Echocardiographic features of heart failure with preserver ejection fraction with atrial fibrillation
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摘要: 目的 研究射血分数保留心力衰竭(HFpEF)合并心房颤动(AF)患者肺动脉压及右心结构功能改变的特点。方法 HFpEF患者共349例，其中221例无AF病史且心脏彩超检查时无AF发作(HFpEF+N-AF组)、45例有AF病史但检查时无AF发作(HFpEF+E-AF组)、83例有AF病史且检查时有AF发作(HFpEF+C-AF组)。观察3组肺动脉压及右心结构改变的特点，另以同期102例健康人群为参考，得出3组右心结构指标的异常率。结果 HFpEF+C-AF组的RV-D1、RV-D2、RVOT2、RA-D1、RA-D2、RAA、LAD、LADi、LAV、LAVi大于HFpEF+E-AF组和HFpEF+N-AF组(P < 0.05)；与HFpEF+N-AF组比较，HFpEF+C-AF组FS、EF、DT、IVRT、E/E′L、E/E′s、E/E′、FPV减低，E、E′L、E′s增加(P < 0.01)；与HFpEF+E-AF组比较，HFpEF+C-AF组FS减低，E、E′L、E′s、FPV增加(P < 0.01)。多元逐步回归分析显示，3组RV-D2、RV-D3与LVEDVi独立相关，HFpEF+C-AF组和HFpEF+N-AF组RV-D1、RV-D2、RA-D2与LAVi独立相关，HFpEF+N-AF组RV-D1、RV-D2、RA-D1、RA-D2、RAA与PASP独立相关。结论 在HFpEF患者中，AF患者右心结构异常更显著，并且这种异常以右心房为主。AF患者存在明显的右心结构改变，但其舒张功能减退并不明显。相关性分析显示AF与右心结构改变之间的关系与肺动脉压无关，可能与HFpEF进展的原因、AF的减压机制有关。
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关键词:
- 射血分数保留心力衰竭 /
- 心房颤动 /
- 肺动脉压 /
- 超声心动图
Abstract: Objective To investigate the changes of pulmonary artery pressure and right heart structure and function in patients with HFpEF with atrial fibrillation(AF).Methods A total of 349 HFpEF patients were enrolled, including 221 patients who had no history of AF and had no AF at the time of echocardiography(HFpEF+N-AF group), 45 patients who had a history of AF but had no AF at the time of echocardiography(HFpEF+E-AF group), and 83 patients who had a history of AF and had AF at the time of echocardiography(HFpEF+C-AF group). The characteristics of pulmonary artery pressure and right heart structure of the three groups were observed, separately. In addition, taking 102 healthy people as references, the abnormal rates of right heart structure index of the three groups were obtained, separately.Results RV-D1, RV-D2, RVOT2, RA-D1, RA-D2, RAA, LAD, LADi, LAV, and LAVi of HFpEF+C-AF group were higher than those of HFpEF+E-AF group and HFpEF+N-AF group(P < 0.05). Compared with HFpEF+N-AF group, FS, EF, DT, IVRT, E/E′L, E/E′s, E/E′, and FPV in HFpEF+C-AF group were decreased, while E, E′L and E′s were increased(P < 0.01); Compared with HFpEF+E-AF group, FS in HFpEF+C-AF group were decreased, while E, E′L, E′s, FPV were increased(P < 0.01). Multiple stepwise regression analysis showed that RV-D2 and RV-D3 were independently correlated with LVEDVi in the three groups; in HFpEF+C-AF group and HFpEF+N-AF group, RV-D1, RV-D2, and RA-D2 were independently correlated with LAVi; in HFpEF+N-AF group, RV-D1, RV-D2, RA-D1, RA-D2, and RAA were independently correlated with PASP.Conclusion Among patients with HFpEF, the abnormality of right heart structural in AF patients is more significant, and this abnormality is mainly in the right atrium. The right heart structural changes in patients with AF is significant, while the diastolic function was not significantly decreased. Correlation analysis showed that the relationship between AF and right heart structural changes was not related to pulmonary artery pressure. It might be related to the cause of the progression of HFpEF and the decompression mechanism of AF. -
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表 1 各组一般资料
Table 1. General data
例(%), X±S, M(P25, P75) 项目 HFpEF+C-AF组(83例) HFpEF+E-AF组(45例) HFpEF+N-AF组(221例) P值 男性 42(50.6) 26(57.8) 110(49.8) 0.617 年龄/岁 75±8 78±7 77±9 0.078 体重指数/(kg/m2) 25.25±4.482) 23.15±3.00 24.34±3.62 0.011 体表面积/m2 1.85±0.211)2) 1.77±0.17 1.78±0.17 0.005 收缩压/mmHg 132±191)2) 139±18 145±22 < 0.001 舒张压/mmHg 79±131) 76±16 75±11 0.010 心率/(次/min) 85±231) 79±17 74±14 < 0.001 高血压 56(67.5) 30(66.7) 164(74.2) 0.372 冠心病 12(14.5)2) 16(35.6)1) 41(18.6) 0.013 糖尿病 17(20.5)1) 12(26.7) 79(35.7) 0.030 COPD 7(8.4) 5(11.1) 22(10.0) 0.874 NYHAⅢ~Ⅳ级 68(81.9) 36(80.0) 159(71.9) 0.147 NT-proBNP/(pg/mL) 1411(807，2 292)1)2) 746(404，1 393) 633(343，1 309) < 0.001 注：NYHA：纽约心脏协会心功能分级；COPD：慢性阻塞性肺疾病。与HFpEF+N-AF组比较，1)P < 0.05，与HFpEF+E-AF组比较，2)P < 0.05。 
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表 2 各组右心结构比较
Table 2. Comparison of right heart structure in each group
X±S 参数 HFpEF+C-AF组(83例) HFpEF+E-AF组(45例) HFpEF+N-AF组(221例) P值 PASP/mmHg 42.9±11.2 44.6±14.4 41.2±14.2 0.317 RV-FWd/mm 4.5±0.8 4.3±0.6 4.4±0.7 0.270 RV-FWs/mm 6.5±1.1 6.3±1.1 6.3±1.1 0.397 RV-D1/mm 37.7±6.41)2) 33.8±4.9 33.4±5.3 < 0.001 RV-D2/mm 31.5±6.71)2) 28.5±6.4 28.4±5.0 < 0.001 RV-D3/mm 58.5±9.1 58.4±8.5 59.2±6.7 0.729 RVOT1/mm 21.5±4.6 27.0±4.5 26.3±3.9 0.072 RVOT2/mm 28.0±4.11)2) 26.2±3.4 26.6±3.6 0.008 RAD1/mm 46.6±9.11)2) 40.1±6.5 37.9±6.3 < 0.001 RAD2/mm 63.1±8.41)2) 54.2±8.21) 51.0±6.8 < 0.001 RAA/cm2 27.2±9.51)2) 19.8±5.4 18.1±6.3 < 0.001 与HFpEF+N-AF组比较，1)P < 0.05；与HFpEF+E-AF组比较，2)P < 0.05。
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表 3 肺动脉高压及右心结构异常率
Table 3. Rates of pulmonary hypertension and structural abnormalities of the right heart
例(%) 参数 HFpEF+C-AF组(83例) HFpEF+E-AF组(45例) HFpEF+N-AF组(221例) P值 参考范围M(P5，P95) PASP 22(26.5) 15(33.3) 52(23.5) 0.377 34.0(26.4，48.6) RV-FWd 0 0 2(0.9) 0.558 4.0(3.0，6.7) RV-FWs 4(4.8) 1(2.2) 7(3.2) 0.696 5.8(4.7，8.7) RV-D1 23(27.7)1)2) 5(11.1) 21(9.5) < 0.001 31.4(25.2，40.3) RV-D2 23(27.7)1)2) 5(11.1) 22(10.0) < 0.001 25.7(21.0，34.4) RV-D3 16(19.3) 9(20.0) 38(17.2) 0.857 53.4(44.2，65.4) RVOT1 12(14.5) 3(6.7) 16(7.2) 0.123 24.2(19.0，32.1) RVOT2 17(20.5)1) 12(26.7)1) 24(10.9) 0.008 24.4(18.7，31.3) RA-D1 53(63.9)1)2) 15(33.3) 46(20.8) < 0.001 34.7(27.8，42.7) RA-D2 71(85.5)1)2) 20(44.4)1) 58(26.2) < 0.001 45.6(35.5，54.8) RAA 72(86.7)1)2) 19(42.2)1) 58(26.2) < 0.001 14.2(11.0，20.2) 与HFpEF+N-AF组比较，1)P < 0.05；与HFpEF+E-AF组比较，2)P < 0.05。
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表 4 各组左心结构和功能指标
Table 4. Structure and function indexes of left heart
X±S, M(P25, P75) 参数 HFpEF+C-AF组(83例) HFpEF+E-AF组(45例) HFpEF+N-AF组(221例) P值 IVSTd/mm 8.9±2.0 9.1±1.7 9.2±2.2 0.474 PWTd/mm 9.1±1.7 9.2±1.5 9.2±1.7 0.702 RWT/mm 0.38±0.08 0.37±0.07 0.39±0.09 0.514 LVIDd/mm 48.6±7.1 50.3±7.1 48.5±7.2 0.317 LVM-AL/mm 135±42 133±45 132±44 0.855 LVMi-AL/(g/m2) 73.0±20.2 73.5±21.6 74.1±22.5 0.919 LV-EDV/mL 73±27 74±31 79±31 0.226 LVEDVi/(mL/m2) 39.4±13.6 41.4±15.6 44.0±15.7 0.055 LV-ESV/mL 29±13 29±14 29±15 0.975 LAD/mm 46±81)2) 40±9 38±7 < 0.001 LADi/(cm/m2) 25.4±5.11)2) 22.4±4.7 21.1±4.0 < 0.001 LAV/mL 122±411)2) 90±42 78±30 < 0.001 LAVi/(mL/m2) 69.1±31.91)2) 50.4±22.8 45.1±21.7 < 0.001 FS/% 32(27，39)1)2) 38(32，41) 38(33，42) < 0.001 LVEF/% 61(55，66)1) 62(56，65) 64(59，70) 0.001 E/(cm/s) 96.0(86.7，110.3)1)2) 83.7(66.7，96.3)1) 73.7(59.8，90.8) < 0.001 DT/ms 164(142，188)1) 178(134，209)1) 207(163，253) < 0.001 IVRT/ms 76+141) 83±14 88±21 < 0.001 E′L/(cm/s) 10.3(8.0，12.0)1)2) 8.0(6.0，10.0)1) 6.5(5.0，8.0) < 0.001 E/E′L 9.5(7.5，13.7)1) 10.7(8.1，12.8)1) 11.4(9.2，14.7) 0.006 E′s/(cm/s) 7.0(6.0，8.0)1)2) 5.0(4.3，6.5)1) 5.0(4.0，5.6) < 0.001 E/E′s 13.8(11.2，17.3)1) 15.0(13.0，18.3) 15.9(12.5，19.4) 0.024 E/E′ 11.4(9.2，16.1)1) 12.9(10.6，15.7) 13.8(10.9，17.2) 0.007 FPV/(cm/s) 42.6(34.6，56.2)1)2) 35.6(31.7，44.4) 57.7(29.8，47.5) 0.005 与HFpEF+N-AF组比较，1)P < 0.05，与HFpEF+E-AF组比较，2)P < 0.05。
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表 5 右心结构与肺动脉压及左心结构功能多元线性回归分析
Table 5. Multiple linear regression analysis
因变量 组别 自变量 B β 95%CI P VIF RV-D1 HFpEF+C-AF LVEDVi 0.172 0.360 0.079~0.264 < 0.001 1.035 LAVi 0.049 0.244 0.010~0.089 0.015 1.043 IVRT -0.095 -0.205 -0.184~-0.006 0.037 1.022 HFpEF+E-AF PWTd 1.048 0.314 0.159~1.937 0.022 1.027 HFpEF+N-AF LVEDVi 0.055 0.141 0.002~0.109 0.044 1.041 LAVi 0.059 0.239 0.026~0.092 0.001 1.018 PASP 0.131 0.358 0.081~0.181 < 0.001 1.032 RV-D2 HFpEF+C-AF LVEDVi 0.120 0.242 0.021~0.219 0.018 1.035 LAVi 0.071 0.336 0.029~0.113 0.001 1.043 HFpEF+E-AF LVEDVi 0.140 0.339 0.020~0.259 0.023 1.000 HFpEF+N-AF LVEDVi 0.086 0.233 0.033~0.140 0.002 1.123 LAVi 0.047 0.201 0.015~0.079 0.005 1.019 PASP 0.096 0.278 0.048~0.144 < 0.001 1.040 RV-D3 HFpEF+C-AF LVEDVi 0.328 0.495 0.180~0.477 < 0.001 1.603 HFpEF+E-AF LVEDVi 0.176 0.325 0.007~0.346 0.042 1.380 HFpEF+N-AF LVEDVi 0.164 0.385 0.108~0.221 < 0.001 1.299 LADi -0.435 -0.260 -0.637~-0.233 < 0.001 1.088 RA-D1 HFpEF+C-AF LVEDVi 0.143 0.212 0.025~0.261 0.019 1.079 LAVi 0.151 0.529 0.101~0.201 < 0.001 1.068 HFpEF+E-AF LAVi 0.085 0.299 0.022~0.148 0.009 1.384 HFpEF+N-AF LVMi-AL 0.047 0.158 0.003~0.091 0.037 1.099 PASP 0.128 0.289 0.064~0.191 < 0.001 1.045 RA-D2 HFpEF+C-AF LAVi 0.129 0.362 0.053~0.206 0.001 1.177 HFpEF+E-AF PWTd 2.428 0.430 0.715~4.140 0.007 2.711 HFpEF+N-AF PASP 0.097 0.211 0.031~0.164 0.005 1.032 LAVi 0.060 0.192 0.015~0.104 0.009 1.020 RAA HFpEF+C-AF IVRT -0.177 -0.261 -0.318~-0.035 0.015 1.025 HFpEF+E-AF LVMi-AL 0.053 0.217 0.004~0.103 0.034 1.132 HFpEF+N-AF PASP 0.093 0.262 0.042~0.143 < 0.001 1.017 LAV 0.037 0.187 0.007~0.066 0.015 1.120
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[1] 黄鈺婷, 张恺, 苏菁, 等. 射血分数保留型心力衰竭与微血管内皮炎症[J]. 临床心血管病杂志, 2021, 37(6): 400-403. doi: 10.13201/j.issn.1001-1439.2021.06.004
[2] Gorter TM, van Melle JP, Rienstra M, et al. Right heart dysfunction in heart failure with preserved ejection fraction: the impact of atrial fibrillation[J]. J Card Fail, 2018, 24(3): 177-185. doi: 10.1016/j.cardfail.2017.11.005
[3] Members AF, Dickstein K, Cohensolal A, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure[J]. Eur J Heart Fail, 2008, 10: 110-110.
[4] Fuster V, Ryden L, Cannom D. ACC/AHA/ESC 2006 Guidelines for the management of patients with atrial fibrillation-executive summary[J]. J Am Coll Cardiol, 2006, 27(16): 1979-2030. http://d.yimg.com/kq/groups/21616229/241622366/name/ACC-AHA-ESC%202006%20Guidelines%20for%20the%20Management%20of%20Patients%20With%20Atrial%20Fibrillation—Executive%20Summary.pdf
[5] Lang R, Bierig M, Devereux R, et al. Recommendations for chamber quantification[J]. Eur J Echocardiogr, 2006, 7: 79-108. doi: 10.1016/j.euje.2005.12.014
[6] Ommen SR, Nishimura RA, Hurrell DG, et al. Assessment of right atrial pressure with 2-dimensional and Doppler echocardiography: a simultaneous catheterization and echocardiographic study[J]. Mayo Clin Proc, 2000, 75(1): 24-29. doi: 10.4065/75.1.24
[7] Smiseth OA, Waggoner AD, Flachskampf FA, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography[J]. Eur J Echocardiogr, 2009, 22(2): 107-133. doi: 10.1016/j.echo.2008.11.023
[8] Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the american society of echocardiography[J]. J Am Echocardiogr, 2010, 23(7): 685-713. doi: 10.1016/j.echo.2010.05.010
[9] Obokata M, Reddy Yogesh NV, Melenovsky V, et al. Deterioration in right ventricular structure and function over time in patients with heart failure and preserved ejection fraction[J]. Eur Heart J, 2019, 40: 689-697. doi: 10.1093/eurheartj/ehy809
[10] Tedford RJ, Hassoun PM, Mathai SC, et al. Pulmonary capillary wedge pressure augments right ventricular pulsatile loading[J]. Circulation, 2012, 125(2): 289-297. doi: 10.1161/CIRCULATIONAHA.111.051540
[11] Melenovsky V, Hwang SJ, Lin G, et al. Right heart dysfunction in heart failure with preserved ejection fraction[J]. Eur Heart J, 2014, 35(48): 3452-3462. doi: 10.1093/eurheartj/ehu193
[12] Morris DA, Gailani M, Perez AV, et al. Right ventricular myocardial systolic and diastolic dysfunction in heart failure with normal left ventricular ejection fraction[J]. J Am Soc Echocardio, 2011, 24(8): 886-897. doi: 10.1016/j.echo.2011.04.005
[13] Zakeri R, Mohammed SF. Epidemiology of right ventricular dysfunction in heart failure with preserved ejection fraction[J]. Current Heart Failure Reports, 2015, 12(5): 295-301. doi: 10.1007/s11897-015-0267-3
[14] Gorter Thomas M, van Melle Joost P, Rienstra M, et al. Right heart dysfunction in heart failure with preserved ejection fraction: the impact of atrial fibrillation[J]. J Card Fail, 2018, 24: 177-185. doi: 10.1016/j.cardfail.2017.11.005
[15] Bosch L, Lam Carolyn SP, Gong LL, et al. Right ventricular dysfunction in left-sided heart failure with preserved versus reduced ejection fraction[J]. Eur J Heart Fail, 2017, 19: 1664-1671. doi: 10.1002/ejhf.873
[16] 陈楚云, 杨颖, 张岩. 心房衰竭: 新的临床综合征?[J]. 临床心血管病杂志, 2021, 37(10): 500-505. https://www.cnki.com.cn/Article/CJFDTOTAL-LCXB202110002.htm
[17] Pérez JE, Mcgill JB, Santiago JV, et al. Abnormal myocardial acoustic properties in diabetic patients and their correlation with the severity of disease[J]. J Am Coll Cardiol, 1992, 19(6): 1154-1162. doi: 10.1016/0735-1097(92)90316-F
[18] 唐晓笛, 樊瑛. 钠-葡萄糖协同转运蛋白抑制剂对合并射血分数保留型心力衰竭的2型糖尿病患者的心血管保护作用研究[J]. 临床心血管病杂志, 2021, 37(1): 500-510. https://www.cnki.com.cn/Article/CJFDTOTAL-LCXB202101015.htm
[19] Tilman V. Atrial fibrillation and heart failure: Is atrial fibrillation a disease?[J]. Med Hypotheses, 2014, 83(3): 299-301. doi: 10.1016/j.mehy.2014.05.024
[20] Anter E, Jessup M, Callans DJ. Contemprorary reviews in cardiovascular medicine. atrial fibrillation and heart failure. Treatment considerations for a dual epidemic[J]. Circulation, 2009, 119: 2516-2525. doi: 10.1161/CIRCULATIONAHA.108.821306
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