心电图测量可预测慢性肾病患者的心血管原因死亡


  【24drs.com】根据在线发表于7月9日美国肾脏医学会期刊的一篇新研究,搜集标准心电图数据时所用的心电图(ECG)测量可自动产生数据报告,是心血管(cardiovascular,CV)死亡的独立风险标记,可促进对于慢性肾病(chronic kidney disease,CKD)患者的致死事件预测能力。
  
  费城宾州大学Perelman医学院的Rajat Deo医师等人发现,慢性肾功能不全世代(Chronic Renal Insufficiency Cohort)」的3,587名研究对象中,PR interval为200 ms以上者,心血管原因死亡风险比PR interval小于200 ms者高出62%(风险比[HR]为1.62;95%信赖区间[CI]为1.19 - 2.19)。
  
  另外,QRS interval升高达介于100-119 ms者,心血管原因死亡风险增加约64%(HR,1.64;95% CI,1.20 - 2.25),而QRS interval为120 ms以上者,心血管原因死亡风险比QRS interval小于100 ms者增加达75%(HR,1.75;95% CI,1.17 - 2.62)。
  
  校正QT (QTc)方面,相较于QTc小于450 ms的男性以及小于460 ms的女性,男性为450 ms以上、女性为460 ms以上者,心血管原因死亡风险增加达72% (HR,1.72;95% CI,1.19 - 2.49)。
  
  相较于心律每分钟60下以下者,心律每分钟60-90下者,心血管原因死亡风险增加约21% (HR,1.21;95% CI,0.89 - 1.63),而心律每分钟90下以上者,心血管原因死亡风险增加超过2倍(HR,2.35;95% CI,1.03 - 5.33)。
  
  研究者指出,心律增加与三种死亡结果(心血管原因死亡、各种原因死亡、非心血管原因死亡)都有独立相关,而且它也是心电图测量数据中,唯一的非心血管原因死亡的独立标记。
  
  相对的,心电图为依据的左心室肥大以及左心室肥大的严重程度,则都与任何死亡结果无关。
  
  作者们写道,相较于各种原因死亡或者非心血管原因死亡,大部份的心电图测量数据都是心血管原因死亡风险的有力标记。
  
  根据这些研究结果,加上心电图的普及且费用适中,对慢性肾病患者广泛使用心电图将对他们的照护有正面影响,因为可以改善降低心血管风险的策略。
  
  研究者指出,在5年期间,纳入心电图指标可促进预测心血管死亡。
  
  使用标准化的风险因素分析,心血管原因死亡之预测的一致性统计量值为0.77 (95% CI,0.75 - 0.80)。
  
  不过,将心电图的各项指标加入风险因素模式,调整肾脏疾病和心血管风险因素的综合影响,获得整体样本的净重分类值为12.1% (95% CI,8.1% - 16.0%)。
  
  作者们指出,最终死于心血管原因者往上重新分类的人数,大于存活者往下重新分类的人数。
  
  在开始时,慢性肾功能不全世代约三分之一有心血管疾病史;该世代有15%的PR值为200 ms以上,30%的QRS值为100 ms以上, QTc方面,有8%的男性为450 ms以上、女性为460 ms以上,9%患有左心室肥大。
  
  约三分之一研究对象的心律小于每分钟60下,而大部份的心律介于每分钟60-90下,该世代只有3%的心律是每分钟90下以上。
  
  追踪期中位数为7.5年,该世代整体共有750人死亡。
  
  研究者指出,我们检视了最初的497例死亡,区分为256例心血管原因死亡(每年1.1%)和241例非心血管原因死亡(每年1.0%)。
  
  慢性肾功能不全世代中,有2,492人在开始时并没有冠心症、心衰竭、中风,研究者也区分出242例偶发心衰竭以及136例偶发心肌梗塞。
  
  在这些人中,研究者观察发现,心电图的各区间资料和偶发心衰竭与心肌梗塞之间只有中等关联。
  
  举例来说,多变项分析之后,相较于QRS值小于100 ms者,QRS值介于100-119 ms者的偶发心衰竭和心肌梗塞都增加60% 。
  
  QRS值120 ms以上者,偶发心衰竭和心肌梗塞之风险都增加达116% 。QTc变长仅与偶发心衰竭有关。
  
  资料来源:http://www.24drs.com/
  
  Native link:ECG Measures Predict CV Death in Patients With CKD

ECG Measures Predict CV Death in Patients With CKD

By Pam Harrison
Medscape Medical News

Common electrocardiographic (ECG) metrics that are automatically reported during standard ECG acquisition are independent risk markers for cardiovascular (CV) death and enhance the ability to predict fatal events in a population of patients with chronic kidney disease (CKD), according to new research published online July 9 in the Journal of the American Society of Nephrology.

Rajat Deo, MD, from the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, and colleagues found that among 3587 participants from the Chronic Renal Insufficiency Cohort, a PR interval of 200 ms or longer was associated with a 62% greater risk for CV death compared with a normal PR of less than 200 ms (hazard ratio [HR], 1.62; 95% confidence interval [CI], 1.19 - 2.19).

Similarly, an elevated QRS interval of between 100 and 119 ms increased the risk for CV death by 64% (HR, 1.64; 95% CI, 1.20 - 2.25), whereas a QRS interval of 120 ms or more increased the risk for CV death by 75% compared with a QRS interval lower than 100 ms (HR, 1.75; 95% CI, 1.17 - 2.62).

A corrected QT (QTc) in men of 450 ms or longer or of 460 ms or longer in women increased the risk for CV death by 72% (HR, 1.72; 95% CI, 1.19 - 2.49) compared with a QTc of less than 450 ms for men and less than 460 ms for women.

A heart rate of between 60 and 90 beats per minute increased the risk for CV death by 21% (HR, 1.21; 95% CI, 0.89 - 1.63), whereas a heart rate of 90 or more beats per minute increased the risk for CV death by more than twofold (HR, 2.35; 95% CI, 1.03 - 5.33), compared with a heart rate lower than 60 beats per minute.

As the investigators note, an increase in heart rate was independently associated with all three mortality outcomes (CV death, all-cause mortality, and noncardiovascular deaths), and it also was the only ECG measure that was an independent marker for noncardiovascular death.

In contrast, ECG-based left ventricular hypertrophy, along with measures of severity of left ventricular hypertrophy, were not associated with any mortality outcomes.

"Most ECG measures were stronger markers of risk for cardiovascular death than for all-cause mortality or noncardiovascular death," the authors write.

"These findings along with the modest expense and widespread availability of electrocardiography suggest that broader use of ECGs among individuals with CKD may positively impact the care of the CKD population by permitting improved targeting of cardiovascular risk reduction strategies."

ECG Data Enhanced Prediction

"Over a 5-year period, the inclusion of the ECG metrics enhanced the prediction of cardiovascular death," the investigators state.

Using a standard set of risk factors, the prediction of CV death yielded a C-statistic of 0.77 (95% CI, 0.75 - 0.80).

However, the addition of ECG metrics to the risk factor model adjusted for a comprehensive panel of kidney disease and CV risk factors resulted in a net reclassification of 12.1% (95% CI, 8.1% - 16.0%) in the overall sample.

"The upward reclassification of participants that eventually died of cardiovascular causes was greater than the downward reclassification of individuals who survived," as the authors point out.

Baseline CV History

At baseline, approximately one third of the Chronic Renal Insufficiency Cohort participants had a history of CV disease.

Fifteen percent of the cohort had a PR of 200 ms or higher, 30% had a QRS of 100 ms or higher, and 8% had a QTc of 450 ms or higher in men or 460 ms or higher in women. Nine percent had left ventricular hypertrophy.

About one third of participants had a heart rate lower than 60 beats per minute, whereas the majority had a heart rate of between 60 and 90 beats per minute; only 3% of the cohort had a heart rate of 90 beats per minute or higher.

During a median follow-up of 7.5 years, 750 deaths occurred in the cohort overall.

"We adjudicated the initial 497 deaths and identified 256 cardiovascular (1.1% per year) and 241 noncardiovascular deaths (1.0% per year)," the investigators note.

In a subgroup of 2492 Chronic Renal Insufficiency Cohort participants with no baseline history of coronary heart disease, heart failure, or stroke, the investigators also identified 242 cases of incident heart failure and 136 cases of incident myocardial infarction.

Among this subgroup, "we detected modest associations between the ECG intervals and incident heart failure and [myocardial infarction]," the authors observe.

For example, compared with participants with a QRS duration lower than 100 ms, participants with a QRS of between 100 and 119 ms had about a 60% increase in both incident heart failure and myocardial infarction after multivariable analysis.

The risk for incident heart failure and myocardial infarction increased by 116% among participants with a QRS of 120 ms or less.

A long QTc was associated with incident heart failure only.

The authors have disclosed no relevant financial relationships.

J Am Soc Nephrol. Published online July 9, 2015.

    
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