收缩压与灌注状态对急性心力衰竭患者死亡率的协同影响
Synergistic Impact of Systolic Blood Pressure and Perfusion Status on Mortality in Acute Heart Failure.
作者信息
Rossello Xavier, Bueno Héctor, Gil Víctor, Jacob Javier, Martín-Sánchez Francisco Javier, Llorens Pere, Herrero Puente Pablo, Alquézar-Arbé Aitor, Espinosa Begoña, Raposeiras-Roubín Sergio, Müller Christian E, Mebazaa Alexandre, Maggioni Aldo P, Pocock Stuart, Chioncel Ovidiu, Miró Òscar
机构信息
Cardiology Department, Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, Palma (X.R.).
Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain (X.R., H.B. S.R.-R.).
出版信息
Circ Heart Fail. 2021 Mar;14(3):e007347. doi: 10.1161/CIRCHEARTFAILURE.120.007347. Epub 2021 Mar 8.
BACKGROUND
Physical examination remains the cornerstone in the assessment of acute heart failure. There is a lack of adequately powered studies assessing the combined impact of both systolic blood pressure (SBP) and hypoperfusion on short-term mortality.
METHODS
Patients with acute heart failure from 41 Spanish emergency departments were recruited consecutively in 3 time periods between 2011 and 2016. Logistic regression models were used to assess the association of 30-day mortality with SBP (<90, 90-109, 110-129, and ≥130 mm Hg) and with manifestations of hypoperfusion (cold skin, cutaneous pallor, delayed capillary refill, livedo reticularis, and mental confusion) at admission.
RESULTS
Among 10 979 patients, 1143 died within the first 30 days (10.2%). There was an inverse association between 30-day mortality and initial SBP (35.4%, 18.9%, 12.4%, and 7.5% for SBP<90, SBP 90-109, SBP 110-129, and SBP≥130 mm Hg, respectively; <0.001) and a positive association with hypoperfusion (8.0%, 14.8%, and 27.6% for those with none, 1, ≥2 signs/symptoms of hypoperfusion, respectively; <0.001). After adjustment for 11 risk factors, the prognostic impact of hypoperfusion on 30-day mortality varied across SBP categories: SBP≥130 mm Hg (odds ratio [OR]=1.03 [95% CI, 0.77-1.36] and OR=1.18 [95% CI, 0.86-1.62] for 1 and ≥2 compared with 0 manifestations of hypoperfusion), SBP 110 to 129 mm Hg (OR=1.23 [95% CI, 0.86-1.77] and OR=2.18 [95% CI, 1.44-3.31], respectively), SBP 90 to 109 mm Hg (OR=1.29 [95% CI, 0.79-2.10] and OR=2.24 [95% CI, 1.36-3.66], respectively), and SBP<90 mm Hg (OR=1.34 [95% CI, 0.45-4.01] and OR=3.22 [95% CI, 1.30-7.97], respectively); -for-interaction =0.043.
CONCLUSIONS
Hypoperfusion confers an incremental risk of 30-day all-cause mortality not only in patients with low SBP but also in normotensive patients. On admission, physical examination plays a major role in determining prognosis in patients with acute heart failure.
背景
体格检查仍是评估急性心力衰竭的基石。目前缺乏足够大样本量的研究来评估收缩压（SBP）和灌注不足对短期死亡率的综合影响。
方法
在2011年至2016年的3个时间段内，连续招募了来自41个西班牙急诊科的急性心力衰竭患者。采用逻辑回归模型评估入院时30天死亡率与SBP（<90、90 - 109、110 - 129和≥130 mmHg）以及灌注不足表现（皮肤冰冷、皮肤苍白、毛细血管再充盈延迟、网状青斑和精神错乱）之间的关联。
结果
在10979例患者中，1143例在最初30天内死亡（10.2%）。30天死亡率与初始SBP呈负相关（SBP<90 mmHg、SBP 90 - 109 mmHg、SBP 110 - 129 mmHg和SBP≥ 130 mmHg的死亡率分别为35.4%、18.9%、12.4%和7.5%；P<0.001），与灌注不足呈正相关（无灌注不足体征/症状、有1项、有≥2项灌注不足体征/症状的患者死亡率分别为8.0%、14.8%和27.6%；P<0.001）。在对11个风险因素进行调整后，灌注不足对30天死亡率的预后影响在不同SBP类别中有所不同：SBP≥130 mmHg（与无灌注不足表现相比，有1项和≥2项灌注不足表现的比值比[OR]分别为1.03[95%置信区间，0.77 - 1.36]和1.18[95%置信区间，0.86 - 1.62]），SBP 110至129 mmHg（OR分别为1.23[95%置信区间，0.86 - 1.77]和2.18[95%置信区间，1.44 - 3.31]），SBP 90至109 mmHg（OR分别为1.29[95%置信区间，0.79 - 2.10]和2.24[95%置信区间，1.36 - 3.66]），以及SBP<90 mmHg（OR分别为1.34[95%置信区间，0.45 - 4.01]和3.22[95%置信区间，1.30 - 7.97]）；交互作用P = 0.043。
结论
灌注不足不仅在SBP较低的患者中，而且在血压正常的患者中，均会增加30天全因死亡率的风险。入院时，体格检查在确定急性心力衰竭患者的预后方面起着重要作用。
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