依那普利治疗后估算肾小球滤过率的急剧下降与射血分数降低的心力衰竭患者的死亡率和心血管结局。
Acute declines in estimated glomerular filtration rate on enalapril and mortality and cardiovascular outcomes in patients with heart failure with reduced ejection fraction.
机构信息
Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA.
Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts, USA; Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts, USA.
出版信息
Kidney Int. 2019 Nov;96(5):1185-1194. doi: 10.1016/j.kint.2019.05.019. Epub 2019 Jun 11.
Angiotensin-converting enzyme inhibitors are beneficial in heart failure with reduced ejection fraction but are associated with acute declines in estimated glomerular filtration rate (eGFR). Prior studies evaluating thresholds of eGFR decline while using angiotensin-converting enzyme inhibitors in heart failure with reduced ejection have not taken into account this medication-driven decline. Here we used data from the Studies of Left Ventricular Dysfunction (SOLVD) trial of 6245 patients and performed Cox proportional hazards regression models to calculate hazard ratios of all-cause mortality and heart failure hospitalization-associated with percent eGFR decline at two- and six-weeks after randomization to enalapril versus placebo. In reference to placebo with equal degree of percent eGFR decline, any eGFR decline in the enalapril arm was associated with lower hazard of both outcomes. Under a conservative estimate using zero percent eGFR decline in the placebo arm as the reference, up to a 10% decline with enalapril was associated with mortality benefit (hazard ratio 0.87 [95% confidence interval 0.77, 0.99]) while up to a 35% decline was associated with decreased risk of heart failure hospitalization (0.78 [0.61, 0.98]). Under an intermediate estimate, up to a 15% decline with enalapril was associated with a mortality benefit (0.86 [0.77, 0.97]) and all levels of eGFR decline were associated with decreased risk of heart failure hospitalization. There was no percent eGFR decline, including up to 40%, in any models at either two- or six-weeks where enalapril was associated with higher mortality risk. Thus, in patients with reduced ejection fraction heart failure, enalapril is associated with decreased risk of mortality and heart failure hospitalizations. Hence, compelling reasons beyond moderate eGFR decline ought to be considered before its use is withdrawn.
血管紧张素转换酶抑制剂在射血分数降低的心力衰竭中有益，但与估算肾小球滤过率 (eGFR) 的急性下降有关。以前评估在射血分数降低的心力衰竭中使用血管紧张素转换酶抑制剂时 eGFR 下降阈值的研究并未考虑到这种药物引起的下降。在这里，我们使用了来自 Studies of Left Ventricular Dysfunction (SOLVD) 试验的 6245 名患者的数据，并进行了 Cox 比例风险回归模型，以计算随机分配到依那普利与安慰剂后两到六周时 eGFR 下降百分比与全因死亡率和心力衰竭住院相关的风险比。与安慰剂相比，eGFR 下降相同程度的风险比，依那普利组任何 eGFR 下降都与两种结局的风险降低相关。在保守估计中，将安慰剂组 eGFR 下降 0%作为参考，依那普利的 eGFR 下降 10%与死亡率获益相关（风险比 0.87[95%置信区间 0.77, 0.99]），而 eGFR 下降 35%与心力衰竭住院风险降低相关（0.78[0.61, 0.98]）。在中间估计中，依那普利的 eGFR 下降 15%与死亡率获益相关（0.86[0.77, 0.97]），并且所有 eGFR 下降水平都与心力衰竭住院风险降低相关。在任何模型中，在两到六周时，eGFR 没有任何百分比的下降，包括高达 40%，与依那普利相关的死亡率风险更高。因此，在射血分数降低的心力衰竭患者中，依那普利与死亡率和心力衰竭住院风险降低相关。因此，在考虑停用该药之前，除了中度 eGFR 下降之外，还应该考虑其他更有说服力的原因。
Zotero 插件