目的:β受体阻滞剂对心脏淀粉样变性(CA)的疗效尚不清楚,人们仍然担心神经激素阻滞可能会加重心力衰竭的症状。我们旨在评估β受体阻滞剂治疗是否与CA患者的生存率改善相关。
结果:我们进行了系统评价和荟萃分析,以检查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进行了搜索。从观察性研究中提取数据,并通过汇总和随机效应荟萃分析进行综合。本综述纳入了13项研究,包括4215例CA患者(3688例转甲状腺素蛋白淀粉样心肌病(ATTR-CM),502轻链淀粉样心肌病(AL-CM),未指定25岁;年龄74.8±5.5岁,76%男性)。超过一半的队列(52%)接受了β受体阻滞剂,β受体阻滞剂戒断率为28%。全因死亡率为33%(13-51%),中位随访时间为13-36个月。在任何时间点,合并的死亡风险与使用β受体阻滞剂治疗之间呈负相关(RR0.48,95%CI0.29-0.80,I2=83%,P=0.005,七项研究)。死亡率和β受体阻滞剂使用之间没有关联(RR0.65,95%CI0.29-1.47,I2=88%,P=0.30)在仅包括ATTR-CM患者的三项研究中。包括ATTR-CM和AL患者的三项研究表明,使用β受体阻滞剂与死亡率降低相关(OR0.43,95%CI0.29-0.63,I2=4%,P<0.001)。唯一一项仅包括53例AL-CM患者的研究,在能够耐受β受体阻滞剂治疗的53%患者中,患者的生存率提高(RR0.26,95%CI0.08-0.79,P=0.02).缺乏有关CA分期的信息是本研究的重要限制。
结论:β受体阻滞剂治疗可能与CA患者的生存获益相关,但是这些发现受到选择和幸存者偏见的影响。CA需要常规心力衰竭治疗的明确前瞻性随机试验。
OBJECTIVE: 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.
RESULTS: 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, I2 = 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, I2 = 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, I2 = 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.
CONCLUSIONS: 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.