| Part 1:Association between systolic blood pressure change after admission and prognosis in patients hospitalized with heart failureObjective:Observational studies have shown that low systolic blood pressure(SBP)was an independent risk factor of adverse events in patients hospitalized with heart failure.However,the SBP value presented a "reclassification" phenomenon after the standard therapy during hospitalization.In addition,there was a large difference between patients with different admission SBP value on baseline characteristics,disease severity and treatment strategy.It was hard to evaluate the prognosis by SBP value on only one time point.Our aim was to explore the association between SBP change and SBP at discharge with the prognosis through observing the SBP change during hospitalization in patients with heart failure.Methods:Patients with Heart Failure(HF)hospitalized in Fuwai hospital,Heart failure center were enrolled between April 2009 and May 2015 retrospectively.Enrolled patients were divided into groups according to SBP at admission SBP change(?SBP)and SBP at discharge.Study endpoint was 1-year all-cause deaths during follow-up.The association between SBP at admission,?SBP in each group and SBP at discharge with study endpoint during follow-up were analyzed by performing univariable and multivariable Cox regression.Results:A total of 1532 patients were enrolled in our study.Eligible patients were divided into three groups according to the SBP value at admission,SBP<120mmHg group(n=592),120mmHg?SBP<140mmHg group(n=616),and SBP?140mmHg group(n=324).During 1-year follow-up,193 patients(12.6%)died.For patients with SBP<120mmHg at admission,adjusted risk of endpoints in the ?SBP<-1 0mmHg group was approximate twice higher than those in the ?SBP?-10mmHg group(HR=1.805,95%CI=1.200?2.714,P<0.01).For patients with SBP between 120-139mmHg at admission,adjusted risk of endpoints in the ?SBP<-20mmHg group was approximate twice higher than those in the ?SBP?-20mmHg group(HR=1.740,95%CI=1.022?2.963,P=0.042).For patients with SBP?140mmHg at admission,the adjusted risk of endpoints in the ?SBP<-40mmHg group was approximate five times higher than those in the ?SBP?-40mmHg group(HR=5.210,95%CI=2.136?12.707,P<0.001).SBP at discharge was negatively associated with the risk of all-cause death.Compared with patients with SBP?130mmHg at discharge,patients with SBP<100mmHg or 100-109mmHg had significantly increased risk of all-cause death(HR=3.213,95%CI=1.669?6.187,P<0.001;HR=2.204,95%CI=1.053?3.892,P=0.035,respectively).Conclusions:Excessive in-hospital SBP reduction was an independent risk factor for poor prognosis.in HF patients with different SBP value at admission.Low SBP at discharge was independently associated with the poor prognosis.Part 2:Predictors of systolic blood pressure change during hospitalization and its association with worsening renal function in patients hospitalized with heart failureObjective:Previous studies have shown that most patients with HF experienced SBP reduction during hospitalization,the magnetite of SBP reduction was affected not only by baseline SBP at admission,but also by the application of vasoactive drugs and the adjustment of blood pressure lowering agents.However,other clinical profiles at admission affected the magnitude of SBP reduction was unclear.Besides,several studies have demonstrated that SBP decline during hospitalization was an independent predictor of worsening renal function(WRF)in patients with heart failure.However,whether this association remained consistent in patients with different HF phenotype was unknown.Therefore,the goal of our study was to investigate the predictors of the magnitude of SBP reduction during hospitalization and its association with WRF in different HF phenotype.Methods:Patients with HF hospitalized in Fuwai hospital,Heart failure center were retrospectively enrolled between January 2017 and January 2019.Enrolled patients were separated into three groups according to the tertiles of SBP change(?SBP)during hospitalization.Baseline characteristics at admission were compared among each group and analyzed to explore the independent predictors of in-hospital the magnitude SBP reduction.Study endpoint was the occurrence of in-hospital WRF(Serum Creatinine increased>26.5?mol/L during hospitalization).Predictors of the magnitude of SBP reduction and its association with WRF was analyzed by using multiple linear regression and dichotomies logistic regression model.Results:A total of 811 patients were enrolled in our study.Patients were separated into three groups according to the tertiles of ?SBP value.?SBP<-16mmHg group(n=269),-16mmHg??SBP?-4mmHg group(n=259),and ?SBP?-3mmHg group(n=283).A total of 123 patients(15.2%)experienced WRF during hospitalization.Multiple linear regression showed that the magnitude of SBP reduction was negatively correlated with BMI,potassium,the prevalence of diabetes mellitus and renal insufficiency,and positively correlated with SBP and NT-proBNP value at admission(All P<0.05).Multivariable logistic regression showed that ?SBP(decreased every 10mmHg)was associated with a higher risk of WRF(OR=1.343,95%CI=1.129?1.598,P=0.001)after adjusting the confounding factors including age,gender,BMI,history of hypertension,SBP at admission,etc.Adjusted risk of WRF in the ?SBP<-16mmHg group was approximate three times higher than those in the ?SBP?-3mmHg group(OR=3.765,95%CI=2.006?7.068,P<0.001).Subgroup analysis showed that ?SBP(decreased every 10mmHg)was also associated with a higher risk of WRF(OR=1.504,95%CI=1.173?1.927,P=0.001)in patients with HFrEF.No association between ?SBP value and WRF were observed in patients with HFmrEF or HFpEF(OR=1.186,95%CI=0.925?1.521,P=0.179).Conclusion:In HF patients,in-hospital magnitude of SBP reduction was positively correlated with SBP and NT-proBNP value and negatively correlated with BMI,serum potassium,the prevalence of diabetes mellitus and renal insufficiency at admission.SBP reduction was an independent risk factor of WRF during hospitalization,which is more pronounced in patients with HFrEF.Part 3:Association between systolic blood pressure change after discharge and prognosis in patients hospitalized with heart failureObjective:Studies have shown that the association between SBP value at discharge and during follow up and the risk of clinical outcome in patients with heart failure was presented as a "U-shaped" or "J-shaped" curve,either too low or too high SBP value was associated with a increased risk of adverse outcomes including death or readmission.However,previous studies neither exclude patients in the unstable and vulnerable phase,nor consider the post-discharge medicine adjustment.Moreover,few studies focused on the association between updated SBP value and its change during follow up and the prognosis in patients with stable heart failure after discharge.Our study was aimed to investigate the association between SBP value 3 months after discharge along with its change during follow up and adverse outcomes.Methods:Patients with HF hospitalized in Fuwai hospital,Heart failure center were prospectively enrolled between January 2017 and January 2019.Patients were divided into four groups according to the quartiles of the SBP at discharge.SBP value at discharge and its change during follow up were dynamically observed.Adverse outcome was the composite endpoint of cardiovascular death or readmission due to worsening heart failure at 1 year after discharge.Univariate and multivariate Cox regression models were performed to investigate the association between SBP values,along with its change at 3 months after discharge and the risk of composite endpoint.Results:A total of 737 patients were enrolled in our study prospectively.Enrolled patients were stratified into four groups according to the SBP at discharge,SBP<100mmHg group(n=145),100mmHg?SBP<110mmHg group(n=218),110mmHg?SBP<120mmHg group(n=180)and SBP?120mmHg group(n=194).A total of 185(25.1%)patients occurred the composite endpoints.Mean SBP increased significantly 3 months after discharge among patients with different baseline SBP value(All P<0.05).SBP change(increased?10mmHg)at 3-month SBP after discharge was not associated with the risk of adverse outcome.Association between 3-month SBP and the risk of adverse outcomes within 1 year was presented as a "reverse J shaped" curve,the nadir range of the curve was at 110-119mmHg.Patients with 3-month SBP<1 00mmHg had an increased risk of adverse outcome than those in the nadir range(HR=2.306,95%CI=1.454?3.657,P<0.001),whereas patients with 3-month SBP?130mmHg was presented an upward trend in the risk of adverse outcome compared with the nadir range(HR=1.245,95%CI=0.728?2.130,P=0.423)?Conclusions:The 3-month SBP after discharge in patients hospitalized with HF was nonlinearly associated with the risk of clinical outcomes.During the early post-discharge period,SBP value should be controlled within a reasonable range to reduce the adverse outcome in patients with HF.Part 4:Association between liver fibrosis score and the prognosis in patients hospitalized with heart failureObjective:Abnormal liver function is an important target organ damage in patients with heart failure.Besides,there is a complex interaction between the two diseases.Non-alcoholic fatty liver disease(NAFLD)is one of the novel cardiovascular risk factors that has attracted much attention in recent years,and studies have shown that the degree of liver lesions was associated with the changes of cardiac structure or function.The FIB-4 index and the NAFLD fibrosis score(NFS)are two noninvasive indicators of liver fibrosis in patients of NAFLD.They can also be used to predict the risk of NAFLD-related cardiovascular disease.However,the application value of both two kinds of score in the post-discharge risk assessment for patients hospitalized with HF was not clear.Therefore,the purpose of this study is to explore and compare the application value of FIB-4 index and NFS on predicting adverse outcomes in patients hospitalized with heart failure.Methods:A total of 528 patients hospitalized with the heart failure center of Fuwai hospital,with a clinical diagnosis of heart failure were respectively enrolled between March 2009 and May 2015.The FIB-4 index and the NFS were calculated according to the age,liver function and blood routine at discharge.The study endpoint was all-cause mortality during the follow up period.The predictive value of the FIB-4 index and NFS value on the study endpoint was analyzed using multivariable Cox regression hazard model and compared using the area under curve(AUC)of ROC curve.Results:Patients enrolled were divided into three groups according to the FIB-4 index tertile:FIB-4 index<1.27 group(n=176),L27?FIB-4 index?2.00 group(n=176),FIB-4 index?2.01 group(n=176).After adjusted the sex,renal dysfunction,systolic blood pressure,direct bilirubin in the multivariable Cox regression hazard model,we found adjusted risk of all-cause mortality in the FIB-4 index?2.01 group was higher than those in the FIB-4 index<1.27(HR=1.958,95%CI=1.338?2.866,P=0.001).Patients were then divided into three groups according to the NFS tertile:NFS<-1.93 group(n=175),-1.93?NFS?-0.68 group(n=177),NFS?-0.67 group(n=176).After adjusted the confounding factors above in the multivariable Cox regression hazard model,we found adjusted risk of all-cause mortality in the NFS?-0.67 group was higher than those in the NFS<-1.93(HR=2.160,95%CI=1.475?3.165,P<0.001).Compared the AUC on ROC curves,difference in the predictive value of FIB-4 index and NFS was no statistically significant(0.714 vs.0.697,P=0.277).Conclusions:Liver fibrosis score including FIB-4 and NFS can be a useful tool in risk assessment in patients hospitalized with heart failure,with a similar utility value. |
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