心房颤动对轻至中度心力衰竭预后的影响。V-HeFT研究。V-HeFT VA合作研究组。

The influence of atrial fibrillation on prognosis in mild to moderate heart failure. The V-HeFT Studies. The V-HeFT VA Cooperative Studies Group.

作者信息

Carson P E, Johnson G R, Dunkman W B, Fletcher R D, Farrell L, Cohn J N

机构信息

Veterans Affairs Medical Center, Department of Cardiology, Washington, DC 20422.

出版信息

Circulation. 1993 Jun;87(6 Suppl):VI102-10.

PMID:8500233

Abstract

BACKGROUND

Atrial fibrillation occurs commonly in heart failure; however, its importance in terms of prognosis is controversial.

METHODS AND RESULTS

We assessed the relation of atrial fibrillation on first Holter monitor to morbidity and mortality in mild to moderate heart failure in 632 patients in the Veterans Affairs Vasodilator-Heart Failure Trial (V-HeFT) I and 795 patients in V-HeFT II: Ninety-nine patients in atrial fibrillation and 533 patients in sinus rhythm were followed for a mean of 2.5 years (range, 6 months to 5.7 years) in V-HeFT I; 107 patients in atrial fibrillation and 688 patients in sinus rhythm in V-HeFT II were followed for a mean of 2.5 years (range, 6 months to 5.0 years). V-HeFT I compared treatment with prazosin, hydralazine-isosorbide dinitrate, and placebo, whereas V-HeFT II compared hydralazine-isosorbide dinitrate with enalapril. Follow-up evaluations included serial Holter monitors, serial metabolic exercise testing, hospitalization data, and clinical examinations. In V-HeFT I, cumulative mortality at 2 years was 0.34 for patients with atrial fibrillation and 0.30 for patients in sinus rhythm (p = 0.25). Overall cumulative mortality was 0.54 for atrial fibrillation patients and 0.64 for sinus rhythm patients (p = 0.86). In V-HeFT II, cumulative mortality at 2 years was 0.20 for patients with atrial fibrillation and 0.21 for patients with sinus rhythm (p = 0.68), and overall cumulative mortality was 0.46 for atrial fibrillation patients and 0.52 for those in sinus rhythm (p < 0.46). Sudden death was not increased with atrial fibrillation in V-HeFT I patients (p = 0.64) or in V-HeFT II (p = 0.68). By multivariate analysis, the relative mortality risk for atrial fibrillation was 0.95 in V-HeFT I and 0.76 in V-HeFT II: Metabolic exercise testing, showed no significant difference in mean change in peak oxygen consumption between patients with atrial fibrillation and those with sinus rhythm in V-HeFT I and a slight decrease late in V-HeFT II: Hospitalization rate for heart failure was not increased in either study. The embolic event rate was not increased for atrial fibrillation patients: 3% versus 4.9% of patients in sinus rhythm (p = 0.41) in V-HeFT I and 4.0% versus 6.0% in V-HeFT II patients (p = 0.44). A secondary analysis compared mortality of patients in atrial fibrillation with that of patients in sinus rhythm on all Holters: Mortality was not increased overall (p = 0.72 in V-HeFT I and p = 0.35 in V-HeFT II).

CONCLUSIONS

Atrial fibrillation does not increase major morbidity or mortality in mild to moderate heart failure.

摘要

背景

心房颤动在心力衰竭患者中很常见；然而，其对预后的重要性存在争议。

方法与结果

我们在退伍军人事务部血管扩张剂-心力衰竭试验（V-HeFT）I的632例患者和V-HeFT II的795例患者中，评估首次动态心电图监测时心房颤动与轻至中度心力衰竭患者发病率和死亡率的关系：V-HeFT I中，99例心房颤动患者和533例窦性心律患者平均随访2.5年（范围6个月至5.7年）；V-HeFT II中，107例心房颤动患者和688例窦性心律患者平均随访2.5年（范围6个月至5.0年）。V-HeFT I比较了哌唑嗪、肼屈嗪-硝酸异山梨酯和安慰剂的治疗效果，而V-HeFT II比较了肼屈嗪-硝酸异山梨酯与依那普利的治疗效果。随访评估包括系列动态心电图监测、系列代谢运动试验、住院数据和临床检查。在V-HeFT I中，心房颤动患者2年累积死亡率为0.34，窦性心律患者为0.30（p = 0.25）。心房颤动患者总体累积死亡率为0.54，窦性心律患者为0.64（p = 0.86）。在V-HeFT II中，心房颤动患者2年累积死亡率为0.20，窦性心律患者为0.21（p = 0.6），心房颤动患者总体累积死亡率为0.46，窦性心律患者为0.52（p < 0.46）。V-HeFT I患者（p = 0.64）和V-HeFT II患者（p = 0.68）中，心房颤动并未增加猝死发生率。通过多变量分析，V-HeFT I中心房颤动的相对死亡风险为0.95，V-HeFT II中为0.76：代谢运动试验显示，V-HeFT I中心房颤动患者与窦性心律患者的峰值耗氧量平均变化无显著差异，V-HeFT II后期略有下降：两项研究中心力衰竭住院率均未增加。心房颤动患者的栓塞事件发生率未增加：V-HeFT I中为3%，窦性心律患者为4.9%（p = 0.41），V-HeFT II患者中为4.0%，窦性心律患者为6.0%（p = 0.44）。一项二次分析比较了所有动态心电图监测时心房颤动患者与窦性心律患者的死亡率：总体死亡率未增加（V-HeFT I中p = 0.72，V-HeFT II中p = 0.35）。