Division of Cardiology University of Washington Seattle WA.
Department of Biobehavioral Nursing and Health Informatics University of Washington Seattle WA.
J Am Heart Assoc. 2021 Dec 21;10(24):e022859. doi: 10.1161/JAHA.121.022859. Epub 2021 Nov 3.
Background Despite the belief that heart failure therapies are not effective in transthyretin cardiac amyloidosis, data are limited. We tested the association of neurohormonal blockade use with survival. Methods and Results A total of 309 consecutive patients with transthyretin cardiac amyloidosis were identified. Medication inventory was obtained at baseline and subsequent visits. Exposure included a neurohormonal blockade class (β-blocker [βB], angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, and mineralocorticoid antagonist) at baseline and subsequent visits. βB was modeled as baseline use, time-varying use, and in an inverse probability treatment weighted model. Primary outcome was all-cause mortality analyzed with adjusted Cox proportional hazards models. Continuing compared with stopping βB during follow-up was tested. Mean age was 73.2 years, 84.1% were men, and 17.2% had atrial fibrillation/flutter at baseline. At the time of study entry, 49.8% were on βBs, 35.0% were on angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and 23.9% were on mineralocorticoid antagonists. For the total cohort, there was a trend toward harm in the unadjusted model for baseline βB use, but this was neutral after adjustment. When βB use was analyzed as a time-varying exposure, there was no association with mortality. βB discontinuation was associated with decreased mortality for the total cohort. Findings were consistent in inverse probability treatment weighted models. For angiotensin-converting enzyme inhibitor/angiotensin receptor blocker or mineralocorticoid antagonist use, there was no association with mortality after adjustment for the total cohort. Conclusions There was no association of neurohormonal blockade use with survival in transthyretin cardiac amyloidosis. For the total cohort, deprescribing βB may be associated with improved survival. Additional studies are needed to confirm these findings.
尽管人们认为心力衰竭治疗对转甲状腺素蛋白心脏淀粉样变无效，但相关数据有限。我们检验了神经激素阻滞剂的使用与生存率的相关性。
共纳入 309 例连续的转甲状腺素蛋白心脏淀粉样变患者。在基线和随后的就诊时获取药物清单。暴露因素包括基线和随后就诊时的神经激素阻滞剂类别（β 受体阻滞剂[βB]、血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂和盐皮质激素受体拮抗剂）。βB 作为基线使用、时变使用和逆概率治疗加权模型进行建模。使用调整后的 Cox 比例风险模型分析全因死亡率作为主要结局。检验了随访期间继续使用βB与停止使用βB的效果差异。平均年龄为 73.2 岁，84.1%为男性，17.2%在基线时存在心房颤动/扑动。在研究入组时，49.8%的患者正在使用βB，35.0%的患者正在使用血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂，23.9%的患者正在使用盐皮质激素受体拮抗剂。对于整个队列，在未调整模型中，基线时使用βB 有出现危害的趋势，但调整后这种趋势变得中性。当βB 使用作为时变暴露进行分析时，与死亡率无相关性。对于整个队列，βB 停药与死亡率降低相关。在逆概率治疗加权模型中，结果一致。对于血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂或盐皮质激素受体拮抗剂的使用，在对整个队列进行调整后，与死亡率无相关性。
在转甲状腺素蛋白心脏淀粉样变中，神经激素阻滞剂的使用与生存率无相关性。对于整个队列，βB 的减停可能与生存率的提高相关。需要进一步的研究来证实这些发现。
