Division of Nephrology, Tufts Medical Center, Boston, Mass.
Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Mass; Tufts Clinical and Translational Science Institute, Tufts University, Boston, Mass.
Am J Med. 2022 Sep;135(9):e337-e352. doi: 10.1016/j.amjmed.2022.04.003. Epub 2022 Apr 25.
Decongestion is an important goal in the management of acute heart failure. Whether the rate of decongestion is associated with mortality and cardiovascular outcomes is unknown.
Using data from 4133 patients from the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study With Tolvaptan (EVEREST) trial, we used multivariable Cox regression models to evaluate the association between rates of in-hospital change in assessments of volume overload, including b-type natriuretic peptide (BNP), N-terminal pro b-type natriuretic peptide (NT-proBNP), as well as change in hemoconcentration, with risk of all-cause mortality and a composite outcome of cardiovascular mortality or heart failure hospitalization.
More rapid rates of in-hospital decongestion were associated with decreased risk of mortality and the composite outcome over a median 10-month follow-up. In reference to the quartile of slowest decline, the quartile with the fastest BNP and NT-proBNP decline had lower hazards of mortality (hazard rate [HR] = 0.43 [0.31, 0.59] and HR = 0.27 [0.19, 0.40], respectively) and composite outcome (HR = 0.49 [0.39, 0.60] and HR = 0.54 [0.42, 0.71], respectively). In reference to the quartile of slowest increase, the quartile with the fastest hematocrit increase had lower hazards of mortality (HR = 0.77 [0.62, 0.95]) and composite outcome (HR = 0.75 [0.64, 0.88]). Results were also consistent when models were repeated using propensity-score matching.
Faster rates of decongestion are associated with reduced risk of mortality and a composite of cardiovascular mortality and heart failure hospitalization. It remains unknown whether more rapid decongestion provides cardiovascular benefit or whether it serves as a proxy for less treatment resistant heart failure.
减轻充血是急性心力衰竭管理的重要目标。减轻充血的速度是否与死亡率和心血管结局相关尚不清楚。
我们使用来自托伐普坦治疗急性心力衰竭有效性和耐受性试验（EVEREST）的 4133 名患者的数据，使用多变量 Cox 回归模型评估住院期间评估容量超负荷变化率（包括 B 型利钠肽（BNP）和 N 末端 B 型利钠肽前体（NT-proBNP））与全因死亡率以及心血管死亡率或心力衰竭住院的复合结局的关系。
在中位 10 个月的随访期间，更快的住院期间去充血速度与死亡率和复合结局风险降低相关。与最慢下降的四分位数相比，BNP 和 NT-proBNP 下降最快的四分位数死亡率的风险较低（危险比 [HR] = 0.43 [0.31, 0.59] 和 HR = 0.27 [0.19, 0.40]），复合结局的风险也较低（HR = 0.49 [0.39, 0.60] 和 HR = 0.54 [0.42, 0.71]）。与最慢增加的四分位数相比，红细胞压积增加最快的四分位数死亡率的风险较低（HR = 0.77 [0.62, 0.95]），复合结局的风险也较低（HR = 0.75 [0.64, 0.88]）。当使用倾向评分匹配重复模型时，结果也是一致的。
更快的去充血速度与降低死亡率和心血管死亡率及心力衰竭住院的复合风险相关。尚不清楚更快的去充血是否提供心血管益处，或者它是否代表治疗抵抗性更低的心力衰竭。
