Medical School and Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
Weill-Cornell Medicine, Division of Cardiology, New York City, NY, USA.
Eur J Intern Med. 2024 Feb;120:3-10. doi: 10.1016/j.ejim.2023.10.008. Epub 2023 Oct 19.
More than 90 % of patients developing heart failure (HF) have hypertension. The most frequent concomitant conditions are type-2 diabetes mellitus, obesity, atrial fibrillation, and coronary disease. HF outcome research focuses on decreasing mortality and preventing hospitalization for worsening HF syndrome. All drugs that decrease these HF endpoints lower blood pressure. Current drug treatments for HF are (i) angiotensin-converting enzyme inhibitors, angiotensin receptor blockers or angiotensin receptor neprilysin inhibitors, (ii) selected beta-blockers, (iii) steroidal and non-steroidal mineralocorticoid receptor antagonists, and (iv) sodium-glucose cotransporter 2 inhibitors. For various reasons, these drug treatments were first studied in HF patients with a reduced ejection fraction (HFrEF). Subsequently, they have been investigated in HF patients with a preserved left ventricular ejection fraction (LVEF, HFpEF) of mostly hypertensive etiology, and with modest benefits largely assessed on top of background treatment with the drugs already proven effective in HFrEF. Additionally, diuretics are given on symptomatic indications. Patients with HFpEF may have diastolic dysfunction but also systolic dysfunction visualized by lack of longitudinal shortening. Considering the totality of evidence and the overall need for antihypertensive treatment and/or treatment of hypertensive complications in almost all HF patients, the principal drug treatment of HF appears to be the same regardless of LVEF. Rather than LVEF-guided treatment of HF, treatment of HF should be directed by symptoms (related to the level of fluid retention), signs (tachycardia), severity (NYHA functional class), and concomitant diseases and conditions. All HF patients should be given all the drug classes mentioned above if well tolerated.
超过 90%的心力衰竭（HF）患者伴有高血压。最常见的合并症包括 2 型糖尿病、肥胖症、心房颤动和冠心病。HF 结局研究的重点是降低死亡率和预防因 HF 综合征恶化而住院。所有降低这些 HF 终点的药物都会降低血压。HF 的当前药物治疗包括 (i) 血管紧张素转换酶抑制剂、血管紧张素受体阻滞剂或血管紧张素受体脑啡肽酶抑制剂、(ii) 选择性β受体阻滞剂、(iii) 甾体和非甾体盐皮质激素受体拮抗剂，以及 (iv) 钠-葡萄糖共转运蛋白 2 抑制剂。出于各种原因，这些药物治疗首先在射血分数降低的心力衰竭（HFrEF）患者中进行了研究。随后，它们在射血分数保留的左心室（HFpEF，HF 伴有高血压病因的 EF）患者中进行了研究，并且主要是在已经在 HFrEF 中证明有效的药物的背景治疗上进行了适度的获益评估。此外，利尿剂根据症状指征给予。HFpEF 患者可能存在舒张功能障碍，但也可能存在缺乏纵向缩短的收缩功能障碍。考虑到证据的总体情况以及几乎所有 HF 患者对降压治疗和/或治疗高血压并发症的总体需求，HF 的主要药物治疗似乎与 LVEF 无关。HF 的治疗不应基于 LVEF 指导，而应根据症状（与液体潴留水平相关）、体征（心动过速）、严重程度（NYHA 功能分类）以及合并疾病和情况进行治疗。如果耐受良好，所有 HF 患者均应使用上述所有药物类别。
