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心力衰竭的姑息治疗:具有挑战性的预后判断

Palliative Care in Heart Failure: Challenging Prognostication.

作者信息

Egídio de Sousa Inês, Pedroso Ana, Chambino Beatriz, Roldão Marta, Pinto Fausto, Guerreiro Renato, Araújo Inês, Henriques Célia, Fonseca Candida

机构信息

Internal Medicine Department, Hospital São Francisco Xavier, Lisbon, PRT.

Heart Failure Clinic, Department of Internal Medicine, Hospital São Francisco Xavier, Lisbon, PRT.

出版信息

Cureus. 2021 Sep 26;13(9):e18301. doi: 10.7759/cureus.18301. eCollection 2021 Sep.

Abstract

Heart failure (HF) is a chronic progressive disease with high morbimortality and poor quality of life (QoL). Palliative care significantly improves clinical outcomes but few patients receive it, in part due to challenging decisions about prognosis. This retrospective study, included all patients consecutively discharged from an Acute Heart Failure Unit over a period of one year, aiming to assess the accuracy of the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) score in predicting mortality. Additionally, predictors of death at one and three years were explored using a multivariate regression model. The MAGGIC score was useful in predicting mortality, without significant difference between mortality observed at three-years follow-up compared with a mortality given by the score (p=0.115). Selected variables were statistically compared showing that poor functional status, high New York Heart Association (NYHA) at discharge, psychopharmacs use, and high creatininemia were associated with higher mortality (p<0.05). The multivariate regression model identified three predictors of one-year mortality: psychopharmacs baseline use (OR=4.110; p=0.014), angiotensin-converting enzyme inhibitors/angiotensin receptor blocker (ACEI/ARB) medication at discharge (OR=0.297; p=0.033), and higher admission's creatinine (OR=2.473; p=0.028). For three-year mortality outcome, two variables were strong independent predictors: psychopharmacs (OR=3.330; p=0.022) and medication with ACEI/ARB at discharge (OR=0.285; p=0.018). Models' adjustment was assessed through the receiver operating characteristic (ROC) curve. The best model was the one-year mortality (area under the curve, AUC 81%), corresponding to a good discrimination power. Despite prognostication, when setting goals of care an individualised patient-centred approach is imperative, based on the patient's objectives and needs. Risk factors related to poorer outcomes should be considered, in particular, higher NYHA at discharge which also represents symptom burden. Hospitalisation is an opportunity to optimize global care for heart failure patients including palliative care.

摘要

心力衰竭(HF)是一种慢性进行性疾病,具有高病亡率和较差的生活质量(QoL)。姑息治疗可显著改善临床结局,但很少有患者接受,部分原因是关于预后的决策具有挑战性。这项回顾性研究纳入了在一年时间内从急性心力衰竭病房连续出院的所有患者,旨在评估慢性心力衰竭Meta分析全球组(MAGGIC)评分预测死亡率的准确性。此外,使用多变量回归模型探索了1年和3年时的死亡预测因素。MAGGIC评分在预测死亡率方面是有用的,在三年随访中观察到的死亡率与该评分给出的死亡率之间无显著差异(p=0.115)。对选定变量进行统计学比较显示,功能状态差、出院时纽约心脏协会(NYHA)分级高、使用精神药物以及肌酐水平高与较高的死亡率相关(p<0.05)。多变量回归模型确定了1年死亡率的三个预测因素:精神药物基线使用情况(OR=4.110;p=0.014)、出院时使用血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂(ACEI/ARB)药物(OR=0.297;p=0.033)以及入院时肌酐水平较高(OR=2.473;p=0.028)。对于3年死亡率结局,两个变量是强有力的独立预测因素:精神药物(OR=3.330;p=0.022)和出院时使用ACEI/ARB药物(OR=0.285;p=0.018)。通过受试者工作特征(ROC)曲线评估模型的校准。最佳模型是1年死亡率模型(曲线下面积,AUC 81%),对应良好的区分能力。尽管进行了预后评估,但在设定护理目标时,基于患者的目标和需求,采取以患者为中心的个体化方法至关重要。应考虑与较差结局相关的危险因素,特别是出院时较高的NYHA分级,这也代表了症状负担。住院是优化心力衰竭患者整体护理(包括姑息治疗)的一个契机。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/93e6/8548045/102d1af55f5b/cureus-0013-00000018301-i01.jpg

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