Prevalence and related factors of arrhythmia in patients with left heart disease-related pulmonary hypertension
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摘要: 目的 分析左心疾病相关肺动脉高压(PH-LHD)患者不同类型心律失常的患病率及相关因素。方法 连续收集2021年1月—2021年2月于我院住院的PH-LHD患者共500例，根据常规心电图或24 h动态心电图记录心律失常发生情况；将所有患者的一般临床资料、心脏超声参数作为自变量，有无合并心房颤动(房颤)/室性心动过速(室速)/窦房结功能障碍或房室传导阻滞(缓慢型心律失常)作为因变量，运用单因素logistic回归分别分析PH-LHD合并不同类型心律失常的相关因素，进一步将单因素分析中有意义的变量作为自变量进行多因素logistic回归分析。结果 500例PH-LHD患者中，45%合并高血压，其他依次为冠心病(38.4%)、心脏瓣膜病(19.6%)、扩张型心肌病(15.2%)。任何心律失常、室上性心动过速、窦性心动过速、房性心动过速、房颤、心房扑动、房室折返性心动过速、房室结折返性心动过速、室速、窦房结功能障碍、房室传导阻滞的发病率分别为77.4%、66.6%、22.6%、17.8%、35%、5.6%、1%、0.6%、18.4%、11.2%、16%，合并房颤患者中80%为持续性；多因素logistic回归分析结果显示，女性(OR=1.739，P=0.037)、年龄增大(OR=1.065，P=0.001)、左房内径增大(OR=1.084，P=0.001)、右房内径增大(OR=1.092，P=0.001)与PH-LHD患者合并房颤独立相关；肺动脉收缩压(PASP)升高(OR=1.020，P=0.035)、合并冠心病(OR=1.898，P=0.013)与PH-LHD患者合并室速独立相关；男性(OR=1.617，P=0.041)、年龄增大(OR=1.027，P=0.001)、右房内径增大(OR=1.032，P=0.005)与PH-LHD患者合并缓慢型心律失常独立相关。结论 3/4以上的PH-LHD患者合并心律失常，以室上性心动过速多见，亚型中以持续性房颤最常见；PASP及右房结构改变与PH-LHD发生心律失常的相关性较左心系统更显著，其中PASP升高与PH-LHD发生室速独立相关，右房内径增大与PH-LHD患者发生房颤、缓慢型心律失常均独立相关。Abstract: Objective To analyze the prevalence and related factors of different types of arrhythmia in patients with left heart disease-related pulmonary hypertension(PH-LHD).Methods A total of 500 patients with PH-LHD who were hospitalized in our hospital from January 2021 to February 2021 were continuously collected, and the occurrence of arrhythmia was recorded according to regular ECG or 24 h Holter. The general clinical data and cardiac ultrasound parameters of all patients were taken as independent variables, and whether there were or without atrial fibrillation(AF)/ ventricular tachycardia(VT)/ sinoatrial node dysfunction or atrioventricular block(bradyarrhythmia) as the dependent variables, and the related factors of PH-LHD combined with different types of arrhythmias were analyzed separately using univariate logistic regression, and the meaningful variables in the univariate analysis were further analyzed as independent variables for multivariate logistic regression.Results Among the 500 patients with PH-LHD, 45% had hypertension, followed by coronary heart disease(38.4%), valvular heart disease(19.6%), and dilated cardiomyopathy(15.2%). The incidence of any arrhythmia, supraventricular tachycardia, sinus tachycardia, atrial tachycardia, atrial fibrillation, atrial flutter, atrioventricular reentrant tachycardia, atrioventricular node reentrant tachycardia, ventricular tachycardia, sinus node dysfunction, and atrioventricular block was 77.4%, 66.6%, 22.6%, 17.8%, 35%, 5.6%, 1%, 0.6%, 18.4%, 11.2%, and 16%, respectively, and 80% of patients with AF were persistent; The results of multivariate logistic regression analysis showed that female(OR=1.739, P=0.037), age increase(OR=1.065, P=0.001), left atrial diameter increase(OR=1.084, P=0.001), and right atrial diameter increase(OR=1.092, P=0.001) were independently associated with AF in patients with PH-LHD. Elevated pulmonary artery systolic blood pressure(PASP)(OR=1.020, P=0.035), and coronary heart disease(OR=1.898, P=0.013) were independently associated with VT in patients with PH-LHD. Males(OR=1.617, P=0.041), increased age(OR=1.027, P=0.001), and increased right atrial diameter(OR=1.032, P=0.005) were independently associated with bradyarrhythmia in patients with PH-LHD.Conclusion More than 3/4 of patients with PH-LHD have arrhythmia, where supraventricular tachycardia is more common, and persistent AF is the most common in subtypes; The correlation between PASP and right atrial structural changes and arrhythmias in PH-LHD is more significant than that in the left heart system, where elevated PASP is independently associated with the VT of PH-LHD, and enlarged right atrial diameter is independently associated with AF and bradyarrhythmia in patients with PH-LHD.
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Key words:
- pulmonary hypertension /
- left heart disease /
- arrhythmia /
- prevalence /
- related factors
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表 1 500例PH-LHD患者的基线资料
Table 1. Baseline data of 500 PH-LHD patients
例(%) 项目 数值 年龄≥65岁 225(45.0) 男性 287(57.4) PASP 30 mmHg＜PASP≤50 mmHg 364(72.8) 50 mmHg＜PASP≤70 mmHg 104(20.8) >70 mmHg 32(6.4) 心力衰竭分型 HFrEF 116(23.2) HFmEF 85(17.0) HFpEF 299(59.8) 心功能Ⅲ~Ⅳ级 318(63.6) 合并疾病 高血压 225(45.0) 冠心病 192(38.4) 心脏瓣膜病 98(19.6) 扩张型心肌病 76(15.2) 有心脏起搏器 17(3.4) 药物应用 β受体阻滞剂 294(58.8) ACEI/ARB/ARNI 302(60.4) MRA 281(56.2) SGLT2i 52(10.4) 地高辛 81(16.2) 伊伐布雷定 28(5.6) 内皮素受体拮抗剂 21(4.2) 磷酸二酯酶-5抑制剂 24(4.8) 前列环素类似物 8(1.6) 注：心脏瓣膜病：二尖瓣或主动脉瓣膜疾病；ACEI/ARB/ARNI：血管紧张素转换酶抑制剂/血管紧张素受体拮抗剂/血管紧张素受体脑啡肽酶抑制剂；MRA：醛固酮受体拮抗剂；SGLT2i：钠-葡萄糖共转运蛋白2抑制剂。 
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表 2 500例PH-LHD患者的心律失常谱
Table 2. Arrhythmia spectrum of 500 PH-LHD patients
例(%) 分类 轻度(364例) 中度(104例) 重度(32例) 总计(500例) 任何心律失常 283(77.7) 85(81.7) 19(59.4) 387(77.4) 室上性心动过速 237(65.1) 75(72.1) 21(65.6) 333(66.6) 窦性心动过速 71(19.5) 35(33.7) 7(21.9) 113(22.6) 房性心动过速 60(16.5) 22(21.2) 7(21.9) 89(17.8) 房颤 134(36.8) 33(31.7) 8(25.0) 175(35.0) 持续性房颤 111(30.5) 26(25) 3(9.4) 140(28.0) 心房扑动 17(4.8) 7(6.7) 4(12.5) 28(5.6) 持续性心房扑动 9(2.5) 5(4.8) 4(12.5) 17(3.4) 房室结折返性心动过速 3(0.8) 0 0 3(0.6) 房室折返性心动过速 3(0.8) 2(1.9) 0 5(1.0) 室速 57(15.7) 22(21.2) 13(40.6) 92(18.4) 心室颤动 0 1(1.0) 3(9.4) 4(0.8) 窦房结功能障碍 41(11.3) 9(8.7) 6(18.8) 56(11.2) 窦性停搏 1(0.3) 0 1(3.1) 2(0.8) 房室传导阻滞 59(16.2) 16(15.4) 5(15.6) 80(16.0) 一度房室传导阻滞 45(12.4) 13(12.5) 4(12.5) 72(14.4) 二度房室传导阻滞 6(1.6) 1(1.0) 0 7(1.4) 三度房室传导阻滞 0 1(1.0) 0 1(0.2)
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表 3 PH-LHD患者不同类型心律失常的临床资料
Table 3. Clinical data of PH-LHD patients with different types of arrhythmia
X±S, M(P25, P75) 项目 房颤(175例) 室性心动过速(92例) 缓慢型心律失常(134例) 男性/例(%) 86(49.14)2) 61(66.30) 89(66.42)1) 年龄 65.56±12.451) 61.98±14.86 63.0±14.871) 糖尿病/例(%) 40(22.86) 22(23.91) 34(25.37) 高血压/例(%) 69(39.43) 39(42.39) 64(47.76) 冠心病/例(%) 73(41.71)1) 46(50.0)1) 59(44.03) 心脏瓣膜病/例(%) 54(30.86)1) 16(17.39) 23(17.16) NLR 3.68(1.99，7.29) 3.11(1.91，5.42) 3.51(1.87，6.04) PLR 150.25(100.59，230.95) 128.13(84.19，204.52) 144.64(107.60，225.72) RDW/% 14.39±1.98 14.51±1.99 14.66±1.84 D-二聚体/(mg·L-1) 0.36(0.19，0.98) 0.36(0.19，0.88) 0.36(0.19，0.70) 尿酸/(μmol·L-1) 380.07±179.46 409.70±158.361) 387.96±166.74 GFR/(mL·min-1) 76.42(58.72，91.97) 70.25(53.26，84.65) 71.34(45.09，89.57) LVEF/% 57(45，62) 40.0(29.75，57.25)2) 49.50(37.0，61.0)2) PASP/mmHg 42.0(38.0，48.0) 45.5(38，59.5)1) 43.0(38.25，51.0) LVEDV/mL 118.0(93.0，175.0) 192.0(125.50，252.25)1) 154.50(103.50，222.75)1) LVESV/mL 50.0(37.0，93.0) 118.0(57.0，175.0)1) 82.00(40.25，130.75) LVDd/mm 52.41±10.98 60.92±12.781) 56.67±11.731) LAD/mm 48.95±10.311) 47.38±12.361) 47.43±12.091) RVD/mm 18.67±4.63 18.27±3.70 19.11±5.331) RAD/mm 60.50±12.721) 54.92±8.70 57.91±15.031) 注：1)P < 0.05，OR>1；2)P < 0.05，OR < 1。
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表 4 PH-LHD患者不同类型心律失常的多因素logistic回归分析
Table 4. Multivariate analysis in PH-LHD patients with different types of arrhythmia
自变量 SE Wald OR 95%CI P值 房颤 女性 0.553 4.331 1.739 1.033~2.928 0.037 年龄 0.063 36.619 1.065 1.043~1.087 0.001 LAD 0.081 14.847 1.084 1.040~1.127 0.001 RAD 0.088 28.543 1.092 1.057~1.127 0.001 室速 PASP 0.020 4.448 1.020 1.001~1.040 0.035 冠心病 0.641 6.124 1.898 1.143~3.154 0.013 缓慢型心律失常 男性 0.481 4.196 1.617 1.021~2.561 0.041 年龄 0.027 11.779 1.027 1.011~1.043 0.001 RAD 0.032 7.842 1.032 1.010~1.055 0.005
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