Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de València, Valencia, Spain.
Cardiology Department, Hospital de Denia, Alicante, Spain.
JAMA Cardiol. 2024 Apr 1;9(4):392-396. doi: 10.1001/jamacardio.2023.5500.
Increasing the patient's heart rate (HR) has emerged as a therapeutic option in patients with heart failure with preserved ejection fraction (HFpEF). However, the evidence is conflicting, and the profile of patients who benefit most from this strategy remains unclear.
To assess the association of β-blocker treatment withdrawal with changes in the percentage of predicted peak oxygen consumption (VO2) across indexed left ventricular diastolic (iLVEDV) and indexed left ventricular systolic volumes (iLVESV), and left ventricular ejection fraction (LVEF) in patients with HFpEF and chronotropic incompetence.
DESIGN, SETTING, AND PARTICIPANTS: This post hoc analysis was conducted using data from the investigator-blinded multicenter, randomized, and crossover clinical trial, PRESERVE-HR, that took place from October 1, 2018, through December 31, 2020, to investigate the short-term effects (2 weeks) of β-blocker withdrawal on peak oxygen consumption (peak VO2). Patients with stable HFpEF (New York Heart Association functional class II to III) receiving treatment with β-blocker and chronotropic incompetence were included.
Participants in the PRESERVE-HR trial were randomized to withdraw vs continue with β-blocker treatment. After 2 weeks, they were crossed over to receive the opposite intervention. This crossover randomized clinical trial examined the short-term effect of β-blocker withdrawal on peak VO2.
The primary outcome was to evaluate the association between β-blocker withdrawal and short-term changes in percentage of peak VO2 across iLVEDV, iLVESV, and LVEF in patients with HFpEF and chronotropic incompetence treated with β-blocker.
A total of 52 patients (mean age, 73 [SD, 13] years; 60% female) were randomized. The mean resting HR, peak HR, peak VO2, and percentage of peak VO2 were 65 (SD, 9) beats per minute (bpm), 97 (SD, 15) bpm, 12.4 (SD, 2.9) mL/kg per minute, and 72.4% (SD, 17.7%), respectively. The medians (minimum-maximum) of iLVEDV, iLVESV, and LVEF were 44 mL/m2 (IQR, 19-82), 15 mL/m2 (IQR, 7-32), and 64% (IQR, 52%-78%), respectively. After stopping β-blocker treatment, the median increase in peak HR was plus 30 bpm (95% CI, 25-35; P < .001). β-Blocker cessation was differentially associated with change of percentage of peak VO2 across the continuum of iLVESV (P for interaction = .02), indicating a greater benefit in those with lower iLVESV.
In this study, results showed that in patients with HFpEF and chronotropic incompetence receiving treatment with β-blocker, lower iLVESV may identify those with a greater short-term improvement in maximal functional capacity after stopping β-blocker treatment. Further studies are warranted for further investigation.
ClinicalTrials.gov (NCT03871803).
在射血分数保留的心力衰竭（HFpEF）患者中，增加患者的心率（HR）已成为一种治疗选择。然而，证据存在矛盾，哪些患者最受益于这种策略尚不清楚。
评估β受体阻滞剂停药与 HFpEF 和变时功能不全患者的左心室舒张末期指数（iLVEDV）和左心室收缩末期指数（iLVESV）及左心室射血分数（LVEF）的预测峰值摄氧量（VO2）百分比变化之间的关联。
设计、地点和参与者：这是一项事后分析，使用来自多中心、随机、交叉临床试验 PRESERVE-HR 的数据进行，该试验于 2018 年 10 月 1 日至 2020 年 12 月 31 日进行，旨在研究β受体阻滞剂停药对峰值摄氧量（peak VO2）的短期影响（2 周）。纳入了接受β受体阻滞剂治疗且变时功能不全的稳定 HFpEF（纽约心脏协会功能分级 II 至 III）患者。
PRESERVE-HR 试验的参与者被随机分为停药组和继续使用β受体阻滞剂治疗组。2 周后，他们交叉接受相反的干预措施。这项交叉随机临床试验检查了β受体阻滞剂停药对 peak VO2 的短期影响。
主要结局是评估β受体阻滞剂停药与 HFpEF 和变时功能不全患者接受β受体阻滞剂治疗后，左心室舒张末期指数（iLVEDV）、左心室收缩末期指数（iLVESV）和左心室射血分数（LVEF）的峰值 VO2 百分比短期变化之间的关联。
共纳入 52 名患者（平均年龄，73 [标准差，13] 岁；60%为女性）进行随机分组。平均静息心率、峰值心率、峰值 VO2 和峰值 VO2 百分比分别为 65（9）次/分、97（15）次/分、12.4（2.9）mL/kg/min 和 72.4%（17.7%）。iLVEDV、iLVESV 和 LVEF 的中位数（最小值-最大值）分别为 44 mL/m2（IQR，19-82）、15 mL/m2（IQR，7-32）和 64%（IQR，52%-78%）。停止β受体阻滞剂治疗后，峰值心率中位数增加了 30 次/分（95%CI，25-35；P < .001）。β受体阻滞剂停药与 iLVESV 连续变化时的 peak VO2 百分比变化之间存在差异（交互 P 值= .02），表明 iLVESV 较低的患者获益更大。
在这项研究中，结果表明，在接受β受体阻滞剂治疗的 HFpEF 和变时功能不全患者中，较低的 iLVESV 可能表明停药后最大功能能力的短期改善更大。需要进一步的研究来进一步调查。
ClinicalTrials.gov（NCT03871803）。
