Lancet:欧洲心脏病学会β受体阻滞剂使用推荐受挑战

2014-02-27 坞霜降 丁香园

对于ESC推荐的非心脏手术围手术期β指南,界内存在颇多争议,因此,部分心脏病学研究者认为有必要撰写一个新的指南来指导β受体阻滞的临床治疗。 最近在International Journal of Cardiology杂志发布的新指南中,研究者认为β受体阻滞剂并不能作为围手术期保护的常规用药,因为研究显示旧指南方案会造成死亡率升高。 新指南的撰写者来自英国伦敦帝国理工学院,他们的在H

对于ESC推荐的非心脏手术围手术期β指南,界内存在颇多争议,因此,部分心脏病学研究者认为有必要撰写一个新的指南来指导β受体阻滞的临床治疗。

最近在International Journal of Cardiology杂志发布的新指南中,研究者认为β受体阻滞剂并不能作为围手术期保护的常规用药,因为研究显示旧指南方案会造成死亡率升高。

新指南的撰写者来自英国伦敦帝国理工学院,他们的在Heart杂志发布的meta分析中建议,如果按照ESC指南推荐方案,非心脏手术的高危患者围手术期接受β受体阻滞剂治疗后,死亡率可能会上升27%点。

随后, European Heart Journal(EHJ)网站发布了一篇评论,提出ESC指南可能造成了患者的超额死亡,该评论即将发布。

事实上,就ESC指南的研究数据心脏病学专家曾提出过质疑,该指南所依据的数据大多数来自于DECREASE研究,而该研究是由Poldermans教授领导,即ESC指南专家小组的前任主席。早在2011年,Poldermans教授因“学术不端”(篡改了大量研究数据)遭解聘。但是迄今为止,他的研究论文仅一篇被撤回。

在接受Lancet采访时,Francis 和Cole博士一致认为,当前最紧要的问题是如何使指南安的全性得到提高。超额死亡人数的问题上,不同的研究会得出不同的结果,与其在这个问题上争论,不如将精力放在如何捍卫患者的生存率上。

“自从发布meta分析后,我们先后发布了那篇被撤回的文章,按照相关研究数据起草新指南,并向EHJ提交了有关新指南可能性的意见和建议。我们希望藉此来保护患者。”Francis 和Cole博说。

本月EHJ发表了一篇社论力图平息公众的"恐慌"。文中提出警告,“对于医生和患者来说,过早下结论都是非常危险的:另一方面,ESC正着手修正指南,预计于8月份再行发布。”

EHJ的Lüscher 主编提出,Poldermans教授的研究数据确实存在问题,确实需要重新分析数据来更正其中的错误。医生们现在面对如下窘境:已经使用β受体阻滞剂的患者是否需要停药,高危患者是否使用β受体阻滞剂?

目前仅用一个新指南无法解决该类问题,找到适合有效的方案比为某个患者指定治疗方案要困难的多。

对于β受体阻滞剂使用方案,ESC提出,“β受体阻滞剂不能作为常规用药,但是临床医生应按照患者病情差异,仔细斟酌可进行使用”。有医生质疑这种观点是否有实际意义。

作为英国沃特福德医院心内科的领军人物, Khan教授认为ESC指南仅仅告诉大家治疗要因人而异,并没有就过去几年出现的数据问题提出反馈。因此,尽管ESC指南要求临床医生应该逐步增加剂量,但他们不打算这么实施。

研究者们认为必须尽快撤回旧指南,起草更为实用的新指南。

作为Baylor心脏和血管研究所知名心脏病学专家,Reviews in Cardiovascular Medicine杂志编辑,McCullough教授他认为,对于某个亚组的患者群体(如因血管严重阻塞引起的心肌梗死患者),β受体阻滞剂可能是有作用的。

但是,如果回顾下DECREASE研究,会发现很多设计方案不切实际。“我们可能因为部分数据而误入歧途,现在回过头看看,被这些东西所误导确实有点荒谬。”McCullough教授说。

加拿大McMaster大学Devereux教授开展了名为POISE的医学研究,他发现围手术期使用β受体阻滞剂提高了因心肌梗死及中风造成的超额死亡率。

旧指南的审查已经花了相当长的一段时间,但是对于社会进步来说仅仅是一个短暂的过程。另一方面,如果临床医生可以结合患者的个体差异进行诊疗,不会因指南问题而出现太多的失误,Lüscher主编总结道:“指南不是我们医疗工作者逃避责任的免死金牌,恰恰相反,我们应该时时对其进行更正,并因人而异的使用。”

原始出处:

Lilian Anekwe.New guideline on β blockers challenges ESC advice.The Lancet,  22 February 2014 doi:10.1016/S0140-6736(14)60243-9Cite 

Nowbar AN1, Cole GD2, Shun-Shin MJ2, Finegold JA2, Francis DP2.International RCT-based guidelines for use of preoperative stress testing and perioperative beta-blockers and statins in non-cardiac surgery.Int J Cardiol. 2014 Mar 1;172(1):138-43. doi: 10.1016/j.ijcard.2013.12.309. Epub 2014 Jan 15.

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    2014-10-14 howi
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    2014-04-16 zhyy88
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    2014-03-23 qblt
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