心電圖測量可預測慢性腎病患者的心血管原因死亡


  【24drs.com】根據線上發表於7月9日美國腎臟醫學會期刊的一篇新研究,蒐集標準心電圖數據時所用的心電圖(ECG)測量可自動產生數據報告,是心血管(cardiovascular,CV)死亡的獨立風險標記,可促進對於慢性腎病(chronic kidney disease,CKD)患者的致死事件預測能力。
  
  費城賓州大學Perelman醫學院的Rajat Deo醫師等人發現,慢性腎功能不全世代(Chronic Renal Insufficiency Cohort)」的3,587名研究對象中,PR interval為200 ms以上者,心血管原因死亡風險比PR interval小於200 ms者高出62%(風險比[HR]為1.62;95%信賴區間[CI]為1.19 - 2.19)。
  
  另外,QRS interval升高達介於100-119 ms者,心血管原因死亡風險增加約64%(HR,1.64;95% CI,1.20 - 2.25),而QRS interval為120 ms以上者,心血管原因死亡風險比QRS interval小於100 ms者增加達75%(HR,1.75;95% CI,1.17 - 2.62)。
  
  校正QT (QTc)方面,相較於QTc小於450 ms的男性以及小於460 ms的女性,男性為450 ms以上、女性為460 ms以上者,心血管原因死亡風險增加達72% (HR,1.72;95% CI,1.19 - 2.49)。
  
  相較於心律每分鐘60下以下者,心律每分鐘60-90下者,心血管原因死亡風險增加約21% (HR,1.21;95% CI,0.89 - 1.63),而心律每分鐘90下以上者,心血管原因死亡風險增加超過2倍(HR,2.35;95% CI,1.03 - 5.33)。
  
  研究者指出,心律增加與三種死亡結果(心血管原因死亡、各種原因死亡、非心血管原因死亡)都有獨立相關,而且它也是心電圖測量數據中,唯一的非心血管原因死亡的獨立標記。
  
  相對的,心電圖為依據的左心室肥大以及左心室肥大的嚴重程度,則都與任何死亡結果無關。
  
  作者們寫道,相較於各種原因死亡或者非心血管原因死亡,大部份的心電圖測量數據都是心血管原因死亡風險的有力標記。
  
  根據這些研究結果,加上心電圖的普及且費用適中,對慢性腎病患者廣泛使用心電圖將對他們的照護有正面影響,因為可以改善降低心血管風險的策略。
  
  研究者指出,在5年期間,納入心電圖指標可促進預測心血管死亡。
  
  使用標準化的風險因素分析,心血管原因死亡之預測的一致性統計量值為0.77 (95% CI,0.75 - 0.80)。
  
  不過,將心電圖的各項指標加入風險因素模式,調整腎臟疾病和心血管風險因素的綜合影響,獲得整體樣本的淨重分類值為12.1% (95% CI,8.1% - 16.0%)。
  
  作者們指出,最終死於心血管原因者往上重新分類的人數,大於存活者往下重新分類的人數。
  
  在開始時,慢性腎功能不全世代約三分之一有心血管疾病史;該世代有15%的PR值為200 ms以上,30%的QRS值為100 ms以上, QTc方面,有8%的男性為450 ms以上、女性為460 ms以上,9%患有左心室肥大。
  
  約三分之一研究對象的心律小於每分鐘60下,而大部份的心律介於每分鐘60-90下,該世代只有3%的心律是每分鐘90下以上。
  
  追蹤期中位數為7.5年,該世代整體共有750人死亡。
  
  研究者指出,我們檢視了最初的497例死亡,區分為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%)。
  
  慢性腎功能不全世代中,有2,492人在開始時並沒有冠心症、心衰竭、中風,研究者也區分出242例偶發心衰竭以及136例偶發心肌梗塞。
  
  在這些人中,研究者觀察發現,心電圖的各區間資料和偶發心衰竭與心肌梗塞之間只有中等關聯。
  
  舉例來說,多變項分析之後,相較於QRS值小於100 ms者,QRS值介於100-119 ms者的偶發心衰竭和心肌梗塞都增加60% 。
  
  QRS值120 ms以上者,偶發心衰竭和心肌梗塞之風險都增加達116% 。QTc變長僅與偶發心衰竭有關。
  
  資料來源: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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