翻译:苗   猫            校对:叮当丸子麻

收缩压和灌注状态对急性心力衰竭死亡率的协同影响

Synergistic Impact of Systolic Blood Pressure and Perfusion Status on Mortality in Acute Heart Failure

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BACKGROUND

Physical examination remains the cornerstone in the assessment of acute heart failure． There is a lack of adequately powered studies assessing the combined impact of both systolic blood pressure (SBP) and hypoperfusion on short-term mortality．

背景:体格检查仍然是评估急性心力衰竭的基础。目前还缺乏足够有力的研究来评估收缩压(SBP)和低灌注对急性心力衰竭短期死亡率的联合影响。

METHODS

Patients with acute heart failure from 41 Spanish emergency departments were recruited consecutively in 3 time periods between 2011 and 2016． Logistic regression models were used to assess the association of 30-day mortality with SBP (<90, 90–109, 110–129, and ≥130 mm Hg) and with manifestations of hypoperfusion (cold skin, cutaneous pallor,delayed capillary refill, livedo reticularis, and mental confusion) at admission．

方法:2011年至2016年中的3个时间段招募来自西班牙41个急诊科的急性心力衰竭患者。使用Logistic回归模型评估入院时收缩压(<90、90-109、110-129和≥130mmHg)和有灌注不足表现(皮肤湿冷、皮肤苍白、毛细血管再充盈时间延迟、网状青斑和精神错乱)与30天死亡率的相关性。

注:网状青斑是一种非常少见的皮肤血管性疾病,其主要症状表现在患者的皮肤表层通过肉眼可看到紫色或者蓝紫色的青斑。

RESULTS

Among 10979 patients, 1143 died within the first 30 days (10．2%)． There was an inverse association between 30-day mortality and initial SBP (35．4%, 18．9%, 12．4%, and 7 ．5% for SBP<90, SBP 90–109, SBP 110–129, and SBP≥130mmHg, respectively; P<0．001) and a positive association with hypoperfusion (8．0%, 14．8%, and 27 ．6% for those with none, 1, ≥2 signs/symptoms of hypoperfusion, respectively; P<0．001)． After adjustment for 11 risk factors, the prognostic impact of hypoperfusion on 30-day mortality varied across SBP categories: SBP≥130 mm Hg (odds ratio [OR]=1．03 [95% CI, 0．77–1．36] and OR=1．18 [95% CI, 0．86–1．62] for 1 and ≥2 compared with 0 manifestations of hypoperfusion),SBP 110 to 129 mm Hg (OR=1．23 [95% CI, 0．86–1．77] and OR=2．18 [95% CI, 1．44–3．31], respectively), SBP 90 to 109mmHg (OR=1．29 [95% CI, 0．79–2．10] and OR=2．24 [95% CI, 1．36–3．66], respectively), and SBP<90 mm Hg (OR=1．34 [95% CI, 0．45–4．01] and OR=3．22 [95% CI, 1．30–7 ．97], respectively); P-for-interaction =0．043．

结果:10979例患者中,1143例在30天内死亡(10．2%)。收缩压<90mmHg,收缩压90-109mmHg,收缩压110-129mmHg,收缩压≥130mmHg时,30天死亡率与初始收缩压呈负相关(分别为35．4%,18．9%,12．4%和7．5%);P<0．001)和与低灌注呈正相关(无、1、2个低灌注体征/症状者分别为8．0%、14．8%和27．6%;P < 0．001)。在调整了11个危险因素后,低灌注对30天死亡率的影响因收缩压类别而异:SBP≥130 mm Hg(有1和≥2个低灌注表现的患者与无低灌注表现的患者相比,优势比 [OR]=1．03 [95% CI, 0．77–1．36] and OR=1．18 [95% CI, 0．86–1．62] for 1 and ≥2 ), SBP 110-129毫米汞柱(OR=1．23 [95% CI, 0．86–1．77] and OR=2．18 [95% CI, 1．44–3．31], respectively),SBP 90 - 109毫米汞柱(OR=1．29 [95% CI, 0．79–2．10] and OR=2．24 [95% CI, 1．36–3．66], respectively),收缩压<90 mm Hg (OR=1．34 [95% CI, 0．45–4．01] and OR=3．22 [95% CI, 1．30–7 ．97], respectively);交互作用的P值=0．043。

CONCLUSIONS

Hypoperfusion confers an incremental risk of 30-day all-cause mortality not only in patients with low SBP but also in normotensive patients． On admission, physical examination plays a major role in determining prognosis in patients with acute heart failure．

结论:低灌注不仅在低收缩压患者中增加了30天全因死亡的风险,在血压正常的患者中也是如此。入院时,体格检查对急性心力衰竭患者的预后起着重要作用。

注:全因死亡率是指一定时间内各种原因导致的总死亡人数与该人群同期平均人口数之比。

致敬奋战一线劳动者

AHF acute heart failure                  急性心力衰竭

ED  emergency department              急诊科

MEESSI-AHF  Multiple Estimation of risk based on the Spanish Emergency department Score In patients with AHF   西班牙急诊评分的AHF患者风险的多重估计

NT-proBNP     N-terminal pro-B-type natriuretic peptide     B型利尿钠肽  

OR   比值比

SBP systolic blood pressure   收缩压

表1．研究人群的临床特征(10 979名患者)

表2．收缩压分类的患病率、低灌注的临床体征及其与30天死亡率的未调整相关性

↑累积死亡概率

↑30天死亡率与初始收缩压(SBP)之间的关系

↑灌注不足临床表现的累积30天死亡率曲线。30天死亡率之间的关联表现为皮肤冷(A),皮肤苍白(B),毛细血管再充盈延迟(C),网状细胞(D),精神错乱(E)和低灌注表现(F)。

↑图3初始收缩压(SBP)与低灌注临床表现数量之间的关系。

↑图4:按收缩压分类对11个已知危险因素进行调整后存在低灌注临床表现的亚组分析

评估收缩压(<90、90 - 109、110-129和≥130 mm Hg)与低灌注(0、1和≥2种临床表现)之间的相互作用。根据急诊西班牙语急性心力衰竭患者评分(meesi - ahf)风险模型(急诊入院Barthel指数,年龄,年龄)对11个风险预测因子进行校正后,30 d死亡风险以优势比表示,其95% CI。纽约心脏协会IV类,钾水平,n -末端前b型利钠肽,肌钙蛋白水平,呼吸速率,氧饱和度,急性冠状动脉综合征,肌酐水平,心电图肥厚)。

↑图5:低灌注与收缩压(SBP)对30 d死亡率的协同效应

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