Outcome and undertreatment of mitral regurgitation: a community cohort study.
Outcome and undertreatment of mitral regurgitation: a community cohort study.
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DOI：
10.1016/s0140-6736(18)30473-2
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发表时间：
2018-03-10
期刊：
影响因子：
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通讯作者：
Enriquez-Sarano M
中科院分区：
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作者：
Dziadzko V;Clavel MA;Dziadzko M;Medina-Inojosa JR;Michelena H;Maalouf J;Nkomo V;Thapa P;Enriquez-Sarano M
二尖瓣返流是世界上最常见的瓣膜疾病，但社区范围的流行率、糟糕的患者结局和低手术治疗率是否值得开发昂贵的新治疗干预措施仍不确定。因此，我们进行了一项观察性队列研究，以评估社区环境下二尖瓣关闭不全的临床特征、结果和治疗不足的程度。我们使用梅奥诊所电子健康记录和罗切斯特流行病学项目的数据来确定在美国奥姆斯特德县(美国明尼苏达州)10年的社区环境中诊断的所有中或重度孤立单瓣反流病例(没有其他严重的左侧瓣膜疾病或以前的二尖瓣手术)。我们评估了诊断后的临床特征、死亡率、心力衰竭发生率和心脏手术结果。从2000年1月1日至2010年12月31日，1294名社区居民(确诊时的中位年龄77岁[IQR 66-84])被多普勒超声心动图诊断为中度或重度二尖瓣反流(总体患病率为0.46%[95%可信区间0.42-0.49]；成人为0.59%[0.54-0.64])。左心室射血分数低于50%是常见的(538例患者[42%])，这些患者的返流体积比射血分数大于或等于50%的患者略低(平均39毫升[SD16]比45毫升[21]，p<；0.0001)。确诊后死亡主要是心血管疾病(在824名有死因的患者中有420例[51%])，该县居民的年龄或性别高于预期(风险比[RR]2.23[95%可信区间2.06-2.41]，p<；0.0001)。这种超额死亡率影响到所有亚型的患者，无论他们的左心室射血分数低于50%(RR3.17[95%可信区间2.84-3.53]，p<；0.0001)或50%或更高(1.71[1.53-1.91]，p<；0.0001)，并伴有原发性二尖瓣关闭不全(RR1.73[95%可信区间1.53-1.96]，p<；0.0001)或继发性二尖瓣关闭不全(2.72[2.48-3.01]，p<；0.0001)。即使低共病负荷的患者结合有利的特征，如左心室射血分数50%或更高(RR1.28[95%可信区间1.10-1.50]，p<；0.0017)或原发性二尖瓣关闭不全(1.29[1.09-1.52]，p=0.0030)，也会导致额外的死亡率。心力衰竭是常见的(诊断后5年平均%[SE1])，甚至在左心室射血分数大于或等于50%的患者(诊断后5年为49%[2])或有二尖瓣关闭不全的患者(48%[2])。在1294名患者中，只有198名(15%)最终完成了二尖瓣手术，其中主要的手术类型是瓣膜修补术(149名[75%]患者)。左心室射血分数低于50%的538例患者中有28例(5%)接受了二尖瓣手术，而射血分数在50%或以上的756例患者中有170例(22%)接受了二尖瓣手术，723例二尖瓣返流患者中有34例(5%)接受了二尖瓣手术，而571例患者中有164例(29%)接受了二尖瓣手术。所有其他类型的心脏手术仅比接受二尖瓣手术的患者多3%(237例[18%])。在社区中，孤立性二尖瓣反流很常见，在所有患者亚组中，即使在左心室射血分数正常和低合并症的患者中，孤立性二尖瓣反流也与超额死亡率和诊断后频繁的心力衰竭有关。尽管结果很差，但即使在一个所有诊断和治疗手段都随时可用的社区，也只有一小部分受影响的患者接受了二尖瓣(或任何类型的心脏)手术。这表明，在更广泛的人群中，对这种疾病的治疗可能存在大量未得到满足的需求。梅奥诊所基金会。
Mitral regurgitation is the most common valve disease worldwide but whether the community-wide prevalence, poor patient outcomes, and low rates of surgical treatment justify costly development of new therapeutic interventions remains uncertain. Therefore, we did an observational cohort study to assess the clinical characteristics, outcomes, and degree of undertreatment of mitral regurgitation in a community setting. We used data from Mayo Clinic electronic health records and the Rochester Epidemiology Project to identify all cases of moderate or severe isolated single-valvular mitral regurgitation (with no other severe left-sided valvular disease or previous mitral surgery) diagnosed during a 10-year period in the community setting in Olmsted County (MN, USA). We assessed clinical characteristics, mortality, heart failure incidence, and results of cardiac surgery post-diagnosis. Between Jan 1, 2000, and Dec 31, 2010, 1294 community residents (median age at diagnosis 77 years [IQR 66–84]) were diagnosed with moderate or severe mitral regurgitation by Doppler echocardiography (prevalence 0.46% [95% CI 0.42–0.49] overall; 0.59% [0.54–0.64] in adults). Left-ventricular ejection fraction below 50% was frequent (recorded in 538 [42%] patients), and these patients had a slightly lower regurgitant volume than those with an ejection fraction of 50% or higher (mean 39 mL [SD 16] vs 45 mL [21], p<0.0001). Post-diagnosis mortality was mainly cardiovascular in nature (in 420 [51%] of 824 patients for whom the cause of death was available) and higher than expected for residents of the county for age or sex (risk ratio [RR] 2.23 [95% CI 2.06–2.41], p<0.0001). This excess mortality affected all subsets of patients, whether they had a left-ventricular ejection fraction lower than 50% (RR 3.17 [95% CI 2.84–3.53], p<0.0001) or of 50% or higher (1.71 [1.53 –1.91], p<0.0001) and with primary mitral regurgitation (RR 1.73 [95% CI 1.53–1.96], p<0.0001) or secondary mitral regurgitation (2.72 [2.48–3.01], p<0.0001). Even patients with a low comorbidity burden combined with favourable characteristics such as left-ventricular ejection fraction of 50% or higher (RR 1.28 [95% CI 1.10–1.50], p<0.0017) or primary mitral regurgitation (1.29 [1.09–1.52], p=0.0030) incurred excess mortality. Heart failure was frequent (mean 64% [SE 1] at 5 years postdiagnosis), even in patients with left-ventricular ejection fraction of 50% or higher (49% [2] at 5 years postdiagnosis) or in those with primary mitral regurgitation (48% [2]). Mitral surgery was ultimately done in only 198 (15%) of 1294 patients, of which the predominant type of surgery was valve repair (in 149 [75%] patients). Mitral surgery was done in 28 (5%) of 538 patients with left-ventricular ejection fraction below 50% and in 170 (22%) of 756 patients with ejection fraction of 50% or higher, and in 34 (5%) of 723 with secondary mitral regurgitation versus 164 (29%) of 571 with primary regurgitation. All other types of cardiac surgery combined were performed in only 3% more patients (237 [18%] patients) than the number who underwent mitral surgery. In the community, isolated mitral regurgitation is common and is associated with excess mortality and frequent heart failure postdiagnosis in all patient subsets, even in those with normal left-ventricular ejection fraction and low comorbidity. Despite these poor outcomes, only a minority of affected patients undergo mitral (or any type of cardiac) surgery even in a community with all means of diagnosis and treatment readily available and accessible. This suggests that in a wider population there might be a substantial unmet need for treatment for this disorder. Mayo Clinic Foundation.