的所有这些变量均显著改善（NYHA 心功能分级，P=0.001；MLHFQ 评分，P=0.002；E-速度，P=0.005；LAVI，P=0.001；LVEDV，P=0.017；和 LVESV，P=0.011）。
肾动脉支架置入术后 LV 充盈压的变化在 ARAD 合并 HF 与不合并 HF 的患者中不同，HF-ARAD 患者的 LV 充盈压显著改善。这些独特的发现可能支持 ARAD 合并 HF 患者肾动脉支架置入术的临床心脏获益。
