Evidence-Based Medical Therapy in Patients With Heart Failure With Reduced Ejection Fraction and Chronic Kidney Disease.
Evidence-Based Medical Therapy in Patients With Heart Failure With Reduced Ejection Fraction and Chronic Kidney Disease.
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DOI：
10.1161/circulationaha.121.052792
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发表时间：
2022-03
期刊：
影响因子：
37.8
通讯作者：
Damman, Kevin
中科院分区：
文献类型：
--
作者：
Beldhuis, Iris E.;Lam, Carolyn S. P.;Testani, Jeffrey M.;Voors, Adriaan A.;Van Spall, Harriette G. C.;ter Maaten, Jozine M.;Damman, Kevin
通过肾小球滤过率降低（eGFR）确定的慢性肾脏疾病（CKD）是射血分数降低（HFrEF）心力衰竭患者的常见合并症。CKD的存在与更严重的HF相关，并且CKD本身是不良心血管结局的强独立危险因素。此外，CKD的存在通常会影响开始、上调或停止可能挽救生命的HFrEF治疗的决定。由于关键性HFrEF随机临床试验历史上排除了4期和5期CKD患者（eGFR < 30 mL/min/1.73m2），因此关于HFrEF治疗在这些患者中的疗效和耐受性的信息有限。然而，最近使用新型药物的HFrEF试验纳入了更严重的CKD患者。在这篇关于HFrEF和CKD患者药物治疗的综述中，我们发现，对于全因死亡率和/或心血管（CV）死亡或HF住院治疗的联合终点，大多数药物类别在CKD 3B期（eGFR最小值30 mL/min/1.73m2）之前是安全有效的。对于更严重的CKD（4期），有证据表明钠-葡萄糖协同转运蛋白2抑制剂（SGLT 2 i）的安全性和有效性，血管紧张素转换酶抑制剂（ACEi）、vericiguat、地高辛和Omecamtiv mecarbil的安全性和有效性较低，尽管该证据仅限于CV死亡/HF住院的改善。对于任一终点，缺乏关于CKD 5期（eGFR < 15 mL/min/1.73m2或透析）中任何HFrEF治疗的安全性和有效性的数据。最后，尽管在开始几种HFrEF药物类别（ACEi/血管紧张素受体阻滞剂（ARB）/盐皮质激素受体拮抗剂（MRA）/血管紧张素受体阻滞剂脑啡肽酶抑制剂（ARNI）/SGLT 2 i）后观察到eGFR初始下降，但肾功能通常随时间稳定，药物保持其临床疗效。因此，在临床状况稳定或改善的情况下eGFR下降不应引起关注，也不应导致停止挽救生命的HFrEF治疗。
Chronic kidney disease (CKD) as identified by a reduced glomerular filtration rate (eGFR) is a common comorbidity in patients with heart failure with reduced ejection fraction (HFrEF). The presence of CKD is associated with more severe HF, and CKD itself a strong independent risk factor of poor cardiovascular outcome. Furthermore, the presence of CKD often influences the decision to start, uptitrate or discontinue possible life saving HFrEF therapies. Since pivotal HFrEF randomized clinical trials have historically excluded patients with stage 4 and 5 CKD (eGFR < 30 mL/min/1.73m2), information on the efficacy and tolerability of HFrEF therapies in these patients is limited. However, more recent HFrEF trials with novel classes of drugs, included patients with more severe CKD. In this review on medical therapy in patients with HFrEF and CKD, we show that for both all-cause mortality and/or the combined endpoint of cardiovascular (CV) death or HF hospitalization, most drug classes are safe and effective up to CKD stage 3B (eGFR minimum 30 mL/min/1.73m2). For more severe CKD (stage 4), there is evidence of safety and efficacy of sodium glucose co-transporter 2 inhibitors (SGLT2i), and to a lesser extent angiotensin converting enzyme inhibitors (ACEi), vericiguat, digoxin and omecamtiv mecarbil, although this evidence is restricted to improvement of CV death/HF Hospitalization. Data are lacking on the safety and efficacy for any HFrEF therapies in CKD stage 5 (eGFR < 15 mL/min/1.73m2 or dialysis) for either endpoint. Finally, although an initial decline in eGFR is observed upon initiation of several HFrEF drug classes (ACEi/angiotensin receptor blocker(ARB)/mineralocorticoid receptor antagonist (MRA)/angiotensin receptor blocker neprilysin inhibitor(ARNI)/SGLT2i), renal function often stabilizes over time and the drugs maintain their clinical efficacy. A decline in eGFR in the context of a stable or improving clinical condition should therefore not be cause for concern and should not lead to discontinuation of lifesaving HFrEF therapies.