新型医学疗法在接受神经激素抑制剂治疗的射血分数降低的心力衰竭和慢性肾脏病患者中的疗效：一项网络荟萃分析。
Efficacy of new medical therapies in patients with heart failure, reduced ejection fraction, and chronic kidney disease already receiving neurohormonal inhibitors: a network meta-analysis.
机构信息
Cardiology Unit, Cardiothoracic and Vascular Department, IRCCS Ospedale Policlinico San Martino, IRCCS Italian Cardiology Network, Genova, Italy.
Department of Internal Medicine, University of Genova, Viale Benedetto XV, 6, 16132 Genova, Italy.
出版信息
Eur Heart J Cardiovasc Pharmacother. 2022 Dec 2;8(8):768-776. doi: 10.1093/ehjcvp/pvab088.
AIMS
We assessed the efficacy of the drugs developed after neurohormonal inhibition (NEUi) in patients with heart failure (HF) with reduced ejection fraction (HFrEF) and concomitant chronic kidney disease (CKD).
METHODS AND RESULTS
The literature was systematically searched for phase 3 randomized controlled trials (RCTs) involving ≥90% patients with left ventricular ejection fraction <45%, of whom <30% were acutely decompensated, and with published information about the subgroup of estimated glomerular filtration rate <60 mL/min/1.73 m2. Six RCTs were included in a study-level network meta-analysis evaluating the effect of NEUi, ivabradine, angiotensin receptor-neprilysin inhibitor (ARNI), sodium-glucose cotransporter-2 inhibitors (SGLT2i), vericiguat, and omecamtiv mecarbil (OM) on a composite outcome of cardiovascular death or hospitalization for HF. In a fixed-effects model, SGLT2i [hazard ratio (HR) 0.78, 95% credible interval (CrI) 0.69-0.89], ARNI (HR 0.79, 95% CrI 0.69-0.90), and ivabradine (HR 0.82, 95% CrI 0.69-0.98) decreased the risk of the composite outcome vs. NEUi, whereas OM did not (HR 0.98, 95% CrI 0.89-1.10). A trend for improved outcome was also found for vericiguat (HR 0.90, 95% CrI 0.80-1.00). In indirect comparisons, both SLGT2i (HR 0.80, 95% CrI 0.68-0.94) and ARNI (HR 0.80, 95% CrI 0.68-0.95) reduced the risk vs. OM; furthermore, there was a trend for a greater benefit of SGLT2i vs. vericiguat (HR 0.88, 95% CrI 0.73-1.00) and ivabradine vs. OM (HR 0.84, 95% CrI 0.68-1.00). Results were comparable in a random-effects model and in sensitivity analyses. Surface under the cumulative ranking area scores were 81.8%, 80.8%, 68.9%, 44.2%, 16.6%, and 7.8% for SGLT2i, ARNI, ivabradine, vericiguat, OM, and NEUi, respectively.
CONCLUSION
Expanding pharmacotherapy beyond NEUi improves outcomes in HFrEF with CKD.
目的
我们评估了神经激素抑制（NEUi）后开发的药物在射血分数降低的心力衰竭（HFrEF）合并慢性肾脏病（CKD）患者中的疗效。
方法和结果
系统地检索了涉及左心室射血分数<45%的≥90%患者的 3 期随机对照试验（RCT），其中<30%为急性失代偿，并有关于估计肾小球滤过率<60 ml/min/1.73 m2的亚组的出版信息。六项 RCT 被纳入一项研究水平网络荟萃分析，评估了 NEUi、伊伐布雷定、血管紧张素受体-脑啡肽酶抑制剂（ARNI）、钠-葡萄糖共转运蛋白 2 抑制剂（SGLT2i）、维立西胍和 omecamtiv mecarbil（OM）对心血管死亡或心力衰竭住院的复合结局的影响。在固定效应模型中，SGLT2i[风险比（HR）0.78，95%可信区间（CrI）0.69-0.89]、ARNI（HR 0.79，95% CrI 0.69-0.90）和伊伐布雷定（HR 0.82，95% CrI 0.69-0.98）降低了与 NEUi 相比的复合结局风险，而 OM 则没有（HR 0.98，95% CrI 0.89-1.10）。还发现维立西胍（HR 0.90，95% CrI 0.80-1.00）也有改善结局的趋势。在间接比较中，SGLT2i（HR 0.80，95% CrI 0.68-0.94）和 ARNI（HR 0.80，95% CrI 0.68-0.95）与 OM 相比均降低了风险；此外，SGLT2i 优于维立西胍（HR 0.88，95% CrI 0.73-1.00）和伊伐布雷定优于 OM（HR 0.84，95% CrI 0.68-1.00）的获益趋势更大。在随机效应模型和敏感性分析中，结果是可比的。SGLT2i、ARNI、伊伐布雷定、维立西胍、OM 和 NEUi 的累积排序面积得分分别为 81.8%、80.8%、68.9%、44.2%、16.6%和 7.8%。
结论
在神经激素抑制基础上扩展药物治疗可改善合并慢性肾脏病的射血分数降低心力衰竭患者的结局。
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