Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.
Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium.
J Card Fail. 2017 Aug;23(8):597-605. doi: 10.1016/j.cardfail.2017.03.001. Epub 2017 Mar 8.
Cardiac resynchronization therapy (CRT) improves mortality and morbidity on top of optimal medical therapy in heart failure with reduced ejection fraction (HFrEF). This study aimed to elucidate the association between neurohumoral blocker up-titration after CRT implantation and clinical outcomes.
Doses of angiotensin-converting enzyme inhibitors (ACE-Is), angiotensin receptor blockers (ARBs), and beta-blockers were retrospectively evaluated in 650 consecutive CRT patients implanted from October 2008 to August 2015 and followed in a tertiary multidisciplinary CRT clinic. All 650 CRT patients were on a maximal tolerable dose of ACE-I/ARB and beta-blocker at the time of CRT implantation. However, further up-titration was successful in 45.4% for ACE-I/ARB and in 56.8% for beta-blocker after CRT-implantation. During a mean follow-up of 37 ± 22 months, a total of 139 events occurred for the combined end point of heart failure admission and all-cause mortality. Successful, versus unsuccessful, up-titration was associated with adjusted hazard ratios of 0.537 (95% confidence interval 0.316-0.913; P = .022) for ACE-I/ARB and 0.633 (0.406-0.988; P = .044) for beta-blocker on the combined end point heart failure admission and all-cause mortality. Patients in the up-titration group exhibited a similar risk for death or heart failure admission as patients treated with the maximal dose (ACE-I/ARB: P = .133; beta-blockers: P = .709).
After CRT, a majority of patients are capable of tolerating higher dosages of neurohumoral blockers. Up-titration of neurohumoral blockers after CRT implantation is associated with improved clinical outcomes, similarly to patients treated with the guideline-recommended target dose at the time of CRT implantation.
心脏再同步治疗（CRT）可改善射血分数降低的心力衰竭（HFrEF）患者的死亡率和发病率，优于最佳药物治疗。本研究旨在阐明 CRT 植入后神经激素阻滞剂滴定与临床结局之间的关系。
回顾性评估了 2008 年 10 月至 2015 年 8 月期间在一家三级多学科 CRT 诊所接受 CRT 植入的 650 例连续 CRT 患者的血管紧张素转换酶抑制剂（ACE-I）、血管紧张素受体阻滞剂（ARB）和β受体阻滞剂剂量。所有 650 例 CRT 患者在 CRT 植入时均使用 ACE-I/ARB 和β受体阻滞剂的最大耐受剂量。然而，在 CRT 植入后，ACE-I/ARB 的进一步滴定成功了 45.4%，β受体阻滞剂的滴定成功了 56.8%。在平均 37±22 个月的随访期间，共有 139 例患者发生心力衰竭入院和全因死亡率的联合终点事件。与不成功滴定相比，成功滴定与 ACE-I/ARB 的调整后风险比为 0.537（95%置信区间为 0.316-0.913；P=0.022），与β受体阻滞剂的调整后风险比为 0.633（0.406-0.988；P=0.044），用于心力衰竭入院和全因死亡率的联合终点。在滴定组中，患者的死亡或心力衰竭入院风险与接受最大剂量治疗的患者相似（ACE-I/ARB：P=0.133；β受体阻滞剂：P=0.709）。
在 CRT 后，大多数患者能够耐受更高剂量的神经激素阻滞剂。CRT 植入后神经激素阻滞剂的滴定与改善的临床结局相关，与 CRT 植入时接受指南推荐靶剂量治疗的患者相似。
