Palazzuoli Alberto, Ruocco Gaetano, Del Buono Marco Giuseppe, Pavoncelli Simona, Delcuratolo Elvira, Abbate Antonio, Lavie Carl J
Cardiovascular Diseases Unit, Cardiothoracic and Vascular Department, Le Scotte Hospital, University of Siena, Viale Bracci 12, 53100, Siena, Italy.
Cardiology Unit, "Buon Consiglio Hospital" Fatebenefratelli, Naples, Italy.
Heart Fail Rev. 2024 Mar;29(2):535-548. doi: 10.1007/s10741-024-10383-0. Epub 2024 Jan 29.
In the last decades, several classifications and definitions have been proposed for advanced heart failure (ADVHF) patients, including clinical, functional, hemodynamic, imaging, and electrocardiographic features. Despite different inclusion criteria, ADVHF is characterized by some common items, such as drug intolerance, low arterial pressure, multiple organ dysfunction, chronic kidney disease, and diuretic use dependency. Additional features include fatigue, hypotension, hyponatremia, and unintentional weight loss associated with a specific laboratory profile reflecting systemic multiorgan dysfunction. Notably, studies evaluating guideline-directed medical therapy recently endorsed by guidelines in stable HF, including the 4 drug classes all together (i.e., betablocker, mineral corticoid antagonist, renin angiotensin inhibitors/neprilysin inhibitors, and sodium glucose transporter inhibitors), remain scarcely analyzed in ADVHF and New York Heart Association (NYHA) Class IV. Additionally, due to the common conditions associated with advanced stages, the balance between drug tolerance and potential benefits of the contemporary use of all agents is questioned. Therefore, less hard endpoints, such as exercise tolerance, quality of life (QoL) and self-competency, are not clearly demonstrated. Specific analyses evaluating outcome and rehospitalization of each drug provided conflicting results and are often limited to subjects with stable conditions and less advanced NYHA class. Current European Society of Cardiology/American Heart Association (ESC/AHA) Guidelines do not indicate the type of treatment, dosage, and administration modalities, and they do not suggest specific indications for ADVHF patients. Due to these concerns, there is an impelling need to understand what drugs may be used as the first line, what management leads to the better outcome, and what is the best treatment algorithm in this setting. In this paper, we summarize the most common pitfalls and limitations for the use of the traditional agents, and we propose a personalized approach aiming at preserve drug tolerance and maintaining adverse event protection and satisfactory QoL.
在过去几十年中，针对晚期心力衰竭（ADVHF）患者提出了多种分类和定义，包括临床、功能、血流动力学、影像学和心电图特征。尽管纳入标准不同，但ADVHF具有一些共同特征，如药物不耐受、动脉压低、多器官功能障碍、慢性肾脏病和利尿剂使用依赖。其他特征包括疲劳、低血压、低钠血症以及与反映全身多器官功能障碍的特定实验室指标相关的非故意体重减轻。值得注意的是，评估近期指南认可的稳定心力衰竭的指南导向药物治疗的研究，包括所有四类药物（即β受体阻滞剂、盐皮质激素拮抗剂、肾素血管紧张素抑制剂/脑啡肽酶抑制剂和钠葡萄糖转运抑制剂），在ADVHF和纽约心脏协会（NYHA）IV级患者中仍很少被分析。此外，由于与晚期相关的常见情况，同时使用所有药物的药物耐受性和潜在益处之间的平衡受到质疑。因此，较少的硬性终点，如运动耐量、生活质量（QoL）和自我能力，并未得到明确证明。评估每种药物结局和再住院情况的具体分析结果相互矛盾，且通常仅限于病情稳定、NYHA分级较低的患者。当前欧洲心脏病学会/美国心脏协会（ESC/AHA）指南未指明治疗类型、剂量和给药方式，也未针对ADVHF患者提出具体适应症。由于这些问题，迫切需要了解哪些药物可作为一线用药、何种管理方式能带来更好的结局以及在此情况下最佳的治疗方案是什么。在本文中，我们总结了使用传统药物时最常见的陷阱和局限性，并提出一种个性化方法，旨在保持药物耐受性、维持不良事件防护并确保令人满意的生活质量。
