Verdecchia Paolo, Angeli Fabio, Cavallini Claudio, Gattobigio Roberto, Gentile Giorgio, Staessen Jan A, Reboldi Gianpaolo
Ospedale S. Maria della Misericordia, Cardiologia, Perugia, Italy.
Eur Heart J. 2009 Mar;30(6):679-88. doi: 10.1093/eurheartj/ehn575. Epub 2009 Jan 23.
It is unclear whether prevention of congestive heart failure (CHF) by drugs that inhibit the renin-angiotensin system (RAS) occurs over and beyond the reduction in blood pressure (BP) achieved by these drugs.
We conducted a meta-analysis of trials comparing angiotensin-converting enzyme inhibitors (ACEIs), angiotensin-receptor blockers (ARBs), or calcium-channel blockers (CCBs), with diuretics, beta-blockers, or placebo in hypertensive or high-risk subjects without CHF at entry. Both fixed- and random-effect models were used. In trials vs. placebo, the risk of CHF was reduced by 21% with ACEIs (P = 0.007), whereas the effect of ARBs and CCBs was not significant (random-effect models). Thus, CCBs did not increase the risk of CHF. In trials vs. diuretics/beta-blockers, no differences were found between ACEIs and comparators [odds ratio (OR) 1.02; 95% confidence interval (CI) 0.84-1.24], whereas CCBs were associated with an 18% higher risk of CHF (OR 1.18; 95% CI 1.00-1.39; P = 0.048). Therefore, ACEIs were not superior to diuretics/beta-blockers for the prevention of CHF. Because heterogeneity between trials was significant, we investigated potential sources of heterogeneity by meta-regression. The risk of CHF decreased by 24% (P < 0.001) for each 5 mmHg reduction in systolic BP. The risk of CHF was 19% less with ACEIs/ARBs than CCBs (P < 0.001) and 16% less in studies without multiple risk factors required for entry (P = 0.009).
BP reduction is beneficial for the prevention of CHF. Over and beyond BP reduction, the protective effect of ACEIs and ARBs is greater than that of CCBs.
通过抑制肾素 - 血管紧张素系统（RAS）的药物预防充血性心力衰竭（CHF）是否超出这些药物所实现的血压（BP）降低效果尚不清楚。
我们对在入组时无CHF的高血压或高危受试者中，比较血管紧张素转换酶抑制剂（ACEIs）、血管紧张素受体阻滞剂（ARBs）或钙通道阻滞剂（CCBs）与利尿剂、β受体阻滞剂或安慰剂的试验进行了荟萃分析。使用了固定效应模型和随机效应模型。在与安慰剂对照的试验中，ACEIs使CHF风险降低了21%（P = 0.007），而ARBs和CCBs的效果不显著（随机效应模型）。因此，CCBs不会增加CHF风险。在与利尿剂/β受体阻滞剂对照的试验中，ACEIs与对照药物之间未发现差异[比值比（OR）1.02；95%置信区间（CI）0.84 - 1.24]，而CCBs与CHF风险高18%相关（OR 1.18；95% CI 1.00 - 1.39；P = 0.048）。因此，在预防CHF方面，ACEIs并不优于利尿剂/β受体阻滞剂。由于试验之间的异质性显著，我们通过荟萃回归研究了异质性的潜在来源。收缩压每降低5 mmHg，CHF风险降低24%（P < 0.001）。ACEIs/ARBs组的CHF风险比CCBs组低19%（P < 0.001），在无需入组时具备多种风险因素的研究中低16%（P = 0.009）。
降低血压对预防CHF有益。除降低血压外，ACEIs和ARBs的保护作用大于CCBs。
