ХСН-новости

[Dr.Vad]

Шкала прогноза выживаемости

US researchers have developed a risk score for elderly patients hospitalized with heart failure (HF), after finding significant heterogeneity in their survival.

Although median survival was approximately 2.5 years, a quarter of patients died within a year, while another quarter survived more than 5 years.

The researchers say that their risk score, based on factors readily available at the time of admission, "provides a reliable estimate of prognosis."

The Washington University School of Medicine team, based in St Louis, Missouri, developed the score after conducting extended follow-up of a randomized trial in multidisciplinary HF management conducted at their institution between 1990 and 1994.

Of the 282 HF patients included, all aged 70 years or over at the start of the study, 95% died in the 14 years after enrollment, with a median survival of 894 days.

Bao Huynh and co-workers identified seven variables that independently predicted shorter survival: older age (hazard ratio [HR]=1.14 per 5 years), serum sodium levels less than 135 mEq/l (HR=1.67), coronary artery disease (HR=1.51), dementia (HR=2.02), peripheral vascular disease (HR=1.74), systolic blood pressure (HR=0.95 per 10 mmHg), and serum urea nitrogen (HR=1.20 per 10 mg/dl).

One point was assigned to each risk factor, with the sum representing the risk score.

Mortality at 1 year was 9.0% in patients with a risk score of 0-1, 22.2% in those with a score of 2-3, and 73.0% in those with a score of four or more (p<0.001).

Reporting in the Archives of Internal Medicine, the researchers say that their risk score identified patients at low, medium, and high risk of mortality.

They conclude: "The identification of patients at high risk of death within 6 months may enable clinicians to better advise patients about prognosis, adjust management accordingly, and permit consideration of palliative care in those anticipated to have particularly poor short-term survival."

Arch Intern Med 2006; 166: 1892-1898

Еще одна точка приложения триметазидина (итальянцы являются еще одним контрибьютором по клиническому применению данного препарата, как правило все публикации позитивны...):

When added to conventional treatment, long-term treatment with trimetazidine, a partial free fatty acid oxidation inhibitor, can improve functional class and left ventricular (LV) function in patients with heart failure (HF), a small Italian trial indicates.

"We believe that our data suggest that the adjunct of targeted cardiac metabolic therapy opens a new therapeutic window in the treatment of HF," the investigators write in the Journal of the American College of Cardiology.

Trimetazidine is a ketoacyl-coenzyme A thiolase inhibitor that shifts the energy substrate metabolism away from fatty acid metabolism towards glucose metabolism.

Following positive results from small studies in patients with post-ischemic HF, Gabriele Fragasso and colleagues at the Istituto Scientifico-Universita Vita/Salute San Raffaele in Milan conducted an open-label trial in 55 patients at their institution.

The participants, who all had New York Heart Association (NYHA) functional class II to IV HF, were assigned to conventional therapy, with or without trimetazidine 20 mg three times daily.

During a mean follow-up of 13 months, NYHA class improved significantly more with trimetazidine than conventional therapy alone (p<0.0001). LV end-systolic volume decreased significantly with trimetazidine from 98 ml to 89 ml and, accordingly, ejection fraction increased from 34% to 41%. Improvements were also seen in exercise tolerance, which the team attributes to improvements in LV function.

In contrast, there were no significant changes in any of these measures in the conventional therapy group.

Based on their findings, the team concludes: "We believe that the time has come to evaluate the effects of partial fatty acid oxidation inhibition in patients with HF in a multicenter, randomized, placebo-controlled trial."

J Am Coll Cardiol 2006; 48: 992-998

CVN

[Dr.Vad]

Еще один эвиденс, что статины благоприятно влияют на течение ХСН:

Circulation. 2007 Jan 29;

Effect of High-Dose Atorvastatin on Hospitalizations for Heart Failure. Subgroup Analysis of the Treating to New Targets (TNT) Study.

Khush KK, Waters DD, Bittner V, Deedwania PC, Kastelein JJ, Lewis SJ, Wenger NK.

Divisions of Cardiology, University of California, San Francisco School of Medicine, San Francisco, Calif.

BACKGROUND: Statins reduce the rate of major cardiovascular events in high-risk patients, but their potential benefit as treatment for heart failure (HF) is less clear. METHODS AND RESULTS: Patients (n=10 001) with stable coronary disease were randomized to treatment with atorvastatin 80 or 10 mg/d and followed up for a median of 4.9 years. A history of HF was present in 7.8% of patients. A known ejection fraction <30% and advanced HF were exclusion criteria for the study. A predefined secondary end point of the study was hospitalization for HF. The incidence of hospitalization for HF was 2.4% in the 80-mg arm and 3.3% in the 10-mg arm (hazard ratio, 0.74; 95% confidence interval, 0.59 to 0.94; P=0.0116). The treatment effect of the higher dose was more marked in patients with a history of HF: 17.3% versus 10.6% in the 10- and 80-mg arms, respectively (hazard ratio, 0.59; 95% confidence interval, 0.4 to 0.88; P=0.009). Among patients without a history of HF, the rates of hospitalization for HF were much lower: 1.8% in the 80-mg group and 2.0% in the 10-mg group (hazard ratio, 0.87; 95% confidence interval, 0.64 to 1.16; P=0.34). Only one third of patients hospitalized for HF had evidence of preceding angina or myocardial infarction during the study period. Blood pressure was almost identical during follow-up in the treatment groups. CONCLUSIONS: Compared with a lower dose, intensive treatment with atorvastatin in patients with stable coronary disease significantly reduces hospitalizations for HF. In a post hoc analysis, this benefit was observed only in patients with a history of HF. The mechanism accounting for this benefit is unlikely to be due primarily to a reduction in interim coronary events or differences in blood pressure.

[Gilarov]

Да уж, значительно уменьшается частота госпитализаций... Вероятность не загреметь в больницу с ХСН, принимая 10 мг аторва - 96,7%, а с 80 мг - 97,6%. С точки зрения фармакоэкономики такой подход неоправдан. Уж больно дорого. Роли статинов, как средства профилактики ИБС это не умаляет, но про ХСН я бы не стал всерьез говорить. Статья носит чисто теоретический интерес и ничего в реальной практике не меняет.

[Dr.Vad]

Уважаемый Михаил Юрьевич,

Какая ХСН, такой и абсолютный % снижения

я же скорее о тренде HR 0.75-0.8 который устойчиво просматривается на статинах по всем конечным точкам у пациентов с ХСН:


...incident statin use was associated with lower risks of death (age- and sex-adjusted rate of 14.5 per 100 person-years with statin therapy vs 25.3 per 100 person-years without statin therapy; adjusted hazard ratio, 0.76 [95% confidence interval, 0.72-0.80]) and hospitalization for heart failure (age- and sex-adjusted rate of 21.9 per 100 person-years with statin therapy vs 31.1 per 100 person-years without statin therapy; adjusted hazard ratio, 0.79 [95% confidence interval, 0.74-0.85]) even after adjustment for the propensity to take statins, cholesterol level, use of other cardiovascular medications, and other potential confounders.

JAMA. 2006 Nov 1;296(17):2105-11

или

Expert Rev Cardiovasc Ther. 2006 Nov;4(6):917-26.
Primary and secondary prevention of heart failure with statins.
Udell JA, Ray JG.
University of British Columbia, Department of Medicine, Vancouver Hospital and Health Sciences Centre, 2775 Laurel Street, Vancouver, British Columbia, V5Z 1M9, Canada.

Statins are effective in the prevention of coronary heart disease (CHD), a leading cause of heart failure (HF). Secondary analyses from 11 randomized clinical trials of patients with high-risk acute or stable coronary heart disease, but without HF, suggest that statins may prevent new-onset HF or HF-related hospitalization. In persons with established HF, several cohort studies found an approximate 35% relative risk reduction in all-cause mortality. While ongoing randomized clinical trials will help to determine the efficacy of statins in persons with established HF, it is reasonable to consider this class of medications in patients with a history of cardiovascular disease, dyslipidemia or diabetes mellitus, and who have either developed, or who remain at risk of, HF.