Li Yanxuan, Li Zihan, Si Daoyuan, Yang Ping
Department of Cardiovascular Medicine, China-Japan Union Hospital of Jilin University, Changchun, China.
ESC Heart Fail. 2024 Dec;11(6):3687-3701. doi: 10.1002/ehf2.14952. Epub 2024 Jul 9.
We aim to assess the risk of thrombus-associated events (TAE) in patients with heart failure (HF) without atrial fibrillation (AF) and develop an effective scoring system for a risk stratification model.
This retrospective study included 450 patients (median age 64.0 years, interquartile range [55.0, 75.0]; 31.6% women) hospitalized for HF without AF and atrial flutter, but with a left ventricular ejection fraction (LVEF) ≤ 55% and New York Heart Association (NYHA) functional class of III-IV. A median follow-up of 47 months was conducted. In the present study, TAE during follow-up was independently associated with both all-cause death [hazard ratio (HR) 1.756, 95% confidence interval (CI) 1.324-2.328, P < 0.001] and readmission for HF (HR 1.574, 95% CI 1.122-2.208, P = 0.009) after adjustment for covariates. Hypertension (HR 1.573, 95% CI 1.018-2.429, P = 0.041), atrial arrhythmia excluding AF (AAexAF) (HR 2.041, 95% CI 1.066-3.908, P = 0.031), previous ischaemic stroke (HR 2.469, 95% CI 1.576-3.869, P < 0.001), and vascular disease (HR 1.658, 95% CI 1.074-2.562, P = 0.023) were independently associated with TAE. Age (HR 1.021, 95% CI 1.008-1.033, P = 0.001), previous ischaemic stroke (HR 1.685, 95% CI 1.248-2.274, P = 0.001), LVEF ([10, 25] vs. [40, 55]) HR 1.925, 95% CI 1.311-2.826, P = 0.001; (25, 40] vs. (40, 55] HR 1.084, 95% CI 0.825-1.424, P = 0.563), and creatinine clearance rate (Ccr) (HR 0.991, 95% CI 0.986-0.996, P = 0.001) were independently associated with composite events of TAE and death (TAE-D). CHADSVASc modestly predicted 5-year TAE [area under the receiver operating characteristic curves (AUC) 0.660, P < 0.001 compared with 0.5] and TAE-D (AUC 0.639, P < 0.001 compared with 0.5). (C)ACE, formed by incorporating AAexAF, LVEF, and Ccr into CHADSVASc, had higher AUC for predicting 5-year TAE (0.694 vs. 0.660, P = 0.018) and TAE-D (0.708 vs. 0.639, P < 0.001) compared with CHADSVASc. In patients with HF with reduced ejection fraction (HFrEF), (C)ACE and (C)ACEN [formed by incorporating NYHA into (C)ACE] had higher AUC compared with CHADSVASc in predicting 5-year TAE (0.700 and 0.707 vs. 0.649, P = 0.013 and 0.030, respectively) and TAE-D (0.712 and 0.713 vs. 0.622, P < 0.001 and <0.001, respectively). The AUC did not improve statistically from (C)ACE to (C)ACEN (0.700 vs. 0.707, P = 0.600 for TAE; 0.712 vs. 0.713, P = 0.917 for TAE-D).
In HF without AF, TAE during follow-up was associated with adverse prognoses. The independent risk factors of TAE or TAE-D improved CHADS-VASc predictive ability, especially in patients with HFrEF. Our findings provide new evidence for TAE risk stratification in HF without AF, potentially guiding prophylactic anticoagulation.
我们旨在评估无房颤（AF）的心力衰竭（HF）患者发生血栓相关事件（TAE）的风险，并开发一种有效的风险分层模型评分系统。
这项回顾性研究纳入了450例因HF住院的患者（中位年龄64.0岁，四分位间距[55.0, 75.0]；31.6%为女性），这些患者无AF和心房扑动，但左心室射血分数（LVEF）≤55%且纽约心脏协会（NYHA）心功能分级为III - IV级。进行了中位47个月的随访。在本研究中，随访期间的TAE与全因死亡[风险比（HR）1.756，95%置信区间（CI）1.324 - 2.328，P < 0.001]和HF再入院（HR 1.574，95% CI 1.122 - 2.208，P = 0.009）均独立相关，在对协变量进行调整后。高血压（HR 1.573，95% CI 1.018 - 2.429，P = 0.041）、排除AF的房性心律失常（AAexAF）（HR 2.041，95% CI 1.066 - 3.908，P = 0.031）、既往缺血性卒中（HR 2.469，95% CI 1.576 - 3.869，P < 0.001）和血管疾病（HR 1.658，95% CI 1.074 - 2.562，P = 0.023）与TAE独立相关。年龄（HR 1.021，95% CI 1.008 - 1.033，P = 0.001）、既往缺血性卒中（HR 1.685，95% CI 1.248 - 2.274, P = 0.001）、LVEF（[10, 25]与[40, 55]相比）HR 1.925，95% CI 1.311 - 2.826，P = 0.001；（25, 40]与(40, 55]相比HR 1.084，95% CI 0.825 - 1.424，P = 0.563）以及肌酐清除率（Ccr）（HR 0.991，95% CI 0.986 - 0.996，P = 0.001）与TAE和死亡的复合事件（TAE - D）独立相关。CHADSVASc对5年TAE的预测能力一般[受试者操作特征曲线下面积（AUC）为0.660，与0.5相比P < 0.001]以及对TAE - D的预测能力（AUC为0.639,与0.5相比P < 0.001）。（C）ACE通过将AAexAF、LVEF和Ccr纳入CHADSVASc形成，与CHADSVASc相比，在预测5年TAE（0.694对0.660，P = 0.018）和TAE - D（0.708对0.639，P < 0.001）方面具有更高的AUC。在射血分数降低的心力衰竭（HFrEF）患者中，（C）ACE和（C）ACEN[通过将NYHA纳入（C）ACE形成]与CHADSVASc相比，在预测5年TAE（0.700和0.707对0.649，P分别为0.013和0.030）和TAE - D（0.712和0.713对0.622，P分别< 0.001和< 0.001）方面具有更高的AUC。从（C）ACE到（C）ACEN，AUC在统计学上没有改善（对于TAE，0.700对0.707，P = 0.600；对于TAE - D，0.712对0.713，P = 0.917）。
在无AF的HF患者中，随访期间的TAE与不良预后相关。TAE或TAE - D的独立危险因素提高了CHADS - VASc的预测能力，尤其是在HFrEF患者中。我们的研究结果为无AF的HF患者TAE风险分层提供了新证据，可能指导预防性抗凝治疗。
