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JACC:不合并HF的AMI患者使用β-受体阻滞剂能否获益?

2017-07-17 闫盈盈 吴刚 环球医学

对于不合并心衰(HF)的急性心肌梗死(AMI),β-受体阻滞剂和死亡率的降低是否相关是未知的。2017年6月,发表在《J Am Coll Cardiol.》的一项研究调查了不合并HF或心室功能障碍的AMI患者使用β-受体阻滞剂和死亡率之间的相关性。请看本期多学科讨论组临床药师各抒己见为您梳理本文看点—— 目的:旨在确定不合并HF或左心室收缩功能不全(LVSD)的AMI患者使用β-受体阻滞剂和死亡

对于不合并心衰(HF)的急性心肌梗死(AMI),β-受体阻滞剂和死亡率的降低是否相关是未知的。2017年6月,发表在《J Am Coll Cardiol.》的一项研究调查了不合并HF或心室功能障碍的AMI患者使用β-受体阻滞剂和死亡率之间的相关性。请看本期多学科讨论组临床药师各抒己见为您梳理本文看点——

目的:旨在确定不合并HF或左心室收缩功能不全(LVSD)的AMI患者使用β-受体阻滞剂和死亡率之间的相关性。

方法:这项队列研究使用了心肌缺血国家审计项目中英格兰和威尔士注册数据。研究人员总共评估了2007年1月1日~2013年6月30日(最终随访至2013年12月31日)179810名不合并HF或LVSD的AMI住院存活者。生存时间逆概率加权倾向分数和工具变量分析用于调查β-受体阻滞剂和1年死亡率之间的相关性。

结果:91895名ST段抬高心肌梗死和87915名非ST段抬高心肌梗死患者中,分别有88542(96.4%)人和81933(93.2%)人接受了β-受体阻滞剂治疗。对于整个队列,在>163772人年的观察期,共发生9373例(5.2%)死亡。接受β-受体阻滞剂治疗者比未接受者的未调整1年死亡率低(4.9% vs 11.2%;P<0.001)。然而,进行加权和调整后,使用和不使用β-受体阻滞剂的患者间,死亡率不再具有显着性差异(平均治疗效果(ATE)系数,0.07;95% CI,-0.60~0.75;P=0.827)。对于ST段抬高心肌梗死(ATE系数,0.30;95% CI,-0.98~1.58;P=0.637)和非ST段抬高心肌梗死(ATE系数,-0.07;95% CI,-0.68~0.54;P=0.819)患者,结果相似。

结论:住院记录显示的不合并HF或LVSD的AMI住院存活者中,β-受体阻滞剂的使用与1年内任何时间的死亡风险降低不相关。

多学科讨论记实:

在这项针对急性冠状动脉综合征患者管理和结局的前瞻性、观察性队列研究中,使用单一医疗保健系统中所有医院的数据,发现不合并HF或LVSD的AMI患者β-受体阻滞剂的使用与1年内死亡风险的降低不相关。据知,这是迄今为止关于β受体阻滞剂降低无HF或LVSD的AMI患者死亡率的最大规模研究(>18万例)。在这项从MINAP国家注册管理机构的大规模、未选择的患者群体中,使用了倾向评分和工具变量分析对这一重要问题进行了分析。

在2007年至2013年期间,根据人口统计学和临床特征匹配的近17000名患者(平衡倾向评分分析)和180000名患者(工具变量分析)中,尚缺乏在无HF或LVSD的STEMI和NSTEMI患者中,在出院后1个月、6个月、1年时,β受体阻滞剂与生存之间的相关性。这些发现与近期关于合并或不合并ST段抬高型急性冠状动脉综合征患者管理指南的建议一致,当AMI合并HF发生率下降时,具有重大临床意义。

然而,国际指南在AMI后使用β-受体阻滞剂的建议有所不同,美国指南为所有AMI患者推荐这些药物,不论左心室射血分数或HF如何(I级适应证),而欧洲指南则对于不合并LVSD或HF的患者具有IIa级适应证。许多AMI的患者无论是否合并LVSD、HF或两者均不合并,均被处方β受体阻滞剂。这种做法至少部分上是具有不确定性的,因为证据表明AMI时使用β受体阻滞剂相关的临床获益是多变的、历史性的,并且对于不合并HF的AMI患者并不明确。

该研究也存在以下局限性:1、只有在住院期间的存活患者才被纳入研究,因此没有研究住院期间β受体阻滞剂的作用;2、HF或LVSD仅使用住院期间记录数据进行评估;3、本研究中没有关于停药、新的处方或出院后β受体阻滞剂剂量的信息。

原始出处:

Dondo TB, Hall M, et al. β-Blockers and Mortality After Acute Myocardial Infarction in Patients Without Heart Failure or Ventricular Dysfunction. J Am Coll Cardiol. 2017 Jun 6;69(22):2710-2720. doi: 10.1016/j.jacc.2017.03.578.

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    2018-05-18 hbwxf
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    2017-07-17 Chongyang Zhang

    签到学习了很多

    0

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