最新心衰指南开辟新天地

科罗拉多州斯诺马斯——美国心脏病学会(ACC)/美国心脏协会(AHA)发布的最新版心力衰竭指南，首次强调了醛固酮拮抗剂是射血分数下降的症状性或既往症状性心力衰竭的一个关键治疗药物。

 

醛固酮拮抗剂治疗在这部指南中得到了最强的推荐：Ⅰ类/A级证据推荐意见。这一推荐意见是基于多项随机试验的数据。这些试验显示，在使用得当的情况下，醛固酮拮抗剂可使死亡的相对风险降低30%，心力衰竭住院的相对风险降低35%，只需对6例患者治疗36个月，即可预防1例额外死亡。上述数据使得醛固酮拮抗剂在获益方面(见图)进入了非裔美国人Ⅰ类/A级心力衰竭药物的行列，与β受体阻断剂、ACE抑制剂或血管紧张素受体阻断剂以及肼屈嗪/硝酸异山梨酯相比肩。

 

指南引导的心力衰竭药物治疗的获益

药物	死亡相对风险降低	36个月内预防1例死亡的需治数	心力衰竭住院风险相对风险降低
肼屈嗪/硝酸异山梨酯	43%	7	33%
β受体阻断剂	34%	9	41%
醛固酮拮抗剂	30%	6	35%
ACEI或ARB	17%	26	31%

 

2013ACC/AHA指南编撰委员会主席、西北大学心脏病学教授Clyde W. Yancy博士在探讨该指南要点时指出：“这些数据非常引人注目。很多年来，我们始终感到在心力衰竭领域难有大的作为，但我现在不再这么想了。你们可以看到，需治数少得令人难以置信。只需对少量患者进行这类治疗即可带来死亡率的显著下降。我们应当将这些数据融入临床实践中。”

 

需要注意的是，醛固酮拮抗剂仅可用于估计肾小球滤过率＞30 ml/min•1.73m2且血清钾水平＜5.0 mEq/dl的患者。否则Ⅰ类/A级推荐意见会骤降为Ⅲ类/A级，意味着该治疗是不合理甚至可能有害的。

 

这部指南强调了采取指南引导的药物治疗(GDMT)的必要性。专家组发现，一项有说服力的分析显示，在射血分数降低的心力衰竭患者中，接受循证指南引导的2种干预措施者(共推荐7种干预措施)的校正后2年死亡风险，比未接受或仅接受1种干预措施者降低了38%，而接受3种干预措施者的死亡风险降低62%，接受≥4种干预措施者的死亡风险降低约70%(J. Am. Heart Assoc. 2012;1:16-26)。

 

这7种干预措施包括β受体阻断剂、ACE抑制剂或ARB、醛固酮拮抗剂、对房颤患者抗凝、心脏再同步治疗、可植入性心脏复律除颤器，以及对合格患者进行心力衰竭教育。

 

这部指南强烈反对联用ACE抑制剂与ARB，而应二选一。研究显示，这种联合用药没有额外获益，反而增加副作用风险。

 

这部指南的一大创新来自射血分数保留的心力衰竭，即HFpEF。

 

“新版心力衰竭指南的最独特之处在于将HFpEF放到了首页。这非常重要。我们意识到，目前没有任何循证干预措施能改变其自然史，而焦点是对共病的识别和治疗。”

 

该指南的其他要点包括，阐明生物标志物引导的心力衰竭治疗的角色。B型利钠肽(BNP)或N末端BNP前体指标被认为在诊断心力衰竭和确定预后方面是有价值的。可利用一系列检测指标将GDMT滴定至最佳剂量。但目前尚无数据显示，采用生物标志物滴定GDMT至较高剂量可降低死亡率。

 

2013 ACC/AHA心力衰竭治疗指南是由ACC、AHA与美国家庭医师协会(AAFP)、美国胸科医师协会(ACCP)、心律学会(HRS)和国际心肺移植学会(ISHLT)共同制定的(J. Am. Coll. Cardiol. 2013;62:e147-e239)。

 

Yancy博士报告称无相关利益冲突。

 

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By: BRUCE JANCIN, Cardiology News Digital Network

 

SNOWMASS, COLO. – The latest heart failure guidelines from the American College of Cardiology/American Heart Association place a new emphasis on aldosterone antagonists as a central aspect of the management of symptomatic or previously symptomatic heart failure with reduced ejection fraction – while underscoring important caveats to their use.

 

Aldosterone antagonist therapy earns the strongest possible designation in the guidelines: a Class I/Level of Evidence A recommendation. This is based on data from multiple randomized trials showing that, used appropriately, these agents result in a 30% relative risk reduction in mortality and a 35% reduction in the relative risk of heart failure hospitalization, with a number needed to treat for 36 months of just six patients to prevent one additional death. Those figures place the aldosterone antagonists on a par with the other Class I/A heart failure medications – beta-blockers, ACE inhibitors or angiotensin receptor blockers, and hydralazine/isosorbide dinitrate in African Americans – in terms of benefits (see chart).

 

"These data are quite striking," Dr. Clyde W. Yancy observed in presenting highlights of the 2013 ACC/AHA guidelines at the Annual Cardiovascular Conference at Snowmass.

 

"For many years, we’ve functioned in a space where we thought there’s not that much we can do for heart failure, and I would now argue stridently against that. You can see the incredibly low numbers needed to treat here. Only a handful of patients need to be exposed to these therapies to derive a significant benefit on mortality. These are data we should incorporate in our clinical practice without exclusion," declared Dr. Yancy, who chaired the heart failure guideline-writing committee.

 

The important caveat regarding the aldosterone antagonists is that they should be used only in patients with an estimated glomerular filtration rate greater than 30 mL/min per 1.73 m2 and a serum potassium level below 5.0 mEq/dL. Otherwise that Class I/A recommendation plummets to III/B, meaning the treatment is inappropriate and potentially harmful, continued Dr. Yancy, professor of medicine and of medical social sciences and chief of cardiology at Northwestern University, Chicago.

 

The guidelines emphasize the imperative to implement what has come to be termed guideline-directed medical therapy, known by the acronym GDMT. The panel found persuasive an analysis showing that heart failure patients with reduced ejection fraction who were on two of seven evidence-based, guideline-directed management interventions had an adjusted 38% reduction in 2-year mortality risk compared with those on none or one, while those on three interventions had a 62% decrease in the odds of mortality and patients on four or more had mortality reductions of about 70% (J. Am. Heart Assoc. 2012;1:16-26).

 

The seven interventions are beta-blockers, ACE inhibitors or ARBs, aldosterone antagonists, anticoagulation for atrial fibrillation, cardiac resynchronization therapy, implantable cardioverter-defibrillators, and heart failure education for eligible patients.

 

The guidelines advise strongly against the combined use of an ACE inhibitor and ARB. It’s an either/or treatment strategy. Studies indicate there is no additive benefit with the combination, only an increased risk of side effects.

 

An important innovation in the guidelines is the new prominence afforded to heart failure with preserved ejection fraction, known as HFpEF (pronounced heff-peff).

 

"What’s most different in the new heart failure guidelines is that we have uploaded HFpEF to the front page," said Dr. Yancy. "We want you to appreciate how important it is. We recognize that there’s no evidence-based intervention that changes its natural history; rather, the focus is on identification and treatment of the comorbidities. It’s important to emphasize that this is a novel way of thinking about heart failure for a very important iteration of that disease."

 

Among the other highlights of the guidelines is a clarification of the current role for biomarker-guided heart failure therapy. B-type natriuretic peptide (BNP) or N-terminal pro-BNP measurements are deemed useful in making the diagnosis of heart failure as well as in establishing prognosis. Serial measurements can be used to titrate GDMT to optimal doses. But there are as yet no data to show that using the biomarkers to titrate GDMT to higher doses improves mortality.

 

The 2013 ACC/AHA Guideline for the Management of Heart Failure was developed in collaboration with the American Academy of Family Physicians, the American College of Chest Physicians, the Heart Rhythm Society, and the International Society for Heart and Lung Transplantation (J. Am. Coll. Cardiol. 2013;62:e147-e239).

 

Dr. Yancy reported having no financial conflicts.

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学科代码：心血管病学　　　关键词：心力衰竭指南 醛固酮拮抗剂
来源： 爱思唯尔