Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Cardiothoracic Department, Civil Hospitals, Brescia, Italy.
ESC Heart Fail. 2019 Dec;6(6):1105-1127. doi: 10.1002/ehf2.12555.
Heart failure (HF) remains a major cause of mortality, morbidity, and poor quality of life. It is an area of active research. This article is aimed to give an update on recent advances in all aspects of this syndrome. Major changes occurred in drug treatment of HF with reduced ejection fraction (HFrEF). Sacubitril/valsartan is indicated as a substitute to ACEi/ARBs after PARADIGM-HF (hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.73 to 0.87 for sacubitril/valsartan vs. enalapril for the primary endpoint and Wei, Lin and Weissfeld HR 0.79, 95% CI 0.71-0.89 for recurrent events). Its initiation was then shown as safe and potentially useful in recent studies in patients hospitalized for acute HF. More recently, dapagliflozin and prevention of adverse-outcomes in DAPA-HF trial showed the beneficial effects of the sodium-glucose transporter type 2 inhibitor dapaglifozin vs. placebo, added to optimal standard therapy [HR, 0.74; 95% CI, 0.65 to 0.85;0.74; 95% CI, 0.65 to 0.85 for the primary endpoint]. Trials with other SGLT 2 inhibitors and in other patients, such as those with HF with preserved ejection fraction (HFpEF) or with recent decompensation, are ongoing. Multiple studies showed the unfavourable prognostic significance of abnormalities in serum potassium levels. Potassium lowering agents may allow initiation and titration of mineralocorticoid antagonists in a larger proportion of patients. Meta-analyses suggest better outcomes with ferric carboxymaltose in patients with iron deficiency. Drugs effective in HFrEF may be useful also in HF with mid-range ejection fraction. Better diagnosis and phenotype characterization seem warranted in HF with preserved ejection fraction. These and other burning aspects of HF research are summarized and reviewed in this article.
心力衰竭(HF)仍然是死亡、发病和生活质量下降的主要原因。这是一个活跃的研究领域。本文旨在介绍该综合征各方面的最新进展。射血分数降低的心力衰竭(HFrEF)的药物治疗发生了重大变化。沙库巴曲缬沙坦在 PARADIGM-HF 后被推荐替代 ACEi/ARBs(主要终点时沙库巴曲缬沙坦与依那普利的危险比 [HR],0.80;95%置信区间 [CI],0.73 至 0.87;Wei、Lin 和 Weissfeld HR,0.79,95%CI,0.71 至 0.89),最近的研究表明,该药在因急性心力衰竭住院的患者中应用安全且可能有益。最近,达格列净和 DAPA-HF 试验预防不良结局显示钠-葡萄糖共转运蛋白 2 抑制剂达格列净与安慰剂相比,在最佳标准治疗的基础上有获益[HR,0.74;95%CI,0.65 至 0.85;0.74;95%CI,0.65 至 0.85]。其他 SGLT2 抑制剂的试验和其他患者(如射血分数保留的心力衰竭 [HFpEF]或近期失代偿的患者)的试验正在进行中。多项研究表明,血清钾水平异常具有不良预后意义。降低血钾的药物可能使更多患者能够开始和滴定使用盐皮质激素受体拮抗剂。荟萃分析表明,铁缺乏患者使用羧甲司坦铁复合物有更好的结局。在射血分数中间值的心力衰竭中,对 HFrEF 有效的药物可能也有用。HFpEF 的更好诊断和表型特征似乎是合理的。本文总结和回顾了这些和其他HF 研究的热点问题。