冠状动脉灌注压与晚期心力衰竭的不良预后相关。
Coronary perfusion pressure is associated with adverse outcomes in advanced heart failure.
机构信息
University of Virginia Health System, Charlottesville, VA, USA.
White River Health System, Batesville, AZ, USA.
出版信息
Perfusion. 2023 Oct;38(7):1492-1500. doi: 10.1177/02676591221118693. Epub 2022 Aug 10.
BACKGROUND
Myocardial perfusion is an important determinant of cardiac function. We hypothesized that low coronary perfusion pressure (CPP) would be associated with adverse outcomes in heart failure. Myocardial perfusion impacts the contractile efficiency thus a low CPP would signal low myocardial perfusion in the face of increased cardiac demand as a result of volume overload
METHODS
We analyzed patients with complete hemodynamic data in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness trial using Cox Proportional Hazards regression for the primary outcome of the composite risk of death, heart transplantation, or left ventricular assist device [(LVAD). DT × LVAD] and the secondary outcome of the composite risk of DT × LVAD and heart failure hospitalization (DT × LVADHF). CPP was calculated as the difference between diastolic blood pressure and pulmonary artery wedge pressure. Heart failure categories (ischemic vs non-ischemic) were also stratified based on CPP strata.
RESULTS
The 158 patients (56.7 ± 13.6 years, 28.5% female) studied had a median CPP of 40 mmHg (IQR 35-52 mmHg). During 6 months of follow-up, 35 (22.2%) had the composite primary outcome and 109 (69.0%) had the composite secondary outcome. When these outcomes were then stratified based on the median, CPP was associated with these outcomes. Increasing CPP was associated with lower risk of both the primary outcome of DT × LVAD (HR 0.96, 95% CI 0.94-0.99 = .002) and as well as the secondary outcome of DT × LVADHF ( = .0008) There was significant interaction between CPP and ischemic etiology ( = .04).
CONCLUSION
A low coronary artery perfusion pressure below (median) 40mmHg in patients with advanced heart failure undergoing invasive hemodynamic monitoring with a pulmonary artery catheter was associated with adverse outcomes. CPP could useful in guiding risk stratification of advanced heart failure patients and timely evaluation of advanced heart failure therapies.
背景
心肌灌注是心脏功能的一个重要决定因素。我们假设，低冠状动脉灌注压（CPP）与心力衰竭患者的不良预后相关。心肌灌注会影响收缩效率，因此，在容量超负荷导致心脏需求增加的情况下，CPP 降低表明心肌灌注不足。
方法
我们使用 Cox 比例风险回归分析了充血性心力衰竭评估研究和肺动脉导管有效性试验中具有完整血流动力学数据的患者，主要终点为死亡、心脏移植或左心室辅助装置复合风险[（DT×LVAD）]，次要终点为 DT×LVAD 和心力衰竭住院的复合风险（DT×LVADHF）。CPP 计算为舒张期血压与肺动脉楔压之差。根据 CPP 分层，心力衰竭类别（缺血性与非缺血性）也进行分层。
结果
158 例患者（56.7±13.6 岁，28.5%为女性）的 CPP 中位数为 40mmHg（IQR 35-52mmHg）。在 6 个月的随访期间，35 例（22.2%）发生了主要复合终点，109 例（69.0%）发生了次要复合终点。然后根据中位数对这些结局进行分层，CPP 与这些结局相关。CPP 升高与 DT×LVAD 的主要结局（HR 0.96，95%CI 0.94-0.99，P=0.002）和 DT×LVADHF 的次要结局（P=0.0008）风险降低相关。CPP 与缺血性病因之间存在显著交互作用（P=0.04）。
结论
在接受肺动脉导管有创血流动力学监测的晚期心力衰竭患者中，CPP 低于（中位数）40mmHg 与不良预后相关。CPP 可能有助于指导晚期心力衰竭患者的风险分层，并及时评估晚期心力衰竭治疗方法。
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