【摘要】 [目的]探讨心率变异性(HRV)与老年女性射血分数保留的心力衰竭(HFpEF)合并2型糖尿病(T2DM)患者主要不良心血管事件(MACE)发生风险之间的关系，评估HRV在该人群预后分层中的临床意义。[方法]采用回顾性队列研究。纳入2019年9月1日—2022年9月1日在青岛大学附属医院住院的老年女性HFpEF合并T2DM患者103例。初诊时收集患者的临床资料，包括一般资料、实验室检查结果、超声心动图参数及24 h动态心电图HRV参数。随访1年，依据是否发生MACE,将患者分为观察组和对照组，比较两组的基线特征差异。将单因素分析中P<0.1的变量先采用LASSO回归筛选变量后进行多因素Cox回归分析，探讨MACE的独立影响因素；应用Kaplan-Meier法绘制生存函数曲线，并以Log-rank检验比较组间差异。[结果]与对照组相比，观察组的年龄较大，心房颤动史占比更高，N末端B型利钠肽原(NT-proBNP)、舒张早期二尖瓣口血流峰值速度/二尖瓣环舒张早期运动速度(E/e′)及左心房容积指数(LAVI)水平升高(均P<0.05),同时多项HRV指标[正常窦性心律R-R间期标准差(SDNN)、相邻窦性R-R间期差值的均方根(RMSSD)、相邻窦性R-R间期差值>50 ms的心搏数占总窦性心律的百分比(pNN50)、高频功率(HF)、低频功率(LF)及极低频功率(VLF)]均显著降低，且β受体拮抗剂、达格列净使用率较低(均P<0.05)。LASSO-Cox回归分析显示，NT-proBNP升高(HR=1.01,95%CI:1.00～1.01)、LAVI升高(HR=1.16,95%CI:1.04～1.30)及SDNN降低(HR=0.94,95%CI:0.91～0.98)与MACE风险增加相关，使用达格列净(HR=0.18,95%CI:0.07～0.45)为独立保护因素(均P<0.05)。根据SDNN中位数(82 ms)将患者分为低HRV组和高HRV组，Kaplan-Meier生存曲线分析表明，两组无MACE再入院生存率差异有统计学意义(P=0.0043)。[结论] HRV降低(尤其SDNN)与HFpEF合并T2DM患者MACE风险显著增加密切相关，可作为评估自主神经功能紊乱和预后风险的重要参考指标。更多还原

【Abstract】 Aim To investigate the association between heart rate variability(HRV) and the risk of major adverse cardiovascular events(MACE) in elderly female with heart failure with preserved ejection fraction(HFpEF) and type 2 diabetes mellitus(T2DM), and to evaluate the clinical value of HRV for prognostic stratification in this population.Methods A retrospective cohort study was conducted. A total of 103 elderly female patients with HFpEF complicated by T2DM who were hospitalized in the Affiliated Hospital of Qingdao University from September 1, 2019 to September 1, 2022 were enrolled. Baseline clinical data were collected at initial assessment, including demographic characteristics, laboratory results, echocardiographic parameters, and 24-hour Holter-derived HRV indices. Patients were followed for 1 year and divided into the observation group(MACE group) and the control group(non-MACE group) according to the occurrence of MACE. Baseline characteristics were compared between the two groups. Variables with P<0.1 in univariable analysis were entered into least absolute shrinkage and selection operator(LASSO) regression for feature selection, followed by multivariable Cox proportional hazards regression to identify independent factors associated with MACE. Kaplan-Meier curves were constructed to estimate event-free survival, and between-group differences were evaluated using the Log-rank test. Results Compared with the control group, patients were older and had a higher prevalence of prior atrial fibrillation in the observation group(P<0.05). The levels of N-terminal pro-B-type natriuretic peptide(NT-proBNP), the ratio of peak early diastolic mitral inflow velocity to early diastolic mitral annular velocity(E/e′), and left atrial volume index(LAVI) were higher in the observation group(all P<0.05), whereas multiple HRV indices including standard deviation of all normal-to-normal R-R intervals(SDNN), root mean square of successive differences between normal-to-normal R-R intervals(RMSSD), percentage of successive normal-to-normal R-R intervals differing by more than 50 ms(pNN50), high-frequency power(HF), low-frequency power(LF), and very low-frequency power(VLF) were significantly lower(all P<0.05). In addition, the use of β-blockers and dapagliflozin was less frequent in the observation group(P<0.05). LASSO-Cox regression analysis showed higher NT-proBNP(HR=1.01, 95%CI: 1.00～1.01) and LAVI(HR=1.16, 95%CI: 1.04～1.30), as well as lower SDNN(HR=0.94, 95%CI: 0.91～0.98), were independently associated with an increased risk of MACE, whereas dapagliflozin use was an independent protective factor(HR=0.18, 95%CI: 0.07～0.45)(all P<0.05). The patients were divided into low-HRV and high-HRV groups according to the median SDNN(82 ms). Kaplan-Meier survival analysis showed that the difference in MACE-free survival rates between the two groups was statistically significant(P=0.0043). Conclusion Reduced HRV, especially SDNN, was significantly associated with an increased risk of MACE in elderly female patients with HFpEF and T2DM, suggesting that HRV may serve as a valuable indicator for evaluating autonomic dysfunction and adverse cardiovascular prognosis in this population.更多还原