Department of Medicine, Duke University Medical Center, Durham, North Carolina.
Department of Medicine, Duke University Medical Center, Durham, North Carolina; Division of Cardiology, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
J Am Coll Cardiol. 2017 May 23;69(20):2542-2550. doi: 10.1016/j.jacc.2017.03.563.
Heart failure (HF) is associated with significant morbidity and mortality. Although initially thought to be harmful in HF, beta-adrenergic blockers (β-blockers) have consistently been shown to reduce mortality and HF hospitalization in chronic HF with reduced ejection fraction. Proposed mechanisms include neurohormonal blockade and heart rate reduction. A new therapeutic agent now exists to target further heart rate lowering in patients who have been stable on a "maximally tolerated β-blocker dose," but this definition and how to achieve it are incompletely understood. In this review, the authors summarize published reports on the mechanisms by which β-blockers improve clinical outcomes. The authors describe differences in doses achieved in landmark clinical trials and those observed in routine clinical practice. They further discuss reasons for intolerance and the evidence behind using β-blocker dose and heart rate as therapeutic targets. Finally, the authors offer recommendations for clinicians actively initiating and up-titrating β-blockers that may aid in achieving maximally tolerated doses.
心力衰竭（HF）与较高的发病率和死亡率相关。尽管最初认为在心力衰竭中β受体阻滞剂（β-blockers）是有害的，但在射血分数降低的慢性心力衰竭中，β受体阻滞剂一直被证明可以降低死亡率和心力衰竭住院率。提出的机制包括神经激素阻断和心率降低。现在有一种新的治疗药物可以针对那些在“最大耐受剂量β受体阻滞剂”下稳定的患者进一步降低心率，但这个定义以及如何实现它还不完全清楚。在这篇综述中，作者总结了关于β受体阻滞剂改善临床结局的机制的已发表报告。作者描述了在标志性临床试验中达到的剂量与在常规临床实践中观察到的剂量之间的差异。他们进一步讨论了不耐受的原因以及将β受体阻滞剂剂量和心率作为治疗靶点的证据。最后，作者为积极开始和增加β受体阻滞剂剂量的临床医生提供了建议，这可能有助于达到最大耐受剂量。
