Centre d'Investigation Clinique Plurithématique 1433, INSERM U1116, University of Lorraine, Nancy, France.
Department of Physiology and Cardiothoracic Surgery, Cardiovascular Research and Development Unit, Faculty of Medicine, University of Porto, Porto, Portugal.
Eur J Heart Fail. 2017 Aug;19(8):974-986. doi: 10.1002/ejhf.814. Epub 2017 Apr 12.
The aim of personalized medicine is to offer a tailored approach to each patient in order to provide the most effective therapy, while reducing risks and side effects. The use of mineralocorticoid receptor antagonists (MRAs) has demonstrated major benefits in heart failure with reduced ejection fraction (HFrEF), results with challenging inconsistencies in heart failure with preserved ejection fraction (HFpEF), and 'neutral' preliminary results in acute heart failure. Data derived from landmark trials are generally applied in a 'one size fits all' manner and the development and implementation of more personalized MRA management would offer the potential to improve outcomes and reduce side effects. However, the personalization of pharmacotherapy regimens remains poorly defined in the cardiovascular field (in light of current knowledge) and until further trials targeting specific subpopulations have been conducted, MRAs should be provided to the great majority of HFrEF patients in the absence of contraindication. Spironolactone should be considered for symptomatic HFpEF patients with elevated natriuretic peptides. In the near future, trials should target HFrEF patients using exclusion criteria sourced from landmark trials (e.g. severe renal impairment), select more homogeneous HFpEF populations (e.g. with elevated BNP and structural abnormalities on echocardiography), and determine which patients are likely to benefit from MRAs (e.g. according to prespecified biomarkers).
个体化医学的目标是为每个患者提供量身定制的治疗方法，以提供最有效的治疗，同时降低风险和副作用。醛固酮受体拮抗剂（MRA）的使用在心衰射血分数降低（HFrEF）中显示出了显著的益处，在心衰射血分数保留（HFpEF）中结果具有挑战性且不一致，在心衰急性发作中则有初步的“中性”结果。来自标志性试验的数据通常以“一刀切”的方式应用，而开发和实施更个体化的 MRA 管理将有可能改善结果并减少副作用。然而，在心血管领域（根据当前知识），药物治疗方案的个体化仍然定义不明确，在针对特定亚群的进一步试验进行之前，大多数 HFrEF 患者不应存在禁忌证时应给予 MRA。螺内酯应考虑用于有升高的利钠肽的有症状的 HFpEF 患者。在不久的将来，试验应针对使用标志性试验中的排除标准的 HFrEF 患者（例如严重肾功能损害），选择更同质的 HFpEF 人群（例如 BNP 升高和超声心动图上有结构异常），并确定哪些患者可能从 MRA 中获益（例如根据预先指定的生物标志物）。
