消瘦作为慢性心力衰竭患者死亡的独立危险因素。

Wasting as independent risk factor for mortality in chronic heart failure.

作者信息

Anker S D, Ponikowski P, Varney S, Chua T P, Clark A L, Webb-Peploe K M, Harrington D, Kox W J, Poole-Wilson P A, Coats A J

机构信息

Department of Cardiac Medicine, National Heart and Lung Institute, London.

出版信息

Lancet. 1997 Apr 12;349(9058):1050-3. doi: 10.1016/S0140-6736(96)07015-8.

DOI:10.1016/S0140-6736(96)07015-8

PMID:9107242

Abstract

BACKGROUND

Wasting in chronic heart failure (CHF) has long been known but is little investigated. We sought to find out whether the cachectic state in CHF provides additional prognostic information about all-cause mortality.

METHODS

Between June, 1993, and May, 1995, we studied 171 consecutive patients with CHF (mean age 60 years [SD 11; range 27-86]; 17 female). We assessed exercise capacity (peak oxygen consumption; mean 17.5 mL kg-1 min-1 [6.7]), functional status (New York Heart Association [NYHA] class: 21 class I, 63 class II, 68 class III, 19 class IV), and left-ventricular ejection fraction (mean 30% [SD 15]; n = 115). The cachectic status was defined prospectively as a non-intentional documented weight loss of at least 7.5% of previous normal weight (28 patients; range 9-36% or 6-30 kg) during at least 6 months. The Cox proportional-hazards model was used to assess the association of variables with survival, and Kaplan-Meier cumulative survival plots were constructed to estimate the influence of risk factors.

FINDINGS

At the end of follow-up in November, 1996, 49 patients had died (after a mean 324 days [SD 283]). The mean follow-up of the survivors was 834 days (SD 186; range 549-1269). The cachectic state was predictive of 18-month mortality independent of age, NYHA class, left-ventricular ejection fraction, and peak oxygen consumption. Mortality in the cachectic patients (n = 28) was 18% at 3 months, 29% at 6 months, 39% at 12 months, and 50% at 18 months. Patients who had a peak oxygen consumption below 14 mL kg-1 min-1 (n = 53) had mortality at 3, 6, 12, and 18 months of 19%, 30%, 40%, and 51%. 18-month survival was 23% (95% CI 0-46) for the 13 patients with both of these risk factors (cachexia and low peak oxygen consumption) compared with 93% (88-98) in those (n = 103) with neither risk factor (p < 0.0001).

INTERPRETATION

The cachectic state is a strong independent risk factor for mortality in patients with CHF. Combined with a low peak oxygen consumption, it identifies a subset of patients at extremely high risk of death. Assessment of cachexia should be included in transplant programmes and studies that investigate the effect of interventions by survival analyses.

摘要

背景

慢性心力衰竭（CHF）患者的消瘦现象早已为人所知，但相关研究较少。我们试图探究CHF患者的恶病质状态是否能为全因死亡率提供额外的预后信息。

方法

1993年6月至1995年5月期间，我们连续研究了171例CHF患者（平均年龄60岁[标准差11；范围27 - 86岁]；17例女性）。我们评估了运动能力（峰值耗氧量；平均17.5 mL·kg⁻¹·min⁻¹[6.7]）、功能状态（纽约心脏协会[NYHA]分级：21例I级，63例II级，68例III级，19例IV级）以及左心室射血分数（平均30%[标准差15]；n = 115）。恶病质状态被前瞻性地定义为在至少6个月内非故意记录的体重减轻至少达到先前正常体重的7.5%（28例患者；范围9% - 36%或6 - 30 kg）。采用Cox比例风险模型评估变量与生存的关联，并构建Kaplan - Meier累积生存曲线来估计危险因素的影响。

结果

在1996年11月随访结束时，49例患者死亡（平均324天[标准差283]）。幸存者的平均随访时间为834天（标准差186；范围549 - 1269）。恶病质状态可独立于年龄、NYHA分级、左心室射血分数和峰值耗氧量预测18个月死亡率。恶病质患者（n = 28）3个月时的死亡率为18%，6个月时为29%，12个月时为39%，18个月时为50%。峰值耗氧量低于14 mL·kg⁻¹·min⁻¹的患者（n = 53）3、6、12和18个月时的死亡率分别为19%、30%、40%和51%。同时具有这两种危险因素（恶病质和低峰值耗氧量）的13例患者18个月生存率为23%（95%CI 0 - 46），而无这两种危险因素的患者（n = 103）为93%（88 - 98）（p < 0.0001）。