Kwok Chun Shing, Choy Chern Hsiang, Pinney Jennifer, Townend Jonathan N, Whelan Carol, Fontana Marianna, Gillmore Julian D, Steeds Richard P, Moody William E
Department of Cardiology, Queen Elizabeth Hospital Birmingham, University Hospitals of Birmingham NHS Foundation Trust, Birmingham, UK.
Department of Nephrology, Queen Elizabeth Hospital Birmingham, University Hospitals of Birmingham NHS Foundation Trust, Birmingham, UK.
ESC Heart Fail. 2024 Dec;11(6):3901-3910. doi: 10.1002/ehf2.14975. Epub 2024 Jul 23.
The efficacy of beta-blockers in cardiac amyloidosis (CA) is unclear, and concerns persist that neurohormonal blockade could worsen symptoms of heart failure. We aimed to assess whether beta-blocker therapy is associated with improved survival in patients with CA.
We conducted a systematic review and meta-analysis to examine the impact of beta-blocker therapy on mortality in patients with CA. A search of MEDLINE and EMBASE was performed in August 2023. Data were extracted from observational studies and synthesized with pooling and random effects meta-analysis. Thirteen studies including 4215 patients with CA were incorporated in this review (3688 transthyretin amyloid cardiomyopathy (ATTR-CM), 502 light chain amyloid cardiomyopathy (AL-CM), 25 not specified; age 74.8 ± 5.5 years, 76% male). Over half of the cohort (52%) received beta-blockers and the rate of beta-blocker withdrawal was 28%. All-cause mortality was 33% (range: 13-51%) after a median follow-up ranging from 13 to 36 months. There was an inverse association between the pooled risk of mortality and the use of beta-blocker therapy at any time point (RR 0.48, 95% CI 0.29-0.80, I = 83%, P = 0.005, seven studies). There was no association between mortality and beta-blocker use (RR 0.65, 95% CI 0.29-1.47, I = 88%, P = 0.30) in the three studies that only included patients with ATTR-CM. The three studies that included patients with both ATTR-CM and AL demonstrated an association of beta-blocker use with reduced mortality (OR 0.43, 95% CI 0.29-0.63, I = 4%, P < 0.001). The only study that solely included 53 patients with AL-CM, demonstrated improved survival among the 53% who were able to tolerate beta-blocker therapy (RR 0.26, 95% CI 0.08-0.79, P = 0.02). The absence of information on staging of CA is an important limitation of this study.
Treatment with beta-blockers may be associated with a survival benefit in patients with CA, but these findings are subject to selection and survivor biases. Definitive prospective randomized trials of conventional heart failure therapies are needed in CA.
β受体阻滞剂在心脏淀粉样变性（CA）中的疗效尚不清楚，且一直有人担心神经激素阻断可能会加重心力衰竭症状。我们旨在评估β受体阻滞剂治疗是否与CA患者生存率的提高相关。
我们进行了一项系统评价和荟萃分析，以研究β受体阻滞剂治疗对CA患者死亡率的影响。2023年8月对MEDLINE和EMBASE进行了检索。数据从观察性研究中提取，并通过合并和随机效应荟萃分析进行综合。本综述纳入了13项研究，共4215例CA患者（3688例转甲状腺素蛋白淀粉样心肌病（ATTR-CM），502例轻链淀粉样心肌病（AL-CM），25例未明确；年龄74.8±5.5岁，76%为男性）。超过一半的队列（52%）接受了β受体阻滞剂治疗，β受体阻滞剂停药率为28%。在中位随访13至36个月后，全因死亡率为33%（范围：13%-51%）。在任何时间点，合并死亡率风险与β受体阻滞剂治疗的使用之间存在负相关（风险比0.48，95%置信区间0.29-0.80，I²=83%，P=0.005，7项研究）。在仅纳入ATTR-CM患者的3项研究中，死亡率与β受体阻滞剂的使用之间无关联（风险比0.65，95%置信区间0.29-1.47，I²=88%，P=0.30）。纳入ATTR-CM和AL患者的3项研究表明，使用β受体阻滞剂与死亡率降低相关（比值比0.43，95%置信区间0.29-0.63，I²=4%，P<0.001）。唯一一项仅纳入53例AL-CM患者的研究表明，在能够耐受β受体阻滞剂治疗的53%患者中生存率有所提高（风险比0.26，95%置信区间0.08-0.79，P=0.02）。本研究的一个重要局限性是缺乏CA分期信息。
β受体阻滞剂治疗可能与CA患者的生存获益相关，但这些发现存在选择偏倚和幸存者偏倚。CA需要进行关于传统心力衰竭治疗的确定性前瞻性随机试验。
