Macdonald P S, Keogh A M, Aboyoun C L, Lund M, Amor R, McCaffrey D J
Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, Australia.
J Am Coll Cardiol. 1999 Mar 15;33(4):924-31. doi: 10.1016/s0735-1097(98)00680-9.
The purpose of this study was to assess the tolerability and efficacy of carvedilol in patients with New York Heart Association (NYHA) functional class IV symptoms.
Carvedilol, a nonselective beta-adrenergic blocking drug with alpha-adrenergic blocking and antioxidant properties, has been shown to improve left ventricular function and clinical outcome in patients with mild to moderate chronic heart failure.
We retrospectively analyzed the outcomes of 230 patients with heart failure treated with carvedilol who were stratified according to baseline functional class: 63 patients were NYHA class IV and 167 were NYHA class I, II or III. Carvedilol was commenced at 3.125 mg b.i.d. and titrated to 25 mg b.i.d. as tolerated. Patients with class IV symptoms were older (p = 0.03), had lower left ventricular fractional shortening (p < 0.001), had lower six-min walk distance (p < 0.001) and were receiving more heart failure medications at baseline compared with less symptomatic patients.
Nonfatal adverse events while taking carvedilol occurred more frequently in class IV patients (43% vs. 24%, p < 0.0001), and more often resulted in permanent withdrawal of the drug (25% vs. 13%, p < 0.01). Thirty-seven (59%) patients who were NYHA class IV at baseline had improved by one or more functional class at 3 months, 8 (13%) were unchanged and 18 (29%) had deteriorated or died. Among the less symptomatic group, 62 (37%) patients had improved their NYHA status at 3 months, 73 (44%) were unchanged and 32 (19%) had deteriorated or died. The differences in symptomatic outcome at three months between the two groups were statistically significant (p = 0.001, chi-square analysis). Both groups demonstrated similar significant improvements in left ventricular dimensions and systolic function.
Patients with chronic NYHA class IV heart failure are more likely to develop adverse events during initiation and dose titration when compared with less symptomatic patients but are more likely to show symptomatic improvement in the long term. We conclude that carvedilol is a useful adjunctive therapy for patients with NYHA class IV heart failure; however, they require close observation during initiation and titration of the drug.
本研究旨在评估卡维地洛对纽约心脏协会（NYHA）心功能IV级症状患者的耐受性和疗效。
卡维地洛是一种具有α肾上腺素能阻断和抗氧化特性的非选择性β肾上腺素能阻断药物，已被证明可改善轻至中度慢性心力衰竭患者的左心室功能和临床结局。
我们回顾性分析了230例接受卡维地洛治疗的心力衰竭患者的结局，这些患者根据基线心功能分级进行分层：63例为NYHA IV级，167例为NYHA I、II或III级。卡维地洛起始剂量为3.125mg，每日两次，根据耐受情况滴定至25mg，每日两次。与症状较轻的患者相比，IV级症状患者年龄更大（p = 0.03），左心室缩短分数更低（p < 0.001），6分钟步行距离更低（p < 0.001），且在基线时接受更多的心力衰竭药物治疗。
服用卡维地洛期间，非致命性不良事件在IV级患者中更频繁发生（43%对24%，p < 0.0001），且更常导致药物永久性停用（25%对13%，p < 0.01）。37例（59%）基线时为NYHA IV级的患者在3个月时心功能分级改善一级或更多，8例（13%）无变化，18例（29%）恶化或死亡。在症状较轻的组中，62例（37%）患者在3个月时NYHA状态改善，73例（44%）无变化，32例（仅占19%）恶化或死亡。两组在3个月时症状结局的差异具有统计学意义（p = 0.001，卡方分析）。两组在左心室大小和收缩功能方面均显示出相似的显著改善。
与症状较轻的患者相比，慢性NYHA IV级心力衰竭患者在起始治疗和剂量滴定期间更易发生不良事件，但从长期来看更可能出现症状改善。我们得出结论，卡维地洛是NYHA IV级心力衰竭患者有用的辅助治疗药物；然而，在药物起始和滴定期间需要密切观察。
