Clinical Features And Prognostic Analysis Of Secondary Valvular Regurgitation In Patients With Heart Failure

Clinical characteristics and prognosis of secondary mitral regurgitation in patients with heart failureBackground:Secondary mitral regurgitation(SMR)is common in patients with heart failure(HF),and about one third of HF patients have moderate to severe SMR.SMR can lead to the increase of preload and ventricular wall stress,which leads to the progression of symptoms and signs of HF,and SMR is an important factor in the poor prognosis of HF.Previous studies mainly included.patients with HFrEF,but the clinical characteristics and prognostic effects of SMR in patients with HFmrEF and HFpEF are still not clear.The purpose of this study was to evaluate the clinical characteristics of SMR in patients with different types of HF,and to evaluate the effects of different degrees of SMR on the prognosis of patients with different types of HF.Methods:Continuous enrolled patients with HF as the main diagnosis in our hospital from May 2009 to October 2017,of which 2707 were included in the final analysis.The primary outcome was a composite outcome consisting of all-cause death and/or rehospitalization for HF after discharge.According to the degree of SMR,the patients were divided into four groups:no/trivial SMR group(N=799),mild SMR group(N=875),moderate SMR group(N=735),and severe SMR group(N=309).Cox proportional hazard regression analysis(stepwise regression)was used to evaluate the influence of the existence of SMR and the degree of regurgitation(mild,moderate,severe)on the primary outcome.The cumulative probability of outcome events was estimated by Kaplan-Meier survival curve,and the survival rate was compared by log-rank test.Subgroup analysis evaluated the effect of the degree of SMR on the prognosis of patients with HFrEF,HFmrEF and HFpEF.Results:During a median follow-up of 5.8 years(IQR 2.8-9.6),a total of 949 patients(35.0%)had primary outcome events.With the aggravation of the degree of SMR,the proportion of primary outcome events in patients with no/trivial SMR,mild SMR,moderate SMR and severe SMR were 26.3%vs.37.6%vs.50.7%vs.54.9%,P<0.001).Compared with patients with no/trivial SMR,the HRs of patients with mild SMR,moderate SMR and severe SMR were 1.86(95%CI 1.54-2.25)vs.HR 2.74(95%CI 2.27-3.30)vs.HR 3.30(95%CI 2.64-3.84),P<0.001),respectively.After adjustment according to sex,age,SBP,NYHA,LVEF,eGFR and NT-proBNP,SMR were still associated with outcome events(all P<0.01).Kaplan-Meier survival curve' showed that there were statistical differences in the prognosis of patients with different degrees of SMR.Compared with patients with no/trivial SMR,patients with mild SMR,moderate SMR and severe SMR had a significantly higher risk of primary outcome events of all-cause death and rehospitalization for HF(log-rank P<0.0001).Subgroup analyses showed that in HFrEF and HFpEF,compared with patients with no/trivial SMR,patients with moderate and severe SMR had a significantly higher risk of primary outcome events(log-rank P<0.0001).In HFmrEF subgroup,stratified analyses showed that there was no significant difference in the risk of primary outcome events among patients with mild SMR,moderate SMR and severe SMR(log-rank P=0.947,log-rank P=0.394).Conclusion:SMR is common in HF patients.Despite guideline-directed medical therapy,the adverse prognostic effects of SMR still exist in HF patients.With the aggravation of SMR,the all-cause mortality and/or rehospitalization rate for HF increased significantly.Clinical characteristics and prognosis of secondary tricuspid regurgitation in patients with heart failureBackground:Secondary tricuspid regurgitation(STR)is a neglected valvular disease in patients with heart failure(HF).Even moderate STR is associated with severe HF at diagnosis.Long-term and severe STR can reduce the quality of life of patients,lead to rehospitalization,and is associated with poor prognosis.However,present study about HF complicated with STR,the research objects were mainly enrolled patients with HFrEF,and mostly were small-scale studies,and there is a lack of clinical characteristics and prognosis of STR in the other two types of HF.The purpose of this study was to evaluate the clinical and echocardiographic characteristics of STR in patients with different types of HF,and to evaluate the effects of different degrees of STR on the prognosis of patients with different types of HF.Methods:Continuous enrolled patients with HF as the main diagnosis in our hospital from May 2009 to October 2017,of which 2654 patients who were included in the final analysis.The primary outcome was a composite outcome consisting of all-cause death and/or rehospitalization for HF after discharge.According to the degree of STR,the patients were divided into four groups:no/trivial STR group(N=1399),mild STR group(N=643),moderate STR group(N=417),and severe STR group(N=155).Cox proportional hazard regression analysis(stepwise regression)was used to evaluate the influence of the existence of STR and the degree of regurgitation(mild,moderate,severe)on the primary outcomes.The cumulative probability of outcome events was estimated by Kaplan-Meier survival curve,and the survival rate was compared by log-rank test.Subgroup analysis evaluated the effect of the degree of STR on the prognosis of patients with HFrEF,HFmrEF and HFpEF.Results:During a median follow-up of 5.8 years(IQR 2.8-9.6),a total of 936 patients(35.0%)had major end point events.Compared with patients with no/trivial STR,the HRs of patients with mild STR,moderate STR and severe STR were HR 1.42(95%CI 1.34-1.51)vs.HR 1.95(95%CI 1.82-2.10)vs.HR 2.67(95%CI 2.42-2.95),P<0.001,respectively.Kaplan-Meier curve showed that the risk of primary outcome events in patients with mild STR,moderate STR and severe STR were significantly higher than that in patients with no/trivial STR(log-rank P<0.0001).Multivariate Cox regression analysis showed that after adjusting for sex,age,SBP,NYHA,LVEF,eGFR and NT-proBNP,STR was an independent predictor of the primary outcome events(HR 1.311,95%CI 1.205-1.428,P<0.001).Subgroup analysis showed that among HFrEF patients,patients with mild STR,moderate STR and severe STR had a significantly higher risk of primary outcome events than those no/trivial STR(log-rank P<0.0001).In patients with HFmrEF,patients with mild STR,moderate STR and severe STR had a significantly higher risk of major end point events than patients with no/trivial STR(log-rank P<0.001).However,there was no significant difference in the risk of primary outcome events between mild STR,moderate STR and severe STR(log-rank P=0.135,log rank P=0.123,respectively).In patients with HFpEF,patients with mild STR,moderate STR and severe STR had a significantly higher risk of primary outcome events than patients with no/trivial STR(log-rank P<0.001).Conclusion:STR is common in patients with HF,and despite guideline-directed medical therapy,the adverse prognostic effects of STR still exist in patients with HF.STR is an independent predictor of all-cause mortality and/or rehospitalization for HF.With the aggravation of STR,the all-cause mortality and/rehospitalization rate for HF patients increased significantly.Clinical characteristics and prognosis of bivalvular functional regurgitation in patients with heart failureBackground Bivalvular functional regurgitation(BVFR)is common in patients with heart failure.However,previous studies have limited to explore the epidemiological characteristics and prognosis of single secondary valvular regurgitation in patients with heart failure(HF),without the potential superposition effect of BVPR volume load.Epidemiological investigation,pathophysiological mechanism exploration and clinical prognosis study in patients with BVFR complicated with different spectrums of HF can provide corresponding reference for risk stratification and comprehensive management of follow-up treatment.The purpose of this study was to evaluate the clinical and echocardiographic characteristics of BVFR in patients with different spectrums of HF,and to evaluate the effect of BVFR on the prognosis of patients with different spectrums of HF.Methods:Continuous enrolled patients with HF as the main diagnosis in our hospital from May 2009 to October 2017,of which 2654 patients who were included in the final analysis.The primary outcome was a composite outcome consisting of all-cause death and/or rehospitalization for HF after discharge.According to the condition of valvular regurgitation,the patients were divided into three groups:no regurgitation group(N=631),only one valvular regurgitation group(N=854),BVFR group(N=1169).The effects of no valvular regurgitation,single valvular regurgitation and BVFR on the primary composite outcome were analyzed by univariate and multivariate Cox proportional hazard regression.The cumulative probability of event rates was estimated by Kaplan-Meier survival curve and compared with log-rank test.In addition,subgroup analysis was performed to evaluate the effect of the degree of valvular regurgitation on the prognosis of patients with HFrEF,HFmrEF and HFpEF.Results:During the median follow-up of 5.8 years(IQR 2.8-9.6),a total of 936(35.3%)patients had primary outcome.Compared with the non-regurgitation group,the hazard ratio(HR)of the primary outcome in only one valvular regurgitation group and BVFR group were HR 2.00(95%CI 1.61-2.48)vs.HR 3.43(95%CI 2.81-4.18),P<0.001),respectively.After adjustment according to sex,age,SBP,NYHA,LVEF,eGFR,NT-proBNP,compared with patients without regurgitation,there was only one primary outcome HR1.61(95%CI 1.18-2.22),P=0.003 in valvular regurgitation group,and HR1.98(95%CI 1.42-2.71)P<0.001 in BVFR group.Kaplan-Meier survival curve showed that compared with the non-regurgitation group,only one valvular regurgitation group and BVFR group had a significantly higher risk of primary outcome events(log-rank P<0.0001).In patients with HFrEF,compared with patients without regurgitation,only one valvular regurgitation and BVFR group had a significantly higher risk of primary outcome events(log-rank P<0.0001).Stratified analysis showed that there was a significant difference in the risk of primary outcome events among the three groups(log-rank P<0.001).In patients with HFmrEF,compared with patients without regurgitation,only one valvular regurgitation group had a significantly increased risk of primary outcome events in the BVFR group(log-rank P<0.001).Stratified analysis showed that there was no significant difference in the risk of primary outcome events between the group without regurgitation and the group with only one valvular regurgitation(log-rank P=0.079).In patients with HFpEF,compared with patients without regurgitation,only one valvular regurgitation and BVFR group had a significantly higher risk of primary outcome events(log-rank P<0.0001).Stratified analysis showed that there was a significant difference in the risk of primary outcome events among the three groups(log-rank P<0.001).Conclusion:This is the first study to evaluate the clinical characteristics and prognosis of BVFR in patients with HF.Patients with HF complicated with BVFR have a significantly increased risk of outcome events,and have the greatest impact on the prognosis of patients with HFrEF.For HF patients complicated with BVFR,we recommend an overall assessment of the volume load of valvular regurgitation,ratherthan a risk assessment of a single valve.