低钠血症与慢性心力衰竭患者的心脏功能和预后的关系
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摘要
目的
通过病例回顾的方法研究低钠血症与慢性心力衰竭患者心脏功能和临床预后的关系。
方法
收集2003年7月-2004年8月期间在中南大学湘雅二医院心内科住院诊断为慢性心力衰竭(CHF)的患者806例,根据患者血钠水平分为2组,血钠≥135mmol/L归为正常血钠组,血钠＜135mmol/L归为低血钠组。临床资料收集采用电脑分类查询结合人工病历抄录的方法,记录患者一般临床资料、基础心脏病因、伴随疾病、实验室检查结果、心脏彩超检查结果、住院治疗的转归。用多因素Logistic回归分析血钠水平与CHF患者心功能及临床预后的关系。
结果
1、研究对象中低钠血症为102例,占所有病例的12.66%。
2、低血钠组的高血压病、心肌病所致心力衰竭的比例高于正常血钠组,差异有统计学意义(P＜0.05)。两组间其他人口统计学资料及冠心病、瓣膜病、糖尿病病因学方面的资料均无统计学差异(P＞0.05)。
3、低血钠组中的血氯水平显著降低(P＜0.05),白细胞计数、血尿素氮、肌酐水平显著升高(P＞0.05)。两组间血钾、尿酸、空腹血糖水平、血红蛋白浓度及血小板计数比较差异无统计学意义(P＞0.05)。
4、二维超声心动图(Ultrasonic Cardiography,UCG)测定的两组左房内径、左室舒张末期内径及左室射血分数的差异有统计学意义(P＜0.05),CHF伴发低钠血症的患者左房、左室内径显著增大,射血分数明显减低。患者血钠水平与LVEF正相关,与LAD、LVDD负相关。
5、NYHA心功能评级比较,两组差异有显著性意义(P＜0.05);多分类Logistic回归分析结果显示患者血钠水平是心功能评级的重要影响因素(P＜0.05)。
6、两组患者的临床预后差异有统计学意义(P＜0.05)。多分类Logistic回归分析,结果显示血钠水平是临床预后的重要影响因素(P＜0.05)。
7、患者血钠水平、NYHA心功能评级与临床预后的相关性分析,结果显示组别、NYHA心功能评级都是临床预后的重要影响因素(P＜0.01)。以NYHA心功能评级和临床预后两指标比较看,其拟合优度检验p=0.964,相关模型拟合效果较好,两指标存在相关性(P＜0.01),提示随心功能评级的增加,临床预后亦相应恶化。
结论
1、CHF患者的血钠水平是患者心脏功能(NYHA心功能评级、LAD、LVDD、LVEF)的重要影响因素,血钠水平越低,其心脏功能越差。
2、CHF患者的血钠水平、心脏功能是影响患者临床预后的重要因素,其血钠水平越低,NYHA心脏功能越差,临床预后越差。
Objectives
The aims of this study were to investigate the relationships between hyponatremia and the cardiac function and prognostic status of the patients with chronic heart failure(CHF).
Methods
Eight hundred and six subjects were collected from the patients with CHF who were hospitalized in the second Xiangya hospital of central south university from July 2003 to August 2004.The patients with CHF were divided into 2 groups according to serum sodium levels:normal serum sodium group(Na≥135mmol/L)and lower serum sodium group(Na＜135 mmol/L).The methods of computerized sorting accompanized with a excerpting medical records were used to collect the clinical data.Demographic data and general clinical data including underlying cardiac diseases,concomitant diseases,clinical chemistry, echocardiogram results and residential treatment regimens were all recorded.The correlations of serum sodium levels with NYHA cardiac function class as well as prognostic status in patients with CHF were analyzed by multi-factor logistic statistical method.
Results
1.One hundred and two cases were concomitant with hyponatremia, accounting for 12.66%of study population.
2 The proportion of hypertension and cardiomyopathy in CHF with hyponatremia group was significantly higher than that in CHF with normal serum sodium group(p＜005),While there were no statistical differences between two groups in general information(including age, gender,smoking,drinking,BMI,family history of cardiovascular disease) and the history of coronary heart disease,valvular disease and diabetes mellitus(P＞0.05).
3.Serum chlorine was reduced significantly in hyponatremia group(P＜0.05)and the white blood cell count,the levels of serum urea nitrogen and creatinine increased significantly in the hyponatremia group(P＜0.05).The differences of levels of the serum potassium,uric acid and fasting blood glucose(FBS),hemoglobin(Hb)and platelet(PLT) count were not statistically significant between two groups(P＞0.05).
4.Ultrasonic Cardiography revealed the left atrial diameter(LAD), the left ventricular end-diastolic diameter(LVDD)and the left ventricular ejection fraction(LVEF)differs in two groups(P＜0.05).LAD、LVDD increased remarkably,but LVEF decreased significantly in the patients of CHF concomitant with hyponatremia.The level of serum natrium was positively related to the LAD and LVEFand negatively related to the LVDD,respectively.
5.There was a significant difference in NYHA cardiac function class between two groups(P＜0.05).The correlation of serum sodium levels with the cardiac function class in CHF patients were analyzed by multi-factor logistic statistical method,the serum sodium levels may be the key index in cardiac function class(P＜0.05).
6.The prognosis of the lower serum sodium group was worse than the other group(P＜0.05).The relationships between serum sodium levels and the cardiac function rating in CHF patients were analyzed by multi-factor logistic statistical method,the serum sodium levels may be the key index in the prognosis of CHF(P＜0.05).
7.The correlations among serum sodium levels,the NYHA cardiac function class and prognostic value were analyzed,showing that group and NYHA cardiac function class were important factors of the clinical prognosis of patients(P＜0.01).Considering cardiac function class and prognostic status,the goodness-of-fit test and correlating test of them were good.It is concluded that the prognosis aggravates as the NYHA cardiac function class elevates.
Conclusions
1.Serum sodium levels may be the key index in cardiac function of CHF patients.The lower serum sodium levels were,the worse cardiac function were.
2.Serum sodium levels and cardiac function were important factors of the clinical prognosis of patients.The lower serum sodium levels and the worse cardiac function were,the worse prognosis were.
通过病例回顾的方法研究低钠血症与慢性心力衰竭患者心脏功能和临床预后的关系。
方法
收集2003年7月-2004年8月期间在中南大学湘雅二医院心内科住院诊断为慢性心力衰竭(CHF)的患者806例,根据患者血钠水平分为2组,血钠≥135mmol/L归为正常血钠组,血钠＜135mmol/L归为低血钠组。临床资料收集采用电脑分类查询结合人工病历抄录的方法,记录患者一般临床资料、基础心脏病因、伴随疾病、实验室检查结果、心脏彩超检查结果、住院治疗的转归。用多因素Logistic回归分析血钠水平与CHF患者心功能及临床预后的关系。
结果
1、研究对象中低钠血症为102例,占所有病例的12.66%。
2、低血钠组的高血压病、心肌病所致心力衰竭的比例高于正常血钠组,差异有统计学意义(P＜0.05)。两组间其他人口统计学资料及冠心病、瓣膜病、糖尿病病因学方面的资料均无统计学差异(P＞0.05)。
3、低血钠组中的血氯水平显著降低(P＜0.05),白细胞计数、血尿素氮、肌酐水平显著升高(P＞0.05)。两组间血钾、尿酸、空腹血糖水平、血红蛋白浓度及血小板计数比较差异无统计学意义(P＞0.05)。
4、二维超声心动图(Ultrasonic Cardiography,UCG)测定的两组左房内径、左室舒张末期内径及左室射血分数的差异有统计学意义(P＜0.05),CHF伴发低钠血症的患者左房、左室内径显著增大,射血分数明显减低。患者血钠水平与LVEF正相关,与LAD、LVDD负相关。
5、NYHA心功能评级比较,两组差异有显著性意义(P＜0.05);多分类Logistic回归分析结果显示患者血钠水平是心功能评级的重要影响因素(P＜0.05)。
6、两组患者的临床预后差异有统计学意义(P＜0.05)。多分类Logistic回归分析,结果显示血钠水平是临床预后的重要影响因素(P＜0.05)。
7、患者血钠水平、NYHA心功能评级与临床预后的相关性分析,结果显示组别、NYHA心功能评级都是临床预后的重要影响因素(P＜0.01)。以NYHA心功能评级和临床预后两指标比较看,其拟合优度检验p=0.964,相关模型拟合效果较好,两指标存在相关性(P＜0.01),提示随心功能评级的增加,临床预后亦相应恶化。
结论
1、CHF患者的血钠水平是患者心脏功能(NYHA心功能评级、LAD、LVDD、LVEF)的重要影响因素,血钠水平越低,其心脏功能越差。
2、CHF患者的血钠水平、心脏功能是影响患者临床预后的重要因素,其血钠水平越低,NYHA心脏功能越差,临床预后越差。
Objectives
The aims of this study were to investigate the relationships between hyponatremia and the cardiac function and prognostic status of the patients with chronic heart failure(CHF).
Methods
Eight hundred and six subjects were collected from the patients with CHF who were hospitalized in the second Xiangya hospital of central south university from July 2003 to August 2004.The patients with CHF were divided into 2 groups according to serum sodium levels:normal serum sodium group(Na≥135mmol/L)and lower serum sodium group(Na＜135 mmol/L).The methods of computerized sorting accompanized with a excerpting medical records were used to collect the clinical data.Demographic data and general clinical data including underlying cardiac diseases,concomitant diseases,clinical chemistry, echocardiogram results and residential treatment regimens were all recorded.The correlations of serum sodium levels with NYHA cardiac function class as well as prognostic status in patients with CHF were analyzed by multi-factor logistic statistical method.
Results
1.One hundred and two cases were concomitant with hyponatremia, accounting for 12.66%of study population.
2 The proportion of hypertension and cardiomyopathy in CHF with hyponatremia group was significantly higher than that in CHF with normal serum sodium group(p＜005),While there were no statistical differences between two groups in general information(including age, gender,smoking,drinking,BMI,family history of cardiovascular disease) and the history of coronary heart disease,valvular disease and diabetes mellitus(P＞0.05).
3.Serum chlorine was reduced significantly in hyponatremia group(P＜0.05)and the white blood cell count,the levels of serum urea nitrogen and creatinine increased significantly in the hyponatremia group(P＜0.05).The differences of levels of the serum potassium,uric acid and fasting blood glucose(FBS),hemoglobin(Hb)and platelet(PLT) count were not statistically significant between two groups(P＞0.05).
4.Ultrasonic Cardiography revealed the left atrial diameter(LAD), the left ventricular end-diastolic diameter(LVDD)and the left ventricular ejection fraction(LVEF)differs in two groups(P＜0.05).LAD、LVDD increased remarkably,but LVEF decreased significantly in the patients of CHF concomitant with hyponatremia.The level of serum natrium was positively related to the LAD and LVEFand negatively related to the LVDD,respectively.
5.There was a significant difference in NYHA cardiac function class between two groups(P＜0.05).The correlation of serum sodium levels with the cardiac function class in CHF patients were analyzed by multi-factor logistic statistical method,the serum sodium levels may be the key index in cardiac function class(P＜0.05).
6.The prognosis of the lower serum sodium group was worse than the other group(P＜0.05).The relationships between serum sodium levels and the cardiac function rating in CHF patients were analyzed by multi-factor logistic statistical method,the serum sodium levels may be the key index in the prognosis of CHF(P＜0.05).
7.The correlations among serum sodium levels,the NYHA cardiac function class and prognostic value were analyzed,showing that group and NYHA cardiac function class were important factors of the clinical prognosis of patients(P＜0.01).Considering cardiac function class and prognostic status,the goodness-of-fit test and correlating test of them were good.It is concluded that the prognosis aggravates as the NYHA cardiac function class elevates.
Conclusions
1.Serum sodium levels may be the key index in cardiac function of CHF patients.The lower serum sodium levels were,the worse cardiac function were.
2.Serum sodium levels and cardiac function were important factors of the clinical prognosis of patients.The lower serum sodium levels and the worse cardiac function were,the worse prognosis were.
引文
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19.姚友云,高血合并心衰237例防治体会,实用临床医药杂志,1997,1:335
20.Cohn JN.Overview of the treatment of heart failure.Am J Cardio1,1997,80(11A):2L-6L.
21.董承琅.陈万春,实用心脏病学,第3版,上海;上海科学技术出版社,1994,496-560。
22.Cohn JN,The management of chronic heart failure.N Engl J Med,1996,335:492-498.
23.Weston R.E.,Grossman J.,Borun E.R.,et al.The pathogenesis and treatment of hyponatremia in congestive heart failure.The American Journal of Med.1958,25(4)558-572
24.Bulter August P,Ferdinand KC,et al,Hypertension:Therepeutic approach to weight loss,exercise and salt intake,Geriatrics,99,54:42-54
25.梁桐,胡建群,叶岚,70岁以上老年慢性心衰病人的低血钠症与低盐饮食,河北医药,2001,8期P580
26.SONNENBLICK M,FRIEDLANDER Y,ROSN A J.Diuretic-induced severe hyponatremia:review and analysis of 129 reported patients[J].Chest。1993。103:601-606.
27.Domenic A.Sica,MD.Hyponatremia and Heart Failure-Pathophysiology and Implications,CHF.2005;11:274-277
28.Claudio Panciroll.Prognostic Value of Hyponatremia in Patients with Severe Chronic Heart Failure Angiology,1990;41:631-638
29.卢东军 充血性心力衰竭合并低血钠症58例,现代医院,2006,6:17-19
30.De Luca L.,Klein L.,Udelson J.E.,et al.Hyponatremia in Patients with Heart Failure.Am J Cardiol 2005;96(suppl):19L-23L
31 Mihai Gheorghiade,MD;Joseph S.Rossi,MD;William Cotts,MD.Characterization and Prognostic Value of Persistent Hyponatremia in Patients With Severe Heart Failure in the ESCAPE Trial.Arch Intern Med.2007;167:1998-2005.
32.M.Gheorghiade,W.T.Abraham,N.M.Albert,et al.Relationship between admission serum sodium concentration and clinical outcomes in patients hospitalized for heart failure:an analysis from the OPTIMIZE-HF registry,European Heart Journal 2007;28:98
33.L.Klein,C.M.O'Connor,J.D.Leimberger,et al.Lower Serum Sodium IS Associated With Increased Short-Term Mortality in Hospitalized Patients With Worsening Heart Failure:Results From the Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure (OPTIME-CHF)Study.Circulation,2005;111:2454-2460.
34.Sica DA.Hyponatremia and heart failure-treatment considerations.Congest Heart Fail.2006;12:55-60
35.De Groote P.Hyponatremia,antagonists of the antidiuretic hormone and cardiac failure.Arch Ma Coeur Vaiss.2006;99:215-220
36.宁阳根,欧淑其,欧阳细平等,高渗盐水治疗126例低血钠性顽固性心力衰竭的临床分析,中国现代医学杂志,2004,14:39-41
37.Paterna S.,Parrinello G.,Amato Piera,et al.Effects of high-dose furosemide and small-volume hypertonic saline solition infusion in comparison with a high dose of furoscmide as a bolus,in refractory congestive heart failure.European J Heart Fail.2000.2:305-313
38.Paterna S,Parrinello G,Amato P,et al.Tolerability and efficacy of high dose furosemide and small volume hypertonic saline solution in refractory corgestive heart failure.Adv ther,1999:16:219-228.
39.陈敏章,蒋朱明,主编.临床水与电解质平衡.第2版.北京:人民卫生出版社,2000:17-18
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1.Young J B.Contemporary management of patients with heart failure[J].Med Clin North Am,1995,79:1171-1190.
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3.Upadhyay A.,Jaber B.L.,Madias N.E.,et al.Incidence and Prevalence of Hyponatremia Am J Med.2006,119(7A):S30-S35
4.Oren R.M.Hyponatremia in Congestive Heart Failure.Am J Cardiol 2005;95(suppl):2B-7B
5.Kian Peng Goh.Management of Hyponatremia.Am Fam Physician 2004;69:2387-2394
6.Wong P.S.,Davidsson G.K.,Timeyin J.,et al.Heart Failure in patients admitted to hospital:mortality is sitll high.European J Intern Med.2002;13:304-310
7.Vanrani E,Casella G,Magnani G,et al.The clinical evaluation of the severity of chronic heart falure:a comparison between the NYHA functional class and the Goldman scake[J].Cardiogia,1990,35:651
8.Hunt S A,Bake D W,Chin M H,et al.ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult [J].Circulation,2001,104:2996
9.智光主编:冠心病诊断学,人民卫生出版社,北京,2001:P.83-89
10.张莉萨,李伟霞,Tei指数评价高血压患者心功能的临床研究中国临床医学2005;12:358
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12.Zncker IH,Eavle Am,Gilmord Jp.The mechanism of adaptatian of left artial stretch receptors in dogs with chronic congestine heart failure.J clin Invest 1997,60:323-331.
13.华守明,黄建飞,管耘园,等,心力衰竭患者低血钠症及与神经内分泌激素的关系,临床荟萃 2004,19:733-735
14.Sica DA.Sodium and water retention in heart failure and direutic therapy:basic mechanisms.Cleve Clin J Med.2006;73(Suppl 2):S2-7;discussion S30-35
15.李光明,低血钠症对慢性心力衰竭预后的影响,川北医学院学报,1998,13:45-46
16.Goldsmith S.R.,Current Treatments and Novel Pharmacologic Treatments for Hyponatremia in Congestive Heart Failure.Am J Cardiol 2005;95(suppl):14B-23B
17.朱继金,祝普俊.充血性心力衰竭过程中心钠素与血管紧张素对肾脏的调节作用[A].见:祝普俊,徐成斌.心力衰竭基础与临床[M].北京:人民军医出版社,2001.112-115
18.DARGIE H J.Interrelation of electrolytes and reninangiotensin system in congestive heart failure[J].Am J Cardiol,1990.65:28E一32E.
19.姚友云,高血合并心衰237例防治体会,实用临床医药杂志,1997,1:335
20.Cohn JN.Overview of the treatment of heart failure.Am J Cardio1,1997,80(11A):2L-6L.
21.董承琅.陈万春,实用心脏病学,第3版,上海;上海科学技术出版社,1994,496-560。
22.Cohn JN,The management of chronic heart failure.N Engl J Med,1996,335:492-498.
23.Weston R.E.,Grossman J.,Borun E.R.,et al.The pathogenesis and treatment of hyponatremia in congestive heart failure.The American Journal of Med.1958,25(4)558-572
24.Bulter August P,Ferdinand KC,et al,Hypertension:Therepeutic approach to weight loss,exercise and salt intake,Geriatrics,99,54:42-54
25.梁桐,胡建群,叶岚,70岁以上老年慢性心衰病人的低血钠症与低盐饮食,河北医药,2001,8期P580
26.SONNENBLICK M,FRIEDLANDER Y,ROSN A J.Diuretic-induced severe hyponatremia:review and analysis of 129 reported patients[J].Chest。1993。103:601-606.
27.Domenic A.Sica,MD.Hyponatremia and Heart Failure-Pathophysiology and Implications,CHF.2005;11:274-277
28.Claudio Panciroll.Prognostic Value of Hyponatremia in Patients with Severe Chronic Heart Failure Angiology,1990;41:631-638
29.卢东军 充血性心力衰竭合并低血钠症58例,现代医院,2006,6:17-19
30.De Luca L.,Klein L.,Udelson J.E.,et al.Hyponatremia in Patients with Heart Failure.Am J Cardiol 2005;96(suppl):19L-23L
31 Mihai Gheorghiade,MD;Joseph S.Rossi,MD;William Cotts,MD.Characterization and Prognostic Value of Persistent Hyponatremia in Patients With Severe Heart Failure in the ESCAPE Trial.Arch Intern Med.2007;167:1998-2005.
32.M.Gheorghiade,W.T.Abraham,N.M.Albert,et al.Relationship between admission serum sodium concentration and clinical outcomes in patients hospitalized for heart failure:an analysis from the OPTIMIZE-HF registry,European Heart Journal 2007;28:98
33.L.Klein,C.M.O'Connor,J.D.Leimberger,et al.Lower Serum Sodium IS Associated With Increased Short-Term Mortality in Hospitalized Patients With Worsening Heart Failure:Results From the Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure (OPTIME-CHF)Study.Circulation,2005;111:2454-2460.
34.Sica DA.Hyponatremia and heart failure-treatment considerations.Congest Heart Fail.2006;12:55-60
35.De Groote P.Hyponatremia,antagonists of the antidiuretic hormone and cardiac failure.Arch Ma Coeur Vaiss.2006;99:215-220
36.宁阳根,欧淑其,欧阳细平等,高渗盐水治疗126例低血钠性顽固性心力衰竭的临床分析,中国现代医学杂志,2004,14:39-41
37.Paterna S.,Parrinello G.,Amato Piera,et al.Effects of high-dose furosemide and small-volume hypertonic saline solition infusion in comparison with a high dose of furoscmide as a bolus,in refractory congestive heart failure.European J Heart Fail.2000.2:305-313
38.Paterna S,Parrinello G,Amato P,et al.Tolerability and efficacy of high dose furosemide and small volume hypertonic saline solution in refractory corgestive heart failure.Adv ther,1999:16:219-228.
39.陈敏章,蒋朱明,主编.临床水与电解质平衡.第2版.北京:人民卫生出版社,2000:17-18
40.Goh K P.Management of hyponatremia[J].Am Fam Physician,2004;69:2387