Gouveia R, Madureira S, Elias C, Neves A, Soares P Ribeirinho, Soares-Carreira M, Pereira J, Ribeiro A, Amorim M, Almeida J, Araújo J P, Lourenco P
Internal Medicine Department, Centro Hospitalar e Universitário de São João, Porto, Portugal.
Heart Failure Clinic, Internal Medicine Department, Centro Hospitalar Universitário de São João, Porto, Portugal.
Int J Cardiol Cardiovasc Risk Prev. 2023 Jul 16;18:200197. doi: 10.1016/j.ijcrp.2023.200197. eCollection 2023 Sep.
In patients with established heart failure (HF) low total cholesterol levels associate with worse prognosis. Evidence concerning the impact of Low-density lipoprotein cholesterol (LDL-c) in HF is scarce. We aimed to evaluate the prognostic impact of LDL-c in patients with HF, both with and without diabetes (DM).
We retrospectively analyzed outpatients with chronic HF with systolic dysfunction followed in our HF clinic from January/2012 to May/2018. LDL-c was calculated using the Friedewald's formula. Patients without a complete lipid profile were excluded. The endpoint under analysis was all-cause mortality. Patients were followed until January/2021. A Cox-regression analysis was used to study the prognostic impact of LDL-c. The LDL-c cut-off used was 100 mg/dL (mean value). Analysis was stratified according to the coexistence of DM. Multivariate models were built adjusting for age, sex, coronary artery disease, atherosclerotic non-coronary artery disease, arterial hypertension, smoking status, statin use, severity of systolic dysfunction, creatinine clearance and evidence-based therapy.
We studied 522 chronic HF patients, mean age was 70 years, 66.5% males. Severe systolic dysfunction was present in 42.7%, 30.5% had coronary heart disease, 60.5% had arterial hypertension, 41.6% had DM. A total of 92.0% were treated with beta blocker, 87.5% with an ACEi/ARB and 29.1% with a MRA. During a median follow-up of 53 (interquartile range 33-73) months, 235 (45%) patients died. Patients with LDL-c ≤100 mg/dL presented increased multivariate-adjusted risk of all-cause mortality: HR = 1.58 (95% CI: 1.08-2.30), p = 0.02. When patients were stratified according to DM, LDL-c ≤100 mg/dL was independently associated with increased death risk - HR = 1.55 (95% CI:1.05-2.30), p = 0.03 in patients without DM; in patients with DM no association was detected - multivariate-adjusted HR = 1.18 (95% CI: 0.77-1.80), p = 0.44.
Non-DM HF patients with LDL-c>100 mg/dL have a 35% reduction in the mortality risk when compared with those with lower values. The "cholesterol paradox" in HF also applies to LDL-c in non-DM patients.
在已确诊的心力衰竭（HF）患者中，总胆固醇水平较低与预后较差相关。关于低密度脂蛋白胆固醇（LDL-c）对HF影响的证据很少。我们旨在评估LDL-c在有和没有糖尿病（DM）的HF患者中的预后影响。
我们回顾性分析了2012年1月至2018年5月在我们的HF诊所随访的慢性HF合并收缩功能障碍的门诊患者。使用Friedewald公式计算LDL-c。排除没有完整血脂谱的患者。分析的终点是全因死亡率。对患者随访至2021年1月。使用Cox回归分析研究LDL-c的预后影响。使用的LDL-c临界值为100mg/dL（平均值）。根据DM的共存情况进行分层分析。建立多变量模型，对年龄、性别、冠状动脉疾病、非冠状动脉粥样硬化疾病、动脉高血压、吸烟状况、他汀类药物使用、收缩功能障碍的严重程度、肌酐清除率和循证治疗进行调整。
我们研究了522例慢性HF患者，平均年龄70岁，男性占66.5%。42.7%存在严重收缩功能障碍，30.5%患有冠心病，60.5%患有动脉高血压，41.6%患有DM。共有92.0%的患者接受了β受体阻滞剂治疗，87.5%接受了ACEi/ARB治疗，29.1%接受了MRA治疗。在中位随访53（四分位间距33 - 73）个月期间，235例（45%）患者死亡。LDL-c≤100mg/dL的患者全因死亡率的多变量调整风险增加：HR = 1.58（95%CI：1.08 - 2.30），p = 0.02。当根据DM对患者进行分层时，LDL-c≤100mg/dL与死亡风险增加独立相关 - 在无DM的患者中HR = 1.55（95%CI：1.05 - 2.30），p = 0.03；在有DM的患者中未检测到相关性 - 多变量调整HR = 1.18（95%CI：0.77 - 1.80），p = 0.44。
与LDL-c值较低的非DM HF患者相比，LDL-c>100mg/dL的患者死亡风险降低35%。HF中的“胆固醇悖论”也适用于非DM患者的LDL-c。
