心率和节律以及心力衰竭患者β受体阻滞剂的获益。
Heart Rate and Rhythm and the Benefit of Beta-Blockers in Patients With Heart Failure.
机构信息
University of Birmingham Institute of Cardiovascular Sciences, Birmingham, United Kingdom; Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia.
Norwich Medical School, University of East Anglia, Norwich, United Kingdom.
出版信息
J Am Coll Cardiol. 2017 Jun 20;69(24):2885-2896. doi: 10.1016/j.jacc.2017.04.001. Epub 2017 Apr 30.
BACKGROUND
The relationship between mortality and heart rate remains unclear for patients with heart failure with reduced ejection fraction in either sinus rhythm or atrial fibrillation (AF).
OBJECTIVES
This analysis explored the prognostic importance of heart rate in patients with heart failure with reduced ejection fraction in randomized controlled trials comparing beta-blockers and placebo.
METHODS
The Beta-Blockers in Heart Failure Collaborative Group performed a meta-analysis of harmonized individual patient data from 11 double-blind randomized controlled trials. The primary outcome was all-cause mortality, analyzed with Cox proportional hazard ratios (HR) modeling heart rate measured at baseline and approximately 6 months post-randomization.
RESULTS
A higher heart rate at baseline was associated with greater all-cause mortality for patients in sinus rhythm (n = 14,166; adjusted HR: 1.11 per 10 beats/min; 95% confidence interval [CI]: 1.07 to 1.15; p < 0.0001) but not in AF (n = 3,034; HR: 1.03 per 10 beats/min; 95% CI: 0.97 to 1.08; p = 0.38). Beta-blockers reduced ventricular rate by 12 beats/min in both sinus rhythm and AF. Mortality was lower for patients in sinus rhythm randomized to beta-blockers (HR: 0.73 vs. placebo; 95% CI: 0.67 to 0.79; p < 0.001), regardless of baseline heart rate (interaction p = 0.35). Beta-blockers had no effect on mortality in patients with AF (HR: 0.96, 95% CI: 0.81 to 1.12; p = 0.58) at any heart rate (interaction p = 0.48). A lower achieved resting heart rate, irrespective of treatment, was associated with better prognosis only for patients in sinus rhythm (HR: 1.16 per 10 beats/min increase, 95% CI: 1.11 to 1.22; p < 0.0001).
CONCLUSIONS
Regardless of pre-treatment heart rate, beta-blockers reduce mortality in patients with heart failure with reduced ejection fraction in sinus rhythm. Achieving a lower heart rate is associated with better prognosis, but only for those in sinus rhythm.
背景
在窦性节律或心房颤动（AF）的射血分数降低的心力衰竭患者中，死亡率与心率之间的关系尚不清楚。
目的
本分析探讨了在比较β受体阻滞剂和安慰剂的随机对照试验中，射血分数降低的心力衰竭患者心率的预后重要性。
方法
β受体阻滞剂在心力衰竭协作组对 11 项双盲随机对照试验的协调个体患者数据进行了荟萃分析。主要结局是全因死亡率，使用 Cox 比例风险比（HR）模型分析基线和随机分组后约 6 个月时测量的心率。
结果
窦性节律患者的基线心率较高与全因死亡率增加相关（n=14166；校正 HR：每 10 次/分钟增加 1.11；95%置信区间[CI]：1.07 至 1.15；p<0.0001），但在 AF 中则不然（n=3034；HR：每 10 次/分钟增加 1.03；95%CI：0.97 至 1.08；p=0.38）。β受体阻滞剂使窦性节律和 AF 患者的心室率降低 12 次/分钟。窦性节律患者随机接受β受体阻滞剂治疗的死亡率较低（HR：0.73 比安慰剂；95%CI：0.67 至 0.79；p<0.001），无论基线心率如何（交互作用 p=0.35）。β受体阻滞剂对任何心率的 AF 患者（HR：0.96，95%CI：0.81 至 1.12；p=0.58）的死亡率均无影响（交互作用 p=0.48）。无论治疗如何，实现较低的静息心率仅与窦性节律患者的预后更好相关（HR：每增加 10 次/分钟增加 1.16，95%CI：1.11 至 1.22；p<0.0001）。
结论
无论治疗前心率如何，β受体阻滞剂均可降低窦性节律射血分数降低的心力衰竭患者的死亡率。实现较低的心率与更好的预后相关，但仅适用于窦性节律患者。
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