Krum Henry, Haas Steven Joseph, Eichhorn Eric, Ghali Jalal, Gilbert Edward, Lechat Philippe, Packer Milton, Roecker Ellen, Verkenne Patricia, Wedel Hans, Wikstrand John
NHMRC Centre of Clinical Research Excellence in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University Central and Eastern Clinical School, Alfred Hospital, Melbourne 3004, Australia.
Eur Heart J. 2005 Oct;26(20):2154-8. doi: 10.1093/eurheartj/ehi409. Epub 2005 Jul 13.
Beta-blockers (BBs) confer significant prognostic benefit in patients (pts) with systolic chronic heart failure (CHF). However, major trials have thus far studied BBs mainly in addition to ACE-Inhibitors or angiotensin receptor blockers (ARBs) as background therapy. The magnitude of the prognostic benefit of BBs in the absence of ACE-I or ARB has not as yet been determined.
We performed a meta-analysis of all placebo-controlled BB studies in patients with CHF (n>200). Trials were identified via Medline literature searches, meeting abstracts, and contact with study organizations. Results for all-cause mortality and death or heart failure hospitalization were pooled using the Mantel-Haenszel (fixed effects) method. The impact of BB therapy on all-cause mortality in CHF, in the absence (4.8%) and presence (95.2%) of ACE-I (or ARB), was determined from six trials of 13 370 patients. The risk ratio (RR) for BBs vs. placebo was 0.73 [95% confidence interval (CI) 0.53-1.02] in the absence of ACE-I or ARB at baseline, compared with a RR of 0.76 (95% CI 0.71-0.83) in the presence of these agents. When ACE-Inhibitors were analysed in the same way (pre-BB), a RR of 0.89 (0.80-0.99) vs. placebo was observed in studies of >90 days. The impact of BB therapy on death or HF hospitalization in systolic CHF, in the absence and presence of ACE-I, was determined from three trials of 8988 patients. The RR for BBs vs. placebo was 0.81 (95% CI 0.61-1.08) in the absence of ACE-I or ARB at baseline, compared with a RR of 0.78 (95% CI 0.74-0.83) in the presence of these agents. When ACE-Is were analysed in the same way (pre-BB), a RR of 0.85 (95% CI 0.78-0.93) vs. placebo was observed in studies of >90 days.
The magnitude of the prognostic benefit conferred by BBs in the absence of ACE-I appears to be similar to those of ACE-Is in systolic CHF. These data therefore suggest that either ACE-Is or BBs could be used as first-line neurohormonal therapy in patients with systolic CHF. Prospective studies directly comparing these agents are required to definitively address this issue.
β受体阻滞剂（BBs）对收缩性慢性心力衰竭（CHF）患者具有显著的预后益处。然而，迄今为止，主要试验主要研究了在ACE抑制剂或血管紧张素受体阻滞剂（ARBs）作为背景治疗的基础上加用BBs。在没有ACE-I或ARB的情况下，BBs的预后益处程度尚未确定。
我们对所有CHF患者（n>200）的安慰剂对照BB研究进行了荟萃分析。通过Medline文献检索、会议摘要以及与研究机构联系来识别试验。使用Mantel-Haenszel（固定效应）方法汇总全因死亡率和死亡或心力衰竭住院的结果。在13370例患者的六项试验中，确定了在没有（4.8%）和有（95.2%）ACE-I（或ARB）的情况下，BB治疗对CHF全因死亡率的影响。在基线时没有ACE-I或ARB的情况下，BBs与安慰剂相比的风险比（RR）为0.73 [95%置信区间（CI）0.53 - 1.02]，而在有这些药物的情况下RR为0.76（95% CI 0.71 - 0.83）。当以同样方式分析ACE抑制剂（BB治疗前）时，在超过90天的研究中观察到与安慰剂相比RR为0.89（0.80 - 0.99）。在8988例患者的三项试验中，确定了在没有和有ACE-I的情况下，BB治疗对收缩性CHF死亡或HF住院的影响。在基线时没有ACE-I或ARB的情况下，BBs与安慰剂相比的RR为0.81（95% CI 0.61 - 1.08），而在有这些药物的情况下RR为0.78（95% CI 0.74 - 0.83）。当以同样方式分析ACE-Is（BB治疗前）时，在超过90天的研究中观察到与安慰剂相比RR为0.85（95% CI 0.78 - 0.93）。
在没有ACE-I的情况下，BBs所带来的预后益处程度似乎与收缩性CHF中ACE-Is的相似。因此，这些数据表明，ACE-Is或BBs均可作为收缩性CHF患者的一线神经激素治疗药物。需要进行直接比较这些药物的前瞻性研究来明确解决这个问题。
