Sokolska Justyna Maria, Sokolski Mateusz, Zymliński Robert, Biegus Jan, Siwołowski Paweł, Nawrocka-Millward Sylwia, Swoboda Katarzyna, Gajewski Piotr, Jankowska Ewa Anita, Banasiak Waldemar, Ponikowski Piotr
Department of Heart Diseases, Wroclaw Medical University, ul. Borowska 213, Wrocław, 50-556, Poland.
Department of Cardiology, University Heart Center, University Hospital Zurich, Zürich, Switzerland.
ESC Heart Fail. 2020 Dec;7(6):3830-3840. doi: 10.1002/ehf2.12973. Epub 2020 Sep 10.
Patients with acute heart failure (AHF) are included into clinical trials regardless of differences in baseline clinical characteristics. The aim of this study was to assess patients with AHF according to the presence of central and/or peripheral congestion at hospital admission and evaluate treatment response and outcomes in studied phenotypes.
We investigated retrospectively 352 patients (mean age: 68 ± 13 years, 77% men) hospitalized due to AHF with the signs of congestion on admission. Patients were divided according to the type of signs of congestion into three groups: A, isolated pulmonary congestion (n = 52, 15%); B, isolated peripheral congestion (n = 31, 9%); and C, signs of mixed (peripheral and central) congestion (n = 269, 76%). Patients from Group A had lower concentration of urea, bilirubin, and gamma-glutamyl transferase whereas higher level of haematocrit, albumin, and leukocytes on admission. The highest baseline N-terminal pro-B-type natriuretic peptide level (median: 4113 vs. 3634 vs. 6093 pg/mL) and percentage of patients with chronic heart failure (56 vs. 58 vs. 74%; A vs. B. vs. C, respectively, all P < 0.01) were observed in Group C. There were no differences in terms of demographics, co-morbidities, left ventricular ejection fraction, and applied treatment between studied groups. Patients from Group A had the highest systolic blood pressure on admission (145 ± 37 vs. 122 ± 20 vs. 130 ± 29 mmHg) and the biggest decrease in systolic blood pressure [-22 (-45 to -4) vs. -2 (-13 to 2) vs. -10 (-25 to 0) mmHg] and heart rate [-16 (-35 to -1.5) vs. -1 (-10 to 5) vs. -7 (-20 to 0) b.p.m.] with the lowest weight change [-1.0 (-1.0 to 0) vs. -2.9 (-3.8 to -0.9) vs. -2.0 (-3.0 to -1.0) kg; all P < 0.01] after 48 h of hospitalization. There were differences in short-term and long-term outcomes with favourable results in Group A. Group A experienced less frequent in-hospital heart failure worsening during the first 48 h (4 vs. 23 vs. 7%), had shorter length of hospital stay [6 (5-8) vs. 7 (5-11) vs. 7 (6-11) days], and had lower 1 year all-cause mortality (12 vs. 28 vs. 29%; all P < 0.05). Presence of peripheral congestion on admission was independent predictor for all-cause mortality within 1 year [hazard ratio (95% confidence interval): 2.68 (1.06-6.79); P = 0.04].
Patterns of congestion in AHF are associated with differences in clinical characteristics, treatment response, and outcomes. It needs to be considered once planning clinical trials in AHF.
急性心力衰竭（AHF）患者无论基线临床特征有无差异均被纳入临床试验。本研究旨在根据入院时是否存在中心性和/或外周性充血对AHF患者进行评估，并评估所研究表型的治疗反应和预后。
我们回顾性调查了352例因AHF入院且入院时有充血体征的患者（平均年龄：68±13岁，77%为男性）。根据充血体征类型将患者分为三组：A组，单纯肺充血（n = 52，15%）；B组，单纯外周充血（n = 31，9%）；C组，混合性（外周和中心）充血体征（n = 269，76%）。A组患者入院时尿素、胆红素和γ-谷氨酰转移酶浓度较低，而血细胞比容、白蛋白和白细胞水平较高。C组观察到最高的基线N末端B型利钠肽前体水平（中位数：4113 vs. 3634 vs. 6093 pg/mL）和慢性心力衰竭患者百分比（分别为56% vs. 58% vs. 74%；A组 vs. B组 vs. C组，P均<0.01）。研究组之间在人口统计学、合并症、左心室射血分数和应用的治疗方面无差异。A组患者入院时收缩压最高（145±37 vs. 122±20 vs. 130±29 mmHg），住院48小时后收缩压下降幅度最大[-22（-45至-4）vs. -2（-13至2）vs. -10（-25至0）mmHg]，心率下降幅度也最大[-16（-35至-1.5）vs. -1（-10至5）vs. -7（-20至0）次/分钟]，体重变化最小[-1.0（-1.0至0）vs. -2.9（-3.8至-0.9）vs. -2.0（-3.0至-1.0）kg；P均<0.01]。A组在短期和长期预后方面有差异，结果较好。A组在入院后最初48小时内心力衰竭恶化频率较低（4% vs. 23% vs. 7%），住院时间较短[6（5 - 8）天 vs. 7（5 - 11）天 vs. 7（6 - 11）天]，1年全因死亡率较低（12% vs. 28% vs. 29%；P均<0.05）。入院时存在外周充血是1年内全因死亡的独立预测因素[风险比（95%置信区间）：2.68（1.06 - 6.79）；P = 0.04]。
AHF中的充血模式与临床特征、治疗反应和预后的差异相关。在规划AHF临床试验时需要考虑这一点。
