Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France.
Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands.
Clin Cardiol. 2021 Jun;44(6):780-788. doi: 10.1002/clc.23576. Epub 2021 May 7.
Achieving target doses of angiotensin-converting-enzyme inhibitor/angiotensin-receptor blockers (ACEi/ARB) and beta-blockers in heart failure with reduced ejection fraction (HFrEF) is often underperformed. In BIOlogy Study to TAilored Treatment in chronic heart failure (BIOSTAT-CHF) study, many patients were not up-titrated for which no clear reason was reported. Therefore, we hypothesized that perceived-risk profile might influence treatment optimization.
We studied 2100 patients with HFrEF (LVEF≤40%) to compare the clinical characteristics and adverse events associated with treatment up-titration (after a 3-month titration protocol) between; a) patients not reaching target doses for unclear reason; b) patients not reaching target doses due to symptoms and/or side effects; c) patients reaching target doses.
For ACEi/ARB, (a), (b) and (c) was observed in 51.3%, 25.9% and 22.7% of patients, respectively. For beta-blockers, (a), (b) and (c) was observed in 67.5%, 20.2% and 12.3% of patients, respectively. By multinomial logistic regression analysis for ACEi/ARB, patients in group (a) and (b) had lower blood pressure and poorer renal function, and patients in group (a) were older and had lower ejection fraction. For beta-blockers, patients in group (a) and (b) had more severe congestion and lower heart rate. At 9 months, adverse events (i.e., hypotension, bradycardia, renal impairment, and hyperkalemia) occurred similarly among the three groups.
Patients in whom clinicians did not give a reason why up-titration was missed were older and had more co-morbidities. Patients in whom up-titration was achieved did not have excess adverse events. However, from these observational findings, the pattern of subsequent adverse events among patients in whom up-titration was missed cannot be determined.
在射血分数降低的心力衰竭（HFrEF）中，血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂（ACEi/ARB）和β受体阻滞剂的目标剂量往往无法达到。在 BIOlogy Study to TAilored Treatment in chronic heart failure（BIOSTAT-CHF）研究中，许多患者未进行剂量递增，且未报告明确的原因。因此，我们假设感知风险状况可能会影响治疗优化。
我们研究了 2100 例 HFrEF（LVEF≤40%）患者，以比较治疗剂量递增（经过 3 个月的滴定方案后）与以下因素之间的临床特征和不良事件的相关性：a）因不明原因而未达到目标剂量的患者；b）因症状和/或副作用而未达到目标剂量的患者；c）达到目标剂量的患者。
对于 ACEi/ARB，a）、b）和 c）组分别观察到 51.3%、25.9%和 22.7%的患者。对于β受体阻滞剂，a）、b）和 c）组分别观察到 67.5%、20.2%和 12.3%的患者。通过 ACEi/ARB 的多项逻辑回归分析，a）和 b）组的患者血压和肾功能较差，而 a）组的患者年龄较大且射血分数较低。对于β受体阻滞剂，a）和 b）组的患者充血更为严重且心率较低。在 9 个月时，三组之间发生的不良事件（即低血压、心动过缓、肾功能损害和高钾血症）相似。
未给出剂量递增未达到原因的患者年龄较大且合并症较多。达到剂量递增的患者没有过多的不良事件。但是，从这些观察结果来看，无法确定剂量递增未达到的患者随后发生不良事件的模式。
