ACEI/ARBCEI/ARB治疗舒张性心力衰竭疗效及安全性的系统评价

Efficacy and Safety of ACEI/ARB for Patients with Diastolic Heart Failure: A Systematic Review

目的系统评价血管紧张素转化酶抑制剂/血管紧张素受体拮抗剂(ACEI/ARB)治疗舒张性心衰的疗效及安全性。方法计算机检索Pub Med、EMbase、The Cochrane Library(2014年第11期)、CNKI、Wan Fang Data、VIP和CBM数据库,搜集ACEI/ARB治疗舒张性心衰的相关随机对照试验(RCT),检索时限均为从建库至2014年11月。同时,追溯纳入研究的参考文献,以补充获取相关文献。由2位研究者按照纳入与排除标准独立进行文献筛选、资料提取和偏倚风险评价后,采用Rev Man 5.2软件进行Meta分析。结果共纳入22个研究,共计9 557例患者。Meta分析结果显示:与对照组相比,ACEI/ARB能显著改善舒张性心衰患者的运动耐量[6分钟步行距离:SMD=0.22,95%CI(0.05,0.38),P=0.01;运动时间:MD=40.58,95%CI(14.06,67.10),P=0.003]和左心室舒张功能[E/A值:MD=0.20,95%CI(0.09,0.31),P=0.000 4;E/E’值:MD=–1.69,95%CI(–2.11,–1.27),P<0.000 01],降低血浆BNP[SMD=–0.44,95%CI(–0.72,–0.16),P=0.002]和NT-pro BNP水平[SMD=–0.68,95%CI(–1.24,–0.12),P=0.02]。结论当前证据显示,ACEI/ARB能显著改善舒张性心衰患者的运动耐量、左心室舒张功能,降低血浆BNP、NT-pro BNP水平。受纳入研究质量和舒张性心衰诊断不规范的限制,上述结论尚需开展更多高质量研究加以验证。

Objective To systematically review the efficacy and safety of angiotensin-converting enzyme inhibitor（ACEI） and/or angiotensin receptor blocker（ARB） in the treatment of patients with diastolic heart failure（DHF）. Methods PubMed, EMbase, The Cochrane Library（Issue 11, 2014）, CNKI, Wan Fang Data, VIP and CBM were electronically searched from inception to November 2014 for randomized controlled trials（RCTs） of ACEI/ARB for DHF patients. References of included studies were also retrieved. Two reviewers independently screened literature according to the inclusion and exclusion criteria, extracted data and assessed the risk of bias of included studies. Then, meta-analysis was performed using Rev Man 5.2 software. Results A total of 22 RCTs involving 9 557 patients were included. The results of meta-analysis indicated that, compared with the control group, the ACEI/ARB group had significant improvements in exercise capacity（6-minute walk distance： SMD=0.02, 95% CI 0.05 to 0.38, P=0.01; Exercise time： MD=40.58, 95% CI 14.06 to 67.10, P=0.003） and diastolic function（E/A ratio： MD=0.20, 95% CI 0.09 to 0.31, P=0.000 4; E/E＇ ratio： MD = –1.69, 95% CI –2.11 to –1.27, P0.000 01）. In addition, compared with the control treatment, ACEI/ARB could significantly decrease the serum BNP level（SMD= –0.44, 95% CI –0.72 to –0.16, P=0.002） and NT-pro BNP level（SMD= –0.68, 95% CI –1.24 to –0.12, P=0.02）. Conclusion Current evidence shows that ACEI/ARB can improve the exercise capacity and diastolic function, and reduce the levels of serum BNP and NT-pro BNP in DHF patients. Due to the limited quality of the included studies and discrepancies in the diagnostic criteria of DHF, more high-quality studies are needed to verify the above conclusion.