Moon Mi-Gil, Hwang In-Chang, Choi Wonsuk, Cho Goo-Yeong, Yoon Yeonyee E, Park Jun-Bean, Lee Seung-Pyo, Kim Hyung-Kwan, Kim Yong-Jin
Department of Cardiology, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, South Korea.
Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea.
ESC Heart Fail. 2021 Jun;8(3):2058-2069. doi: 10.1002/ehf2.13285. Epub 2021 Mar 7.
Despite well-established benefits of sacubitril/valsartan for cardiac reverse remodelling and the prognosis of patients with heart failure with reduced ejection fraction (HFrEF), there are some patients with limited therapeutic response, even with optimal therapy. We assessed the treatment response to sacubitril/valsartan in patients with HFrEF, focusing on the association between reverse remodelling and the prognosis.
Using a retrospective cohort of consecutive patients with HFrEF treated with sacubitril/valsartan, we compared the time trajectory of cardiac function in 415 patients (1258 echocardiograms), according to the occurrence of cardiovascular death and hospitalization for HF during a median follow-up of 19.1 (interquartile range, 10.9-27.6) months. A higher sacubitril/valsartan dose was associated with a better prognosis, whereas advanced age, diabetes, left ventricular (LV) hypertrophy, left atrial enlargement, and pulmonary hypertension were associated with a worse prognosis. Patients without an event (n = 337; 81.2%) showed LV reverse remodelling (LV ejection fraction ≥45% or LV end-systolic volume reduction by 15% from baseline), which was typically observed within 6 months of sacubitril/valsartan treatment. Reverse remodelling achievement was significantly associated with a better prognosis. However, patients without reverse remodelling had a worse prognosis, as poor as that in patients with HFrEF not treated with sacubitril/valsartan.
In patients with HFrEF treated with sacubitril/valsartan, LV reverse remodelling reflects the treatment response and predicts the prognosis, whereas a lack of reverse remodelling indicates the lack of treatment benefits. Prediction and assessment of reverse remodelling may facilitate the selection of patients with greater benefits by sacubitril/valsartan.
尽管沙库巴曲缬沙坦对射血分数降低的心力衰竭（HFrEF）患者的心脏逆向重构及预后具有公认的益处，但仍有一些患者治疗反应有限，即使接受了最佳治疗。我们评估了HFrEF患者对沙库巴曲缬沙坦的治疗反应，重点关注逆向重构与预后之间的关联。
利用一个接受沙库巴曲缬沙坦治疗的连续性HFrEF患者回顾性队列，我们比较了415例患者（1258次超声心动图检查）的心功能随时间变化轨迹，这些患者在中位随访19.1（四分位间距，10.9 - 27.6）个月期间发生了心血管死亡或因心力衰竭住院。较高的沙库巴曲缬沙坦剂量与较好的预后相关，而高龄、糖尿病、左心室（LV）肥厚、左心房扩大和肺动脉高压与较差的预后相关。无事件发生的患者（n = 337；81.2%）出现了左心室逆向重构（左心室射血分数≥45%或左心室收缩末期容积较基线减少15%），这通常在沙库巴曲缬沙坦治疗的6个月内观察到。逆向重构的实现与较好的预后显著相关。然而，未发生逆向重构的患者预后较差，与未接受沙库巴曲缬沙坦治疗的HFrEF患者一样差。
在接受沙库巴曲缬沙坦治疗的HFrEF患者中，左心室逆向重构反映治疗反应并预测预后，而缺乏逆向重构则表明缺乏治疗益处。对逆向重构的预测和评估可能有助于选择能从沙库巴曲缬沙坦治疗中获得更大益处的患者。
