Clin Res Cardiol:β受体阻滞剂与慢性心力衰竭——达到“目标剂量”还是“目标心率”?

2018-11-29 阿拉蕾 中国医学论坛报

2018年11月26日是全国心力衰竭日。心力衰竭(简称“心衰”)是各种心脏疾病的严重表现或晚期阶段,死亡率和再住院率居高不下。我国心衰患病率呈持续升高的趋势,包括“中国心力衰竭诊断和治疗指南 2018”在内的国内外相关指南均推荐β受体阻滞剂作为射血分数降低的心衰(HFrEF)的常规治疗用药。

2018年11月26日是全国心力衰竭日。心力衰竭(简称“心衰”)是各种心脏疾病的严重表现或晚期阶段,死亡率和再住院率居高不下。我国心衰患病率呈持续升高的趋势,包括“中国心力衰竭诊断和治疗指南 2018”在内的国内外相关指南均推荐β受体阻滞剂作为射血分数降低的心衰(HFrEF)的常规治疗用药。

临床试验已证实,HFrEF患者长期应用β受体阻滞剂(琥珀酸美托洛尔、比索洛尔及卡维地洛),能改善症状和生活质量,降低死亡、住院、猝死风险。

β受体阻滞剂起始剂量须小,每隔2~4周可剂量加倍,逐渐达到指南推荐的目标剂量或最大可耐受剂量。

“中国心力衰竭诊断和治疗指南2018”中推荐琥珀酸美托洛尔、比索洛尔及卡维地洛的目标剂量分别为190 mg 1次/d,10 mg 1次/d,25 mg 2次/d。

指南同时也提出,静息心率降至60次/分左右的剂量为β受体阻滞剂应用的目标剂量或最大耐受剂量。

然而,在临床实际应用中,究竟是以“目标剂量”还是“目标心率”作为β受体阻滞剂的治疗标准,尚不清楚。2018年11月,发表于《Clinical Research in Cardiology》杂志的回顾性临床研究结果或许能给我们些启示。

研究设计

入组人群:缺血性心脏病或特发性扩张性心肌病所致的慢性收缩性心力衰竭患者,共1669名。所有患者均接受血管紧张素转换酶抑制剂(ACEI)或血管紧张素II受体拮抗剂(ARB)治疗,确诊慢性心衰病史至少6个月,左室射血分数(LVEF)≤40%。

中位随访时间:42.8个月。

分组:

A组,β受体阻滞剂达到目标剂量。

B组,治疗达到目标心率,但是β受体阻滞剂未达到目标剂量。

C组,目标剂量和目标心率均未达到。

D组,未使用β受体阻滞剂。

主要研究结果

1、A组,B组,C组和D组的5年死亡率分别为23.7%,22.7%,37.6%和55.6%。



2、A组患者中,静息心率≥70次/分的患者,死亡率为28.8%;心率在50-70次/分的患者,死亡率为14.8%。



3、既达到目标剂量又达到目标心率的患者,死亡率最低,但是差异未达到统计学意义(P=0.16)。

4、亚组分析显示,在窦性心律患者中,A组和B组的死亡率相近,分别为24.9%和19.8%,但是在房颤患者中,A组和B组的死亡率分别为29.2%和38.2%。

讨论部分重点

这项研究的主要发现包括以下几点:

1、仅有约2/3处于稳定期的慢性心力衰竭患者接受β受体阻滞剂治疗,仅有约12%的患者达到了推荐的目标剂量,约17.1%的患者达到目标心率。

2、与未使用β受体阻滞剂相比,使用β受体阻滞剂能显着改善患者的长期预后。

3、达到目标剂量与达到目标心率,对预后的影响相似。

4、研究结果显示既达到目标剂量又达到目标心率的患者,死亡率最低,虽然差异未达到统计学意义(P=0.16)。因此,如果在达到目标剂量的基础上,把达到目标心率作为附加治疗目标,可能会取得更高的生存获益。

研究者表示,与MERIT-HF、CIBIS II和COPERNICUS研究结果相似,这项研究结果同样显示,使用β受体阻滞剂能使患者的全因死亡率降低约35%。尽管如此,还是有相当多的患者在出院后没有接受β受体阻滞剂治疗。

这项研究结果也提示心率控制在慢性心力衰竭中的重要性,B组(达到目标心率,但是未达到目标剂量)与A组(达到目标剂量)患者的死亡率相近。

此外,针对慢性心力衰竭合并房颤的患者,心率控制是否能产生获益,尚有争议。本研究结果显示,在房颤患者中达到目标心率并未显示出生存获益,未来需要进一步研究以明确。

原始出处:Corletto AFröhlich HTäger T, et al, Beta blockers and chronic heart failure patients: prognostic impact of a dose targeted beta blocker therapy vs. heart rate targeted strategy. Clin Res Cardiol. 2018 Nov;107(11):1040-1049.

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