老年扩张型心肌病并发恶性心律失常的危险因素与远期预后分析

刘磊; 罗贵全; 刘溢均; 李小平; 任宏强

doi:10.16766/j.cnki.issn.1674-4152.003024

老年扩张型心肌病并发恶性心律失常的危险因素与远期预后分析

doi: 10.16766/j.cnki.issn.1674-4152.003024

1.
遂宁市中心医院心血管中心，四川遂宁 629000
2.
四川省医学科学院·四川省人民医院，四川成都 621000

基金项目:

四川省科技厅重点研发项目 2019YFS0345

详细信息

通讯作者:
任宏强，Email：rhq1980@163.com

中图分类号: R542.2 R541.7
计量
- 文章访问数: 117
- HTML全文浏览量: 24
- PDF下载量: 7
- 被引次数: 0
出版历程
- 收稿日期: 2023-01-03
- 网络出版日期: 2023-08-26

Risk factors and long-term prognosis of malignant arrhythmia in elderly patients with dilated cardiomyopathy

1.
Department of Cardiology, Suining Central Hospital, Suining, Sichuan 629000, China

摘要

摘要: 目的筛查老年扩张型心肌病并发恶性心律失常(MA)的危险因素与影响该类患者临床预后的相关因素。方法选取2017年1月—2021年4月199例在遂宁市中心医院心血管中心住院的大于60岁的扩张型心肌病患者，根据资料是否并发恶性心律失常将其分为MA组(54例)与non-MA组(145例)。回顾性分析发生恶性心律失常的危险因素。并且对MA组进行随访，根据是否出现复合终点事件分为事件组与非事件组，并进行生存分析明确影响预后的因素。结果对MA组与non-MA组进行多因素logistic回归分析结果显示：慢性肾脏病、纽约心脏协会(NYHA)心功能分级Ⅲ~Ⅳ级、左室射血分数(LVEF)＜35%、频发室性早搏是老年扩张型心肌病患者并发恶性心律失常的独立危险因素；对事件组与非事件组进行Kaplan-Meier生存分析显示：并发恶性心律失常的老年扩张型心肌病患者中，合并慢性肾脏病、慢性阻塞性肺疾病、频发室性早搏的患者心脏死亡风险更高。将Kaplan-Meier生存分析有意义的自变量纳入多因素Cox回归模型校正，结果显示合并慢性阻塞性肺疾病、频发室早是并发恶性心律失常的老年扩张型心肌病患者心脏死亡的独立危险因素(HR=7.593，95% CI：2.018~28.576，P=0.003；HR=4.090，95% CI：1.042~16.057，P=0.043)。结论慢性肾脏病、NYHA分级Ⅲ~Ⅳ级、LVEF＜35%、频发室性早搏是老年扩张型心肌病患者恶性心律失常发生的潜在危险因素；事件组中，慢性阻塞性肺疾病、频发室早是影响预后的独立危险因素，能够较好地预测心源性死亡。
- 扩张型心肌病 /
- 心律失常 /
- 危险因素 /
- 预后
Abstract: Objective To investigate the risk factors and long-term prognosis of malignant arrhythmia (MA) in elderly patients with dilated cardiomyopathy. Methods A total of 199 patients with dilated cardiomyopathy over 60 years old who were hospitalized in the Cardiovascular Center of Suining Central Hospital were selected from January 2017 to April 2021. They were divided into MA group (54 cases) and non-MA group (145 cases) according to whether they were complicated with malignant arrhythmia. The risk factors of malignant arrhythmia were analyzed retrospectively. The MA group was followed up and divided into event group and non-event group according to the presence or absence of a composite endpoint event. The survival analysis was performed to clarify the factors affecting prognosis. Results Multifactorial logistic regression analysis of MA group and non-MA group showed that chronic kidney disease, NYHA class Ⅲ-Ⅳ, left ventricular ejection fration (LVEF) < 35%, and frequent premature ventricular beats were independent risk factors for complications of malignant arrhythmias in elderly patients with dilated cardiomyopathy. Kaplan-meier survival analysis of event group and non-event group showed that among elderly patients with dilated cardiomyopathy complicated by malignant arrhythmias, patients with comorbid chronic kidney disease, chronic obstructive pulmonary disease, and frequent premature ventricular beats were at higher risk of cardiac death. The independent variables that were significant for Kaplan-meier survival analysis were included in a multifactorial cox regression model correction, which showed that comorbid chronic obstructive pulmonary disease, frequent premature ventricular beats was an independent risk factor for cardiac death in elderly patients with dilated cardiomyopathy complicated by malignant arrhythmias (HR=7.593, 95% CI: 2.018-28.576, P=0.003; HR=4.090, 95% CI: 1.042-16.057, P=0.043). Conclusion Chronic kidney disease, NYHA class Ⅲ~Ⅳ, LVEF < 35%, and frequent premature ventricular beats are potential risk factors for the development of malignant arrhythmias in elderly patients with dilated cardiomyopathy. For event group, chronic obstructive pulmonary disease, and frequent premature ventricular beats are independent risk factors for prognosis and could better predict cardiac death.
- Dilated cardiomyopathy /
- Arrhythmia /
- Risk factors /
- Prognosis

HTML全文

图 1 慢性肾脏病Kaplan-Meier生存分析

Figure 1. Kaplan-Meier survival analysis of chronic kidney disease

下载: 全尺寸图片幻灯片

图 2 慢性阻塞性肺疾病Kaplan-Meier生存分析

Figure 2. Kaplan-Meier survival analysis of chronic obstructive pulmonary disease

下载: 全尺寸图片幻灯片

图 3 频发室性早搏Kaplan-Meier生存分析

Figure 3. Kaplan-Meier survival analysis of frequent premature ventricular beats

下载: 全尺寸图片幻灯片

表 1 MA组与non-MA组基线资料比较

Table 1. Comparison of baseline data between MA group and non-MA group

项目	Non-MA (n=145)	MA (n=54)	统计量	P值
年龄(x±s，岁)	71.23±8.07	71.11±7.75	0.092^a	0.927
性别[例(%)]
男性	106(73.1)	39(72.2)	0.015^b	0.901
女性	39(26.9)	15(27.8)
慢性肾脏病[例(%)]	14(9.7)	18(33.3)	16.347^b	＜0.001
慢性阻塞性肺疾病[例(%)]	14(9.7)	12(22.2)	5.471^b	0.019
糖尿病[例(%)]	21(14.5)	5(9.3)	0.945^b	0.331
频发室早[例(%)]	17(11.7)	20(37.0)	16.656^b	＜0.001
β受体阻滞剂[例(%)]	135(93.1)	52(96.3)	0.257^b	0.613
螺内酯[例(%)]	136(93.8)	49(90.7)	0.191^b	0.662
ACEI/ARB[例(%)]	114(78.6)	31(57.4)	8.955^b	0.003
ARNI[例(%)]	53(36.8)	15(27.8)	1.419^b	0.233
SGLT2i[例(%)]	39(26.9)	16(29.6)	0.147^b	0.701
高同型半胱氨酸血症[例(%)]	66(45.5)	34(63.0)	4.790^b	0.029
低蛋白血症[例(%)]	33(22.8)	17(31.5)	1.591^b	0.207
高甘油三酯[例(%)]	60(41.4)	26(48.1)	0.735^b	0.391
LAEDD(x±s，mm)	43.82±3.84	46.51±3.98	-4.354^a	＜0.001
LVEDD(x±s，mm)	59.46±5.54	63.28±6.28	-4.161^a	＜0.001
LVEF＜35%[例(%)]	17(11.7)	26(48.1)	30.817^b	＜0.001
中重度二尖瓣反流[例(%)]	59(40.7)	39(72.2)	15.653^b	＜0.001
附壁血栓[例(%)]	17(11.7)	13(24.1)	4.687^b	0.030
LBBB[例(%)]	14(9.7)	8(14.8)	1.065^b	0.302
RBBB[例(%)]	16(11.0)	7(13.0)	0.143^b	0.705
Tp-Te间期(x±s，ms)	98.86±16.88	106.50±16.86	-2.839^a	0.005
fQRS[例(%)]	11(7.6)	10(18.5)	4.982^b	0.026
NYHA分级Ⅲ~Ⅳ级[例(%)]	84(57.9)	45(83.3)	11.135^b	0.001
注：^a为t值，^b为χ²值。

下载: 导出CSV

表 2 不同危险因素预测恶性心律失常患病风险二元logistic回归分析

Table 2. Binary logistic regression analysis of different risk factors predicting the risk of malignant arrhythmia

变量	B	SE	Waldχ²	P值	OR (95% CI)
慢性肾脏病	1.248	0.482	6.702	0.010	3.483(1.354~8.957)
NYHA Ⅲ~Ⅳ级	1.062	0.490	4.691	0.030	2.893(1.106~7.564)
LVEF＜35%	1.127	0.458	6.062	0.014	3.087(1.258~7.573)
频发室早	1.194	0.464	6.624	0.010	3.299(1.329~8.188)

下载: 导出CSV

表 3 影响心脏死亡的多因素Cox回归分析

Table 3. Multivariate Cox regression analysis of cardiac death

变量	β	SE	Waldχ²	P值	HR(95% CI)
慢性阻塞性肺疾病	2.027	0.676	8.988	0.003	7.593(2.018~28.576)
频发室早	1.409	0.698	4.076	0.043	4.090(1.042~16.057)

下载: 导出CSV

参考文献(23)

[1]	中华医学会心血管病学分会, 中国心肌炎心肌病协作组. 中国扩张型心肌病诊断和治疗指南[J]. 临床心血管病杂志, 2018, 34(5): 421-434. doi: 10.13201/j.issn.1001-1439.2018.05.002 Chinese Association of Cardiology Branch, Chinese myocarditis Cardiomyopathy Collaboration Group. Guidelines for diagnosis and treatment of dilated cardiomyopathy in China[J]. Journal of Clinical Cardiology, 2018, 34(5): 421-434. doi: 10.13201/j.issn.1001-1439.2018.05.002
[2]	LIU X, YU H, PEI J, et al. Clinical characteristics and long-term prognosis in patients with chronic heart failure and reduced ejection fraction in China[J]. Heart Lung Circ, 2014, 23(9): 818-826. doi: 10.1016/j.hlc.2014.02.022
[3]	ZEPPENFELD K, WIJNMAALEN A P, EBERT M, et al. Clinical outcomes in patients with dilated cardiomyopathy and ventricular tachycardia[J]. J Am Coll Cardiol, 2022, 80(11): 1045-1056. doi: 10.1016/j.jacc.2022.06.035
[4]	SHIMOKAWA H. Trends in clinical characteristics, Treatments and prognosis in patients with dilated cardiomyopathy in japan-epidemiologic insights from the CHART Studies[J]. J Card Fail, 2016, 22(9): S154-S154.
[5]	ANGELIS G D, MERLO M, BARBATI G, et al. Longitudinal arrhythmic risk assessment based on ejection fraction in patients with recent-onset non-ischaemic dilated cardiomyopathy[J]. J Am Soc Echocardiogr, 2021, 35(8): 801-809.
[6]	YANCY C W, JESSUP M, BOZKURT B, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the american college of cardiology/american heart association task force on clinical practice guidelines and the Heart Failure Society of America[J]. J Card Fail, 2017, 23(8): 628-651. doi: 10.1016/j.cardfail.2017.04.014
[7]	PONIKOWSKI P, VOORS A A, ANKER S D, et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure[J]. Kardiol Pol, 2016, 74(10): 1037-1147. doi: 10.5603/KP.2016.0141
[8]	DI MARCO A, ANGUERA I, SCHMITT M, et al. Late gadolinium enhancement and the risk for ventricular arrhythmias or sudden death in dilated cardiomyopathy: systematic review and meta-analysis[J]. ACC Heart Fail, 2017, 5(1): 28-38. doi: 10.1016/j.jchf.2016.09.017
[9]	MARCO A D, BROWN P, BRADLEY J, et al. Improved risk stratification for ventricular arrhythmias and sudden death in patients with nonischemic dilated cardiomyopathy[J]. J Am Coll Cardiol, 2021, 77(23): 2890-2905. doi: 10.1016/j.jacc.2021.04.030
[10]	KHAN M Z, MUNIR M B, KHAN M U, et al. Sudden cardiac arrest in patients with chronic obstructive pulmonary disease: trends and outcomes from the national inpatient sample[J]. Am J Med Sci, 2022, 363(6): 502-510. doi: 10.1016/j.amjms.2021.10.025
[11]	BRUSSELLE, GUY G, VERHAMME, et al. Cardiac effects of current treatments of chronic obstructive pulmonary disease[J]. Lancet Respir Med, 2016, 4(2): 149-164. doi: 10.1016/S2213-2600(15)00518-4
[12]	RUSNAK J, BEHNES M, SCHUPP T, et al. COPD increases cardiac mortality in patients presenting with ventricular tachyarrhythmias and aborted cardiac arrest[J]. Respir Med, 2018, 145: 153-160. doi: 10.1016/j.rmed.2018.10.019
[13]	WANG M T, LAI J H, TSAI C L, et al. Risk of adverse cardiovascular events with use of inhaled long-acting bronchodilators in management of chronic obstructive pulmonary disease[J]. J Food Drug Anal, 2019, 27(3): 657-670. doi: 10.1016/j.jfda.2018.12.006
[14]	ZHANG Q X, ZHANG H F, WANG J J, et al. Indacaterol/glycopyrronium affects lung function and cardiovascular events in patients with chronic obstructive pulmonary diseases: a meta-analysis[J]. Heart Lung, 2021, 50(4): 532-541. doi: 10.1016/j.hrtlng.2021.02.018
[15]	LIU S H, LO L W, CHOU Y H, et al. Renal denervation prevents myocardial structural remodeling and arrhythmogenicity in a chronic kidney disease rabbit model[J]. Heart Rhythm, 2021, 18(9): 1596-1604. doi: 10.1016/j.hrthm.2021.05.014
[16]	SAMANTA R, CHAN C, CHAUHAN V. Arrhythmias and sudden cardiac death in end stage renal disease: epidemiology, risk factors, and management[J]. Can J Cardiol, 2019, 35(9): 1228-1240. doi: 10.1016/j.cjca.2019.05.005
[17]	TALHA K M, JAIN V, YAMANI N, et al. Temporal trends and outcomes of implantable cardioverter defibrillators in heart failure and chronic kidney disease in the United States[J]. Curr Probl Cardiol, 2023, 45(4): 101548. DOI: 10.1016/j.cpcardiol.2022.101548.
[18]	余福海, 沈才杰, 陆曹杰, 等. 慢性肾脏病患者心率变异性相关影响因素及预防对策[J]. 中华全科医学, 2021, 19(5): 798-800, 855. doi: 10.16766/j.cnki.issn.1674-4152.001920 YU F H, SHEN C J, LU C J, et al. Related influencing factors and preventive measures of heart rate variability in patients uffer from chronic kidney disease[J]. Chinese Journal of General Practice, 2021, 19(5): 798-800, 855. doi: 10.16766/j.cnki.issn.1674-4152.001920
[19]	MOK Y, BALLEW S H, MATSUSHITA K. Chronic kidney disease measures for cardiovascular risk prediction[J]. Atherosclerosis, 2021, 335: 110-118. doi: 10.1016/j.atherosclerosis.2021.09.007
[20]	PUN P H, SMARZ T R, HONEYCUTT E F, et al. Chronic kidney disease is associated with increased risk of sudden cardiac death among patients with coronary artery disease[J]. Kidney Int, 2009, 76(6): 652-658. doi: 10.1038/ki.2009.219
[21]	AL-KHATIB S M, STEVENSON W G, ACKERMAN M J, et al. 2017 AHA/ACC/HRS guideline for management of patients With ventricular arrhythmias and the prevention of sudden cardiac death: executive summary[J]. Heart Rhythm, 2017, 15(10): e190-e252.
[22]	LEE V, HEMINGWAY H, HARB R, et al. The prognostic significance of premature ventricular complexes in adults without clinically apparent heart disease: a meta-analysis and systematic review[J]. Heart, 2012, 98(17): 1290-1298. doi: 10.1136/heartjnl-2012-302005
[23]	VOSKOBOINIK A, HADJIS A, ALHEDE C, et al. Predictors of adverse outcome in patients with frequent premature ventricular complexes: the ABC-VT risk score[J]. Heart Rhythm, 2020, 17(7): 1066-1074. doi: 10.1016/j.hrthm.2020.02.020