Department of Internal Medicine, Yale University School of Medicine, Yale University and Yale University School of Medicine, New Haven, Connecticut.
Center for Outcomes Research & Evaluation, Yale University and Yale University School of Medicine, New Haven, Connecticut.
JAMA Cardiol. 2020 Feb 1;5(2):175-182. doi: 10.1001/jamacardio.2019.4965.
Left ventricular assist devices (LVADs) improve outcomes in patients with advanced heart failure, but little is known about the role of neurohormonal blockade (NHB) in treating these patients.
To analyze the association between NHB blockade and outcomes in patients with LVADs.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort analysis of the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) included patients from more than 170 centers across the United States and Canada with continuous flow LVADs from 2008 to 2016 who were alive with the device in place at 6 months after implant. The data were analyzed between February and November 2019.
Patients were stratified based on exposure to NHB and represented all permutations of the following drug classes: angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, β-blockers, and mineralocorticoid antagonists.
The outcomes of interest were survival at 4 years and quality of life at 2 years based on Kansas City Cardiomyopathy Questionnaire scores and a 6-minute walk test.
A total of 12 144 patients in INTERMACS met inclusion criteria, of whom 2526 (20.8% ) were women, 8088 (66.6%) were white, 3024 (24.9%) were African American, and 753 (6.2%) were Hispanic; the mean (SD) age was 56.8 (12.9) years. Of these, 10 419 (85.8%) were receiving NHB. Those receiving any NHB medication at 6 months had a better survival rate at 4 years compared with patients not receiving NHB (56.0%; 95% CI, 54.5%-57.5% vs 43.9%; 95% CI, 40.5%-47.7%). After sensitivity analyses with an adjusted model, this trend persisted with patients receiving triple therapy with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, β-blocker, and mineralocorticoid antagonist having the lowest hazard of death compared with patients in the other groups (hazard ratio, 0.34; 95% CI, 0.28-0.41). Compared with patients not receiving NHB, use of NHB was associated with a higher Kansas City Cardiomyopathy Questionnaire score (66.6; bootstrapped 95% CI, 65.8-67.3 vs 63.0; bootstrapped 95% CI, 60.1-65.8; P = .02) and a 6-minute walk test (1103 ft; bootstrapped 95% CI, 1084-1123 ft vs 987 ft; bootstrapped 95% CI, 913-1060 ft; P < .001).
Among patients with LVADs who tolerated NHB therapy, continued treatment was associated with improved survival and quality of life. The optimal heart failure regimen for patients after LVAD implant may be the initiation and continuation of guideline-directed medical therapy.
左心室辅助装置 (LVAD) 可改善晚期心力衰竭患者的预后，但对于神经激素阻断 (NHB) 在治疗这些患者中的作用知之甚少。
分析 NHB 阻断与 LVAD 患者结局之间的关系。
设计、地点和参与者：这项对美国和加拿大 170 多个中心的 INTERMACS 进行的回顾性队列分析纳入了使用连续血流 LVAD 的患者，时间范围为 2008 年至 2016 年，这些患者在植入后 6 个月时仍在使用该设备，并且存活。数据于 2019 年 2 月至 11 月之间进行分析。
根据是否接受 NHB 进行分层，这些患者代表了以下药物类别所有可能的组合：血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂、β受体阻滞剂和盐皮质激素拮抗剂。
感兴趣的结局是 4 年生存率和基于堪萨斯城心肌病问卷评分和 6 分钟步行试验的 2 年生活质量。
INTERMACS 共纳入了 12144 名符合条件的患者，其中 2526 名（20.8%）为女性，8088 名（66.6%）为白人，3024 名（24.9%）为非裔美国人，753 名（6.2%）为西班牙裔；平均（SD）年龄为 56.8（12.9）岁。其中 10419 名（85.8%）正在接受 NHB 治疗。与未接受 NHB 治疗的患者相比，在 6 个月时接受任何 NHB 药物治疗的患者在 4 年时的生存率更高（56.0%；95%CI，54.5%-57.5%比 43.9%；95%CI，40.5%-47.7%）。在使用调整后的模型进行敏感性分析后，这种趋势仍然存在，与其他组相比，接受血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂、β受体阻滞剂和盐皮质激素拮抗剂三联治疗的患者死亡风险最低（风险比，0.34；95%CI，0.28-0.41）。与未接受 NHB 治疗的患者相比，使用 NHB 与更高的堪萨斯城心肌病问卷评分（66.6；bootstrapped 95%CI，65.8-67.3 比 63.0；bootstrapped 95%CI，60.1-65.8；P=0.02）和 6 分钟步行测试（1103 英尺；bootstrapped 95%CI，1084-1123 英尺比 987 英尺；bootstrapped 95%CI，913-1060 英尺；P<0.001）相关。
在能够耐受 NHB 治疗的 LVAD 患者中，持续治疗与生存率和生活质量的提高相关。LVAD 植入后患者的最佳心力衰竭治疗方案可能是启动和持续进行指南导向的药物治疗。
