De Vecchis Renato, Cantatrione Claudio, Mazzei Damiana, Barone Augusto, Maurea Nicola
Cardiology Unit, Presidio Sanitario Intermedio "Elena d'Aosta", ASL Napoli 1 Centro, Napoli, Italy.
Division of Sports Medicine, Presidio Sanitario Intermedio "Elena d'Aosta", ASL Napoli 1 Centro, Napoli, Italy.
J Clin Med Res. 2017 Feb;9(2):130-142. doi: 10.14740/jocmr2851w. Epub 2016 Dec 31.
Aldosterone receptor antagonists (ARAs) have been associated with improved clinical outcomes in patients with heart failure with reduced left ventricular ejection fraction (HFREF), but not in those with heart failure with preserved left ventricular ejection fraction (HFpEF). With the aim to study this topic more deeply, we carried out a meta-analysis of selective and non-selective ARAs in HFREF and HFpEF.
We searched PubMed and Scopus databases. We decided to incorporate in the meta-analysis only randomized controlled trials (RCTs) of ARAs in patients with chronic heart failure (CHF) if they met the following criteria: experimental groups included patients with CHF treated with ARAs in addition to the conventional therapy; control groups included patients with CHF receiving conventional therapy without ARAs. Outcomes of interest were all-cause death, hospitalizations from cardiovascular cause, hyperkalemia, or gynecomastia.
We detected 15 studies representing 15,671 patients. ARAs were associated with a reduced odds of all-cause death (odds ratio (OR): 0.79; 95% confidence interval (CI): 0.73 - 0.87) and hospitalizations from cardiovascular cause (OR: 0.73; 95% CI: 0.61 - 0.89). However, subgroup analysis showed that these advantages were limited to HFREF (all-cause death: OR: 0.77, 95% CI: 0.69 - 0.84; hospitalizations from cardiovascular cause: OR: 0.66, 95% CI: 0.51 - 0.85), but they did not affect the HFpEF group (all-cause death: OR: 0.91, 95% CI: 0.76 - 1.1; hospitalizations from cardiovascular cause: OR: 0.85, 95% CI: 0.7 - 1.09). ARAs increased the risk of hyperkalemia (OR: 2.17; 95% CI: 1.88 - 2.5). Non-selective ARAs, but not selective ARAs, increased the risk of gynecomastia (OR: 8.22, 95% CI: 4.9 - 13.81 vs. OR: 0.74, 95% CI: 0.43 - 1.27).
ARAs reduced the risk of adverse cardiac events in HFREF but not HFpEF. In particular, ARA use in HFpEF patients is questionable, since in this CHF type, no significant improvement in all-cause death and cardiovascular hospitalizations was demonstrated with ARA treatment, in the face of the well-known risks of hyperkalemia and/or gynecomastia that chronic ARA therapy entails. Selective ARAs were equally effective as non-selective ARAs, without the risk of gynecomastia.
醛固酮受体拮抗剂（ARAs）已被证明可改善左心室射血分数降低的心力衰竭（HFREF）患者的临床结局，但对左心室射血分数保留的心力衰竭（HFpEF）患者则不然。为了更深入地研究这一课题，我们对HFREF和HFpEF患者使用选择性和非选择性ARAs进行了一项荟萃分析。
我们检索了PubMed和Scopus数据库。如果慢性心力衰竭（CHF）患者的随机对照试验（RCTs）符合以下标准，我们决定将其纳入荟萃分析：试验组包括除常规治疗外还接受ARAs治疗的CHF患者；对照组包括仅接受常规治疗而未使用ARAs的CHF患者。感兴趣的结局包括全因死亡、心血管原因导致的住院、高钾血症或男性乳房发育。
我们检索到15项研究，涉及15671名患者。ARAs与全因死亡几率降低（优势比（OR）：0.79；95%置信区间（CI）：0.73 - 0.87）和心血管原因导致的住院几率降低（OR：0.73；95%CI：0.61 - 0.89）相关。然而，亚组分析表明，这些益处仅限于HFREF患者（全因死亡：OR：0.77，95%CI：0.69 - 0.84；心血管原因导致的住院：OR：0.66，95%CI：0.51 - 0.85），但对HFpEF组没有影响（全因死亡：OR：0.91，95%CI：0.76 - 1.1；心血管原因导致的住院：OR：0.85，95%CI：0.7 - 1.09）。ARAs增加了高钾血症风险（OR：2.17；95%CI：1.88 - 2.5）。非选择性ARAs而非选择性ARAs增加了男性乳房发育风险（OR：8.22，95%CI：4.9 - 13.81对比OR：0.74，95%CI：0.43 - 1.27）。
ARAs降低了HFREF患者不良心脏事件的风险，但对HFpEF患者无效。特别是，在HFpEF患者中使用ARAs存在疑问，因为在这种CHF类型中，ARAs治疗并未显示出全因死亡和心血管住院方面的显著改善，同时还面临慢性ARAs治疗带来的高钾血症和/或男性乳房发育等已知风险。选择性ARAs与非选择性ARAs同样有效，且无男性乳房发育风险。
