Department of Cardiology, Xinqiao Hospital, Army Military Medical University, Chongqing, China.
The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.
Eur J Heart Fail. 2024 Jun;26(6):1435-1442. doi: 10.1002/ejhf.3208. Epub 2024 Apr 12.
Existing research indicates that patients with heart failure (HF) may have restricted access to guideline-directed medical therapy (GDMT) when their blood pressure (BP) is comparatively low. However, recent clinical trials suggest that HF patients with low BP could still benefit from certain HF medications, which have a minimal impact on BP. This systematic review and meta-analysis was conducted to determine whether this applies to all GDMT.
A systematic search of MEDLINE and EMBASE was conducted for studies published from inception to 10 January 2024. Randomized controlled trials were selected if they reported on the longitudinal change of systolic BP (SBP) due to GDMT, or the risks of cardiovascular events in HF patients based on SBP categories. Weighted mean difference (WMD), hazard ratio or relative risk, and corresponding 95% confidence intervals (CI) were pooled for meta-analysis where possible. Data from 20 studies, encompassing information on 84 782 individuals, were analysed. Overall, GDMT is associated with lower SBP (WMD, -2.16; 95% CI -2.86 to -1.46), with no significant difference between baseline low and non-low BP subgroups (interaction p = 0.810). However, SBP of the treatment group increased by 5.8 mmHg from baseline in the low SBP subgroup during follow-up, while it decreased by 4.0 mmHg in the baseline non-low SBP subgroup. GDMT demonstrated similar cardiovascular benefits and risk of hypotension between low and non-low SBP subgroups (interaction p = 0.318 and 0.903, respectively).
Guideline-directed medical therapy is associated with a negligible decrease in SBP, but can provide similar cardiovascular benefits in both low and non-low SBP HF patients, with no significant interaction with SBP as to hypotension. Therefore, GDMT should be initiated and maintained in HF patients with low BP.
现有研究表明，当心力衰竭（HF）患者的血压（BP）相对较低时，他们可能无法获得指南指导的医学治疗（GDMT）。然而，最近的临床试验表明，血压较低的 HF 患者仍可能受益于某些 HF 药物，这些药物对 BP 的影响很小。本系统评价和荟萃分析旨在确定这是否适用于所有 GDMT。
对 MEDLINE 和 EMBASE 进行了系统检索，检索时间为从建库至 2024 年 1 月 10 日发表的研究。如果研究报告了 GDMT 导致的收缩压（SBP）的纵向变化，或者根据 SBP 类别报告了 HF 患者心血管事件的风险，则选择随机对照试验。在可能的情况下，对加权均数差（WMD）、危险比或相对风险以及相应的 95%置信区间（CI）进行荟萃分析。对 20 项研究的数据进行了分析，这些研究共纳入了 84782 个人。总体而言，GDMT 与 SBP 降低相关（WMD，-2.16；95%CI -2.86 至 -1.46），但基线低 BP 和非低 BP 亚组之间无显著差异（交互 p = 0.810）。然而，在低 SBP 亚组中，治疗组的 SBP 在随访期间从基线增加了 5.8mmHg，而在基线非低 SBP 亚组中则降低了 4.0mmHg。低 SBP 和非低 SBP 亚组之间，GDMT 在心血管获益和低血压风险方面也表现出相似的效果（交互 p = 0.318 和 0.903）。
GDMT 与 SBP 降低相关，但在低 SBP 和非低 SBP HF 患者中均可提供相似的心血管获益，与 SBP 之间无显著交互作用。因此，应在低 BP 的 HF 患者中启动和维持 GDMT。
