肾素血管紧张素系统抑制剂对风湿性心脏病二尖瓣置换术患者的预后分析
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摘要
目的探讨肾素血管紧张素系统抑制剂(RSI)对风湿性心脏病(RHD)二尖瓣置换术患者预后的影响。方法研究对象来源于广州心血管相关疾病队列,采用回顾性队列研究方法,纳入诊断为RHD并且有单纯二尖瓣置换术病史的患者,根据有无服用RSI,将患者分为RSI组和非RSI组,随访并分析两组患者全因死亡、因心衰住院或死亡事件和心脏彩超各心腔内径变化的差异。进一步地,把RSI和基线纳入的变量分别进行单因素和多因素Cox回归分析,了解与患者全因死亡和因心衰住院或死亡事件相关的危险因素。结果研究平均随访时间12年,共纳入191例患者。生存分析结果显示,RSI组患者生存率和无因心衰住院或死亡事件生存率均高于非RSI组患者(P <0.05)。各心腔内径每年变化差值在组间差异均无统计学意义(P> 0.05)。多因素Cox回归分析结果显示,年龄增加和换瓣年限延长是患者全因死亡的危险因素;地高辛治疗、左房内径增大、LVEF降低是患者因心衰住院或死亡事件的危险因素;RSI治疗降低患者全因死亡风险(校正HR=0.445,95%CI:0.235~0.843,P=0.005)和因心衰住院或死亡事件风险(校正HR=0.541,95%CI:0.337~0.870,P=0.005)。结论 RSI能提高RHD二尖瓣置换术患者生存率,降低患者全因死亡和因心衰住院或死亡事件风险。
Objective To investigate the impact of renin angiotensin system inhibitors(RSI)on outcome in rheumatic heart disease(RHD)patients after mitral valve replacement. Methods A retrospective cohort study was performed evaluating patients who were diagnosed as RHD with a history of pure mitral valve replacement in Guangzhou Cardiovascular Disease Cohort. The patients were divided into RSI group and non-RSI group,according to the medication situation of taking RSI. Then outcome of the patients and the difference between of them were analyzed,including all-cause death,hospitalization or death for heart failure events and the change of cardiac inner diameter Furthermore,the baseline variables and RSI were included to access the risk factors of all-cause death and hospitalization or death for heart failure events using both univariate and multivariate Cox proportional hazard model. Results A total of 191 patients with RHD after mitral valve replacement were studied with a mean followup period of 12 years. Survival analysis showed that RSI group were higher than those of non-RSI group in survival rates and the hospitalization or death for heart failure events free survival rates(P < 0.05). There was no difference between two groups on change of cardiac inner diameter(P > 0.05). Multivariate Cox regression analysis showed that older age and prolonged duration of valve replacement were risk factors for all-cause death. Digoxin therapy,increased left atrial diameter and decreased LVEF were risk factors for hospitalization or death for heart failure events. Patients treating with RSI had significantly lower risk of all-cause death(adjusted HR = 0.445,95% CI:0.234 ~ 0.843,P = 0.005)and hospitalization or death for heart failure events(adjusted HR = 0.541,95% CI:0.337 ~ 0.870,P = 0.005). Conclusion The prescription of RSI in patients with RHD after mitral valve replacement could significantly reduc the risk of all-cause death and hospitalization or death for heart failure.
Objective To investigate the impact of renin angiotensin system inhibitors(RSI)on outcome in rheumatic heart disease(RHD)patients after mitral valve replacement. Methods A retrospective cohort study was performed evaluating patients who were diagnosed as RHD with a history of pure mitral valve replacement in Guangzhou Cardiovascular Disease Cohort. The patients were divided into RSI group and non-RSI group,according to the medication situation of taking RSI. Then outcome of the patients and the difference between of them were analyzed,including all-cause death,hospitalization or death for heart failure events and the change of cardiac inner diameter Furthermore,the baseline variables and RSI were included to access the risk factors of all-cause death and hospitalization or death for heart failure events using both univariate and multivariate Cox proportional hazard model. Results A total of 191 patients with RHD after mitral valve replacement were studied with a mean followup period of 12 years. Survival analysis showed that RSI group were higher than those of non-RSI group in survival rates and the hospitalization or death for heart failure events free survival rates(P < 0.05). There was no difference between two groups on change of cardiac inner diameter(P > 0.05). Multivariate Cox regression analysis showed that older age and prolonged duration of valve replacement were risk factors for all-cause death. Digoxin therapy,increased left atrial diameter and decreased LVEF were risk factors for hospitalization or death for heart failure events. Patients treating with RSI had significantly lower risk of all-cause death(adjusted HR = 0.445,95% CI:0.234 ~ 0.843,P = 0.005)and hospitalization or death for heart failure events(adjusted HR = 0.541,95% CI:0.337 ~ 0.870,P = 0.005). Conclusion The prescription of RSI in patients with RHD after mitral valve replacement could significantly reduc the risk of all-cause death and hospitalization or death for heart failure.
引文
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[8] STASZEWSKY L,WONG M,MASSON S,et al. Left atrial remodeling and response to valsartan in the prevention of recurrent atrial fibrillation:the GISSI-AF echocardiographic substudy[J]. Circ Cardiovasc Imaging,2011,4(6):721-728.
[9] YIU K H,NG W S,Chan D,et al. Improved prognosis following renin-angiotensin-aldosterone system blockade in patients undergoing concomitant aortic and mitral valve replacement[J].Int J Cardiol,2014,177(2):680-682.
[10] AMBROSY A P,BUTLER J,AHMED A,et al. The use of digoxin in patients with worsening chronic heart failure:reconsidering an old drug to reduce hospital admissions[J]. J Am Coll Cardiol,2014,63(18):1823-1832.
[2] PARK K J,WOO J S,PARK J Y,et al. Clinical effect of left ventricular dysfunction in patients with mitral stenosis after mitral valve replacement[J]. Korean J Thorac Cardiovasc Surg,2016,49(5):350-355.
[3] NADIR M A,WEI L,ELDER D H,et al. Impact of renin-angiotensin system blockade therapy on outcome in aortic stenosis[J]. J Am Coll Cardiol,2011,58(6):570-576.
[4] GOEL S S,AKSOY O,GUPTA S,et al. Renin-angiotensin system blockade therapy after surgical aortic valve replacement for severe aortic stenosis:a cohort study[J]. Ann intern med,2014,161(10):699-710.
[5]张忠义,王喜明,卯甜甜,等.二尖瓣综合成形术治疗风湿性二尖瓣病变的疗效[J].实用医学杂志,2018,35(19):3269-3272.
[6]李星辰,汤步富,刘剑州,等.风湿性心脏病二尖瓣成形术与置换术的系统评价[J].中国医药导报,2017,14(32):62-67.
[7] BRILLA C G,RUPP H,FUNCK R,et al. The renin-angiotensin-aldosterone system and myocardial collagen matrix remodelling in congestive heart failure[J]. Eur Heart J,1995,16(Suppl O):107-9.
[8] STASZEWSKY L,WONG M,MASSON S,et al. Left atrial remodeling and response to valsartan in the prevention of recurrent atrial fibrillation:the GISSI-AF echocardiographic substudy[J]. Circ Cardiovasc Imaging,2011,4(6):721-728.
[9] YIU K H,NG W S,Chan D,et al. Improved prognosis following renin-angiotensin-aldosterone system blockade in patients undergoing concomitant aortic and mitral valve replacement[J].Int J Cardiol,2014,177(2):680-682.
[10] AMBROSY A P,BUTLER J,AHMED A,et al. The use of digoxin in patients with worsening chronic heart failure:reconsidering an old drug to reduce hospital admissions[J]. J Am Coll Cardiol,2014,63(18):1823-1832.