背景:神经激素阻滞剂的综合上调针对充血发展的基本机制,可能是急性心力衰竭(AHF)后减轻充血的另一种方法。
目的:该假设在STRONG-HF(安全性,耐受性,和快速优化的功效,由心力衰竭治疗的N末端脑钠肽前体测试帮助)试验。
方法:在强HF中,AHF患者被随机分配到高强度治疗(HIC)组,采用快速上调神经激素阻滞治疗,或接受常规治疗(UC).成功的去充血被定义为没有周围水肿,肺部啰音,颈静脉压<6cm。
结果:在基线时,两组患者中相同比例的患者成功解除充血(HIC48%vsUC46%;P=0.52).在第90天,与UC组(68%)相比,HIC组(75%)的患者比例更高(P=0.0001)。在HIC臂中,充血评分的每个单独分量均显着更好(所有,P<0.05)。减轻充血的其他标志物也有利于HIC:体重减轻(调整后的平均差:-1.36kg;95%CI:-1.92至-0.79kg),N末端B型利钠肽原水平,和较低的端坐呼吸严重程度(所有,P<0.001)。尽管在第90天HIC臂中减少了loop利尿剂的平均日剂量,但仍实现了更有效的去充血。在基线时成功缓解充血的患者中,HIC臂中的那些在第90天维持充血的机会明显更好。所有受试者成功缓解充血与180天HF再入院或全因死亡的风险较低相关(HR:0.40;95%CI:0.27-0.59;P<0.0001)。
结论:在强HF中,神经激素阻滞的强化上调与第90天更有效和持续的去充血和主要终点风险较低相关.
BACKGROUND: Comprehensive uptitration of neurohormonal blockade targets fundamental mechanisms underlying development of congestion and may be an additional approach for decongestion after acute heart failure (AHF).
OBJECTIVE: This hypothesis was tested in the STRONG-HF (Safety, Tolerability, and Efficacy of Rapid Optimization, Helped by N-Terminal Pro-Brain Natriuretic Peptide Testing of Heart Failure Therapies) trial.
METHODS: In STRONG-HF, patients with AHF were randomized to the high-intensity care (HIC) arm with fast up-titration of neurohormonal blockade or to usual care (UC). Successful decongestion was defined as an absence of peripheral edema, pulmonary rales, and jugular venous pressure <6 cm.
RESULTS: At baseline, the same proportion of patients in both arms had successful decongestion (HIC 48% vs UC 46%; P = 0.52). At day 90, higher proportion of patients in the HIC arm (75%) experienced successful
decongestion vs the UC arm (68%) (P = 0.0001). Each separate component of the congestion score was significantly better in the HIC arm (all, P < 0.05). Additional markers of
decongestion also favored the HIC: weight reduction (adjusted mean difference: -1.36 kg; 95% CI: -1.92 to -0.79 kg), N-terminal pro-B-type natriuretic peptide level, and lower orthopnea severity (all, P < 0.001). More effective
decongestion was achieved despite a lower mean daily dose of loop diuretics at day 90 in the HIC arm. Among patients with successful decongestion at baseline, those in the HIC arm had a significantly better chance of sustaining
decongestion at day 90. Successful
decongestion in all subjects was associated with a lower risk of 180-day HF readmission or all-cause death (HR: 0.40; 95% CI: 0.27-0.59; P < 0.0001).
CONCLUSIONS: In STRONG-HF, intensive uptitration of neurohormonal blockade was associated with more efficient and sustained decongestion at day 90 and a lower risk of the primary endpoint.