MD, PhD, Professor, Corresponding member of Russian Academy of Sciences, Deputy General Director for Scientific and Analytical Work and Preventive Cardiology, Head of the Laboratory of Preventive Cardiology, Federal State Budgetary Institution “National Medical Research Center of Cardiology named after Academician E.I. Chazov” Ministry of Health of the Russian Federation, Moscow, Russian Federation; Head of the Department of Evidence-Based Medicine, Institute of Medicine, Peoples' Friendship University of Russia named after Patrice Lumumba, Moscow, Russian Federation
Cardiologist, Department of Cardiac Rehabilitation, Federal State Budgetary Institution “National Medical Research Center of Cardiology named after Academician E.I. Chazov” Ministry of Health of the Russian Federation, Moscow, Russian Federation; Assistant, Department of Evidence Based Medicine, Peoples' Friendship University of Russia named after Patrice Lumumba, Moscow, Russian Federation
PhD, Assistant Professor, Department of Internal Diseases Propaedeutics, Yerevan State Medical University after Mkhitar Heratsi, Yerevan, Republic of Armenia
Junior Research Fellow, Laboratory of Preventive Cardiology, Federal State Budgetary Institution “National Medical Research Center of Cardiology named after Academician E.I. Chazov” Ministry of Health of the Russian Federation, Moscow, Russian Federation
PhD, Senior Research Fellow, Laboratory of Preventive Cardiology, Cardiologist, Department of Cardiac Rehabilitation, Federal State Budgetary Institution “National Medical Research Center of Cardiology named after Academician E.I. Chazov” Ministry of Health of the Russian Federation, Moscow, Russian Federation; Senior Lecturer, Department of Evidence Based Medicine, Peoples' Friendship University of Russia named after Patrice Lumumba, Moscow, Russian Federation
PhD, MD, Senior Research Fellow, Laboratory for Study of Geroprotectors and Clinical Trials, Russian Gerontology Clinical and Research Center, Federal State Autonomous Educational Institution of Higher Education “N.I. Pirogov Russian National Research Medical University” of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
PhD, MD, Professor, Head of the Department of Faculty Therapy and Geriatrics, Department of Facultative Therapy and Occupational Diseases, Altay State Medical University, Barnaul, Russian Federation
PhD, Research Fellow, Laboratory of Preventive Cardiology, Federal State Budgetary Institution “National Medical Research Center of Cardiology named after Academician E.I. Chazov” Ministry of Health of the Russian Federation, Moscow, Russian Federation; Assistant, Department of Evidence Based Medicine, Peoples' Friendship University of Russia named after Patrice Lumumba, Moscow, Russian Federation
PhD, Leading Research Fellow, Laboratory of Preventive Cardiology; Head of the Cardiac Rehabilitation Department, Federal State Budgetary Institution “National Medical Research Center of Cardiology named after Academician E.I. Chazov” Ministry of Health of the Russian Federation, Moscow, Russian Federation; Associate Professor, Department of Evidence Based Medicine, Peoples' Friendship University of Russia named after Patrice Lumumba, Moscow, Russian Federation
Основные положения
Актуальность. Хроническая сердечная недостаточность (ХСН) остается состоянием, связанным с высокими показателями смертности, превышающими показатели смертности при онкологической патологии. Традиционные подходы к стратификации риска, основанные на этиологии ХСН и аспектах функционирования левого желудочка, не в полной мере отражают прогноз, что диктует необходимость выявления новых клинически значимых предикторов не благоприятного прогноза.
Цель. Проведение комплексной оценки клинических симптомов, функционального класса (ФК) ХСН и сопутствующих заболеваний в отношении 5-летней смертности и выживаемости у пациентов с ХСН в условиях реальной клинической практики.
Материалы и методы. В данном проспективном когортном исследовании в феврале-мае 2018 г. были включены 150 пациентов с ХСН из амбулаторных клиник и больниц, расположенных в Москве и Барнауле. Информация о состоянии здоровья в течение 5-летнего периода наблюдения (медиана 3,29 года) была получена у 147 (98%) пациентов. Анализ выживаемости проводился с использованием метода Каплана–Мейера. Для оценки предикторов использовалась одномерная регрессия Кокса для расчета коэффициентов риска (HR) и 95% доверительных интервалов (CI).
Результаты. Общая 5-летняя выживаемость составила 59,9% (88/147). Этиология СН не показала статистически значимой связи с исходами. Гепатояремный рефлюкс (p = 0,001) и потеря веса > 4,5 кг в ответ на 5-дневную терапию (p < 0,001) были связаны с самыми высокими показателями смертности. Функциональный класс СН по NYHA продемонстрировал высокую прогностическую значимость: по сравнению с функциональным классом I риск смерти был в 7,7 раза выше у пациентов с функциональным классом III (95% ДИ 3,03–19,76) и в 19 раз выше у пациентов с функциональным классом IV (95% ДИ 4,50–80,29). Наличие сопутствующих заболеваний, включая анемию (ОР = 3,51; 95% ДИ 2,08–5,90), фибрилляцию предсердий (ОР = 2,12; 95% ДИ 1,25–3,61), хроническую обструктивную болезнь легких (ОР = 2,55; 95% ДИ 1,48–4,37) и обструктивное апноэ сна (ОР = 2,73; 95% ДИ 1,32–5,62), было связано с более высокой 5-летней смертностью. Наличие в анамнезе эндоваскулярных вмешательств выступало в качестве превентивного фактора (ОР = 0,44; 95% ДИ 0,24–0,81; p = 0,008).
Заключение. Тяжесть текущих клинических проявлений ХСН и совокупное бремя сопутствующих заболеваний оказывают большее влияние на долгосрочный прогноз, чем исходная этиология. Данные результаты подчеркивают необходимость перехода от статической диагностики к динамической оценке симптоматического статуса и активному воздействию на ключевые коморбидные заболевания для улучшения результатов лечения пациентов с ХСН в клинической практике.
Highlights
Background. Chronic heart failure (HF) remains a condition associated with high mortality rates, exceeding those of oncological diseases. Traditional risk stratification approaches, based on the HF etiology and left ventricular function parameters, do not fully capture individual prognosis, necessitating the identification of new clinically significant predictors.
Aim. To conduct a comprehensive assessment of clinical symptoms, functional class (FC) of HF, and comorbid conditions in relation to 5-years mortality and survival in HF patients in real-world clinical practice settings.
Methods. In this prospective cohort study 150 consecutive patients with HF were enrolled in two outpatient clinics and two hospitals located in Moscow and Barnaul in February-May 2018. Vital status during 5-years of follow-up (median 3.29 years) was obtained in 147 (98%) patients. Survival analysis was performed using the Kaplan-Meier method. For assessment of predictors’ univariate Cox regression was used to calculate hazard ratios (HR) and 95% coincidence intervals (CI).
Results. The 5-years overall survival rate was 59.9% (88/147). HF etiology showed no statistically significant association with outcomes. Hepatojugular reflux (p = 0.001) and weight loss > 4.5 kg in response to 5 days therapy (p < 0.001) were associated with the highest mortality rates. HF NYHA FC demonstrated strong prognostic significance: compared to FC I, the risk of death was 7.7 times higher for patients with FC III (95% CI 3.03–19.76) and 19 times higher for those with FC IV (95% CI 4.50–80.29). The presence of comorbidities, including anemia (HR = 3.51; 95% CI 2.08–5.90), atrial fibrillation (HR = 2.12; 95% CI 1.25–3.61), chronic obstructive pulmonary disease (HR = 2.55; 95% CI 1.48–4.37), and obstructive sleep apnea (HR = 2.73; 95% CI 1.32–5.62), were associated with higher 5-years mortality. A history of endovascular interventions acted as a protective factor (HR = 0.44; 95% CI 0.24–0.81; p = 0.008).
Conclusion. The severity of current clinical manifestations of HF and the cumulative burden of comorbid conditions has a greater impact on long-term prognosis than the initial etiology. These findings underscore the need to shift the focus from a static diagnosis towards dynamic assessment of symptomatic status and active targeting of key comorbidities to improve outcomes in patients with HF in clinical practice.
The authors declare that there are no conflicts of interest present.