ACEI联合ARB治疗慢性心力衰竭的Meta分析

目的系统评价联合使用血管紧张素转换酶抑制剂（ACEI）和血管紧张素Ⅱ受体拮抗剂（ARB）治疗慢性心力衰竭（CHF）的安全性和有效性。方法检索EMBase（1974-2011）、PubMed（1966-2011）、Cochrane图书馆（1995-2011）、中国期刊网数据库CNKI（1994-2011年）、VIP（1989-2011）、CBM（1978-2011）。纳入比较联合使用ACEI和ARB治疗慢性心力衰竭患者的随机对照试验,并应用RevMan5.0软件进行统计分析。结果共纳入16个随机对照试验。Meta分析结果,在左心室舒张末期内径减少量（WMD=-3.72,95%CI：-6.95～-0.48;P=0.02）,6min步行试验的增加量（WMD=25.67,95%CI：4.74～46.61;P=0.02）,心功能改善显效（RR=1.42,95%CI：1.06～1.88;P=0.02）等方面,ACEI联合ARB组显著优于单独使用ACEI组。心功能改善无效[RR=0.39,95%CI：0.22～0.71;P=0.002]方面,ACEI联合ARB组显著低于ACEI组。在左室收缩末期内径减少量、心率减少量、左室射血分数的增加量、心功能改善有效、不良反应、病死率方面,两组没有统计学差异。结论 ACEI联合ARB可显著提高6min步行的距离,改善心脏功能,而没有增加患者的不良反应和死亡率。本研究提示ACEI联合ARB可应用于慢性心力衰竭患者,但仍需高质量的前瞻性研究进一步证实。     

心力衰竭的进展(8)血管紧张素转换酶抑制剂、血管紧张素Ⅱ受体拮抗剂在心力衰竭治疗中的作用

肾素-血管紧张素-醛固酮(RAAS)的过度激活在慢性心力衰竭(心衰)的发病机制中占有重要地位,是影响预后的重要因素之一,血管紧张素转换酶抑制剂(ACEI)和血管紧张素Ⅱ受体拮抗剂(ARB)是阻断RAAS的两类重要药物,它们在心衰治疗中的作用倍受关注.大量证据均已证实ACEI是治疗心衰的基石,近年来的一些试验如VaL-HeFT、CHARM、OPTIMAA和VALIANT确定了ARB在心衰及心肌梗死后心功能不全治疗中的作用.目前推荐ARB用于心衰又不能耐受ACEI者,对于轻、中度心衰的患者,可选择ARB替代ACEI作为一线治疗药物.     

(8)血管紧张素转换酶抑制剂、血管紧张素Ⅱ受体拮抗剂在心力衰竭治疗中的作用

肾素-血管紧张素-醛固酮(RAAS)的过度激活在慢性心力衰竭(心衰)的发病机制中占有重要地位,是影响预后的重要因素之一,血管紧张素转换酶抑制剂(ACEI)和血管紧张素Ⅱ受体拮抗剂(ARB)是阻断RAAS的两类重要药物,它们在心衰治疗中的作用倍受关注。大量证据均已证实ACEI是治疗心衰的基石,近年来的一些试验如VaL-HeFT、CHARM、OFTIMAA和VALIANT确定了ARB在心衰及心肌梗死后心功能不全治疗中的作用。目前推荐ARB用于心衰又不能耐受ACEI者,对于轻、中度心衰的患者,可选择ARB替代ACEI作为一线治疗药物。     

肾素血管紧张素系统抑制剂单药或联合用药对肾病尿蛋白的影响

荟萃分析49个 RCT 比较血管紧张素Ⅱ受体拮抗剂(ARB)与血管紧张素转换酶抑制剂(ACEI)或两药联用,或与钙拮抗剂、安慰剂比较(Ann Intern Med,2008,148:30-48)。观察慢性肾病患者尿微量白蛋白的影响。研究结果:证明 ACEI 与 ARB 减少尿蛋白效果相似,ARB 比钙拮抗剂有效,ARB 与 ACEI 合用较单用一种药有效(表1)。对该文评论者认为这一荟萃分析加上伊贝沙坦治疗尿蛋白及血管事件高危病人(IMPROVE)的结果,提示在早期肾病、尿蛋白较少的情况下,单用肾素血管紧张素醛固酮系统抑制剂就够了,只有严重尿蛋白病人才需要用 ARB 加 ACEI 联合治疗,但迄今,联合治疗慢性肾病尚无安全资料,也不清楚慢性肾病进展速     

开启心力衰竭治疗的新纪元——3类神经激素拮抗剂的应用

以往心力衰竭(心衰)神经激素拮抗治疗主要阻止交感神经系统(SNS)和肾素-血管紧张素-醛固酮系统(RAAS)两个系统的致病作用,降低心衰死亡风险。保护利钠肽系统(NPS)的血管紧张素受体脑啡肽酶抑制剂(ARNI)阻止利钠肽降解,进一步降低全因死亡风险16%,开启了3类系统神经激素拮抗剂治疗心衰的新时代。指南推荐射血分数下降的心衰(HFrEF)患者使用血管紧张素转化酶抑制剂(ACEI)或血管紧张素Ⅱ受体拮抗剂(ARB)或ARNI,联合β受体阻滞剂,部分患者合用醛固酮拮抗剂,减少心衰的发病率及病死率。     

ACEI、ARB及醛固酮受体拮抗剂在心力衰竭患者中的应用

采用血管紧张素转换酶抑制剂(ACEI)、血管紧张素受体拮抗剂(ARB)或醛固酮受体拮抗剂,阻断或削弱肾素-血管紧张素-醛固酮系统的活性,是治疗慢性心力衰竭的主要策略之一。经过10多年的临床试验和实践,这3类药物的适应证和应用要点都已基本明确。ACEI是治疗慢性收缩性心力衰竭的基石和首选药物,ARB主要适用于不能耐受ACEI的患者。醛固酮受体拮抗剂的适应证为严重心力衰竭患者和心肌梗死后心力衰竭,使用时必须密切监测血钾和肌酐水平。     

解析临床试验结果思考慢性心力衰竭的药物治疗

近10年来,慢性心力衰竭（心衰）的治疗观念发生了根本的转变,治疗目标从仅仅改善血流动力学、缓解心衰症状发展到进一步改善预后——延长生存和减少住院。多项临床试验的结果一致显示,长期给予β受体阻滞剂或血管紧张素抑制剂（ACEI）和醛固酮受体拮抗剂能改善心室重构,显著降低心衰患者的死亡率和住院率。稍后于ACEI问世的血管紧张素Ⅱ受体拮抗剂（ARB）被寄托希望于对心衰患者有更好的预后改善作用,     

肾素血管紧张素系统抑制剂单药或联合用药对肾病尿蛋白的影响

荟萃分析49个RCT比较血管紧张素Ⅱ受体拮抗剂（ARB）与血管紧张素转换酶抑制剂（ACEI）或两药联用，或与钙拮抗剂、安慰剂比较（Ann Intern Med，2008，148：30-48）。观察慢性肾病患者尿微量白蛋白的影响。研究结果：证明ACEI与ARB减少尿蛋白效果相似，ARB比钙拮抗剂有效，ARB与ACEI合用较单用一种药有效（表1）。     

抑制血管紧张素系统降低心房颤动的发生:临床和实验的证据

多项临床回顾性研究表明血管紧张素转换酶抑制剂(ACEI)和血管紧张素受体阻滞剂(ARB)能降低高血压和左室肥厚、心肌梗死后左室功能异常、慢性心力衰竭患者心房颤动(AF)的发生,并且能预防电转复AF的复发。说明ACEI和ARB治疗AF危险因素的病人能获益。ACEI和ARB临床抗心律失常机理可能是通过预防基质重构介导,直接的离子通道的调节特性也可能有作用。然而,目前还没有充分的前瞻性双盲试验资料和坚实的临床证据推荐单独使用ACEI或ARB治疗去预防AF。ACEI和ARB抗心律失常机制有待进一步研究。     

血管紧张素受体脑啡肽酶抑制剂治疗伴射血分数降低的心力衰竭的安全性和有效性观察

目的:观察血管紧张素受体脑啡肽酶抑制剂(ARNI)沙库巴曲/缬沙坦在治疗伴有射血分数降低的心力衰竭(HFrEF)的安全性和有效性。方法:收集2017年12月-2018年11月于我院门诊及住院治疗的左室射血分数(LVEF)≤40%的慢性心力衰竭患者。口服沙库巴曲/缬沙坦治疗的患者设为观察组(沙库巴曲/缬沙坦+指南心力衰竭标准治疗,除外ACEI/ARB,50例);选取年龄、性别及LVEF与观察组相匹配,口服贝那普利(洛汀新)的患者设为对照组(贝那普利+指南心力衰竭标准治疗,57例);随访6～12个月,平均随访202 d。主要比较2组患者的心血管死亡事件发生率、全因死亡率及心力衰竭再住院率;同时比较2组患者的6 min步行试验、BNP及LVEF水平;以及对伴有低血压及严重肾功能不全的慢性心力衰竭患者的安全性及耐受性。结果:结果显示,与贝那普利相比,沙库巴曲/缬沙坦使终点事件相对风险降低了33%(HR=0.67,95%CI:0.46～0.87,P=0.022),其中心血管病死率(HR=0.58,95%CI:0.34～0.74,P=0.031)、因心力衰竭无计划再住院率(HR=0.65,95%CI:0.42～0.84,P=0.002)、全因死亡率(HR=0.55,95%CI:0.35～0.76,P=0.043)的发生率均明显低于对照组。试验组6 min步行试验较之基线期的增加显著大于对照组,差异有统计学意义(P0.05)。对伴有低血压及严重肾功能不全的HFrEF患者具有更好的安全性。结论:与贝那普利相比,沙库巴曲/缬沙坦在治疗HFrEF中有着良好的有效性及安全性,且临床耐受性较好。     

肾功能不全对慢性心力衰竭住院患者预后影响的回顾性分析

目的 回顾性分析肾功能不全对慢性心力衰竭(心衰)住院患者预后的影响.方法收集天津医科大学第二医院心脏科1980年1月至2007年8月慢性心衰住院病例,根据肾小球滤过率将全部患者分为A(肾功能正常)、B(肾功能轻度受损)、C(肾功能不全)三组;C组患者以入院年代分为D(1980年1月至1989年12月)、E(1990年1月至1999年12月)、F(2000年1月至2007年8月)三个亚组.分析临床特点及治疗情况.应用logistic回归法对其预后影响因素进行分析.结果分析2459例病例,其中合并肾功能不伞者714例(29.0%).与A、B组的患者相比,C组患者年龄较大,心功能较差,治疗仍以硝酸酯、利尿剂、洋地黄为主,血管紧张素Ⅱ受体拈抗剂、β受体阻滞剂、他汀类药物使用逐年代增加,血管紧张素转换酶抑制剂以20世纪90年代应用比例最高,且住院时间长、住院全因病死率高(均为P＜0.01),使用多变量分析校正其他危险因素后,肾功能不全是增加慢性心衰住院患者病死率的独立危险因素,肾小球滤过率每下降10 ml·min-1·1.73 m-2,病死率增加16.7%.结论慢性心衰合并肾功能不全的发生率较高,且住院时间长、住院病死率高,肾功能不全是增加慢性心衰患者住院病死率的独立危险因素,血管紧张素转换酶抑制剂、血管紧张素Ⅱ受体拮抗剂、β受体阻滞剂、他汀类药物的应用对于改善患者的预后可能具有重要意义.     

Effect of renin-angiotensin system inhibitors on survival in kidney transplant recipients: A systematic review and meta-analysis

Renin-angiotensin system inhibitors, specifically angiotensin II converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB), have confirmed renoprotective benefits in patients with proteinuria and hypertension. However, it remains controversial whether these agents are beneficial to kidney recipients. We conducted this meta-analysis to evaluate the effects of ACEI/ARB treatment on patient and allograft survival after kidney transplant. The PubMed, Embase and Cochrane Library databases were searched for eligible articles from before May 2016, and we included 24 articles (9 randomised controlled trials [RCTs] and 15 cohort studies with 54,096 patients), in which patient or graft survival was compared between an ACEI/ARB treatment arm and a control arm. Pooled results showed that ACEI/ARB was associated with decreased risks of patient death (relative risk [RR] = 0.64; 95% confidence interval [CI]:0.49–0.84) and graft loss (RR = 0.59; 95%CI:0.47–0.74). Subgroup analysis of the cohorts revealed significantly reduced patient death (RR = 0.61; 95%CI:0.50–0.74) and graft loss (RR = 0.58; 95%CI:0.46–0.73), but this was not seen in RCTs (patient survival: RR = 0.84, 95%CI:0.39–1.81; graft survival: RR = 0.70, 95%CI:0.17–2.79). Significantly less graft loss was noted among patients with biopsy-proved chronic allograft nephropathy (CAN) (RR = 0.26, 95%CI:0.16–0.44). Furthermore, the benefit of ACEI/ARB on patient survival (RR = 0.62; 95%CI:0.47–0.83) and graft survival (RR = 0.58, 95%CI:0.47–0.71) was limited to those with ≥3years' follow-up. ACEI/ARB decreased proteinuria (P < 0.001) and lowered haemoglobin (P = 0.002), but the haemoglobin change requires no additional treatment (from 119–131 g/L to 107–123 g/L). We therefore concluded that ACEI/ARB treatment may reduce patient death and graft loss, but additional well-designed prospective studies are needed to validate these findings.     

Adverse Events After Initiating Angiotensin-Converting Enzyme Inhibitor/Angiotensin II Receptor Blocker Therapy in Individuals with Heart Failure and Multimorbidity

BackgroundCurrent clinical practice guidelines recommend routine kidney function and serum potassium testing within 30 days of initiating angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) therapy. However, evidence is lacking on whether routine follow-up testing reduces therapy-related adverse events in adults with heart failure and if multimorbidity influences the association between laboratory testing and these adverse events.MethodsWe conducted a retrospective cohort study among adults with heart failure from 4 US integrated health care delivery systems. Multimorbidity was defined using counts of chronic conditions. Patients with outpatient serum creatinine and potassium tests in the 30 days after starting ACEI or ARB therapy were matched 1:1 to patients without follow-up tests. We evaluated the association of follow-up testing with 30-day all-cause mortality and hospitalization with acute kidney injury or hyperkalemia using Cox regression.ResultsWe identified 3629 matched adults with heart failure initiating ACEI or ARB therapy between January 1, 2005, and December 31, 2012. Follow-up testing was not significantly associated with 30-day all-cause mortality (adjusted hazard ratio [aHR] 0.45, 95% confidence interval [CI] 0.14; 1.39) and hospitalization with hyperkalemia (aHR 0.73, 95% CI, 0.33; 1.61). However, follow-up testing was significantly associated with hospitalization with acute kidney injury (aHR, 1.40, 95% CI, 1.01; 1.94). Interaction between multimorbidity burden and follow-up testing was not statistically significant in any of the outcome models examined.ConclusionsRoutine laboratory monitoring after ACEI or ARB therapy initiation was not associated with risk of 30-day all-cause mortality or hospitalization with hyperkalemia across the spectrum of multimorbidity burden in a cohort of patients with heart failure.     

内源性促红细胞生成素对慢性心力衰竭患者预后的影响

目的了解内源性促红细胞生成素(EPO)对慢性心力衰竭(CHF)患者预后的判定价值。方法选择住院的CHF患者115例,以患者是否存活分为死亡组55例,存活组60例。另选同期住院的年龄、性别相匹配的非CHF患者67例为对照组,以便建立logEPO和血红蛋白(Hb)的回归方程。对CHF患者进行全因死亡和因心力衰竭再次入院的随访观察,测定血EPO,并进行分析。结果与存活组比较,死亡组高龄患者多、心功能(NYHA)Ⅱ级比例低、Hb降低和B型钠尿肽(BNP)水平升高(P<0.01)。Kaplan-Meier生存曲线显示,贫血的CHF患者病死率增高(RR=2.50,95%CI:1.38～4.54,P=0.002)。ROC曲线评估EPO和BNP预测CHF患者死亡的最佳界值分别为44.4 U/L和752 ug/L(P=0.036,=0.000)。年龄、Hb、BNP和NYHA对CHF患者全因死亡有独立预测价值;而男性、BNP和Hb水平对因心力衰竭再次入院有独立预测价值。贫血的CHF患者EPO是独立于Hb的全因死亡的强预测指标(RR=2.86,95%CI:1.18～6.94,P=0.020)。结论贫血是CHF患者不良预后的独立预测因素。EPO是贫血CHF患者全因死亡的独立预测指标。     

老年慢性心力衰竭住院患者药物治疗情况分析

目的 了解老年心衰患者药物干预的实际情况,为临床规范化治疗提供资料和依据.方法 入选天津医科大学第二医院1973年7月至2007年7月、天津市第一中心医院1983年1月至2002年12月年龄60～98岁的心力衰竭住院患者,回顾性调查年龄、性别、病因、心功能、药用等,根据年代分为1973～1979、1980～1989、1990～1999、2000～2007年共4组,建立数据库并应用SPSS13.0软件分析.结果 入选4704例次,占同期成人心力衰竭患者(6602例次)的71.3%,男2430例次(51.7%),女2274例次(48.3%),平均年龄(71.3±7.1)岁,80～98岁的患者占12.8%(4704/6602).1973～1979、1980～1989年组前3位病因分别为肺心病、冠心病和风湿性心脏病(风心病),1990～1999、2000～2007年组的前3位病因则分别为冠心病、肺心病和风心病.心力衰竭治疗药物在4组的应用差异有统计学意义(均P<0.05),血管紧张素转换酶抑制(ACEI)+β受体阻滞剂2种药物合用、ACEI+β受体阻滞剂+醛固酮拮抗剂3药物合用也呈逐年代增加.各种药物及联合应用最多的病因分别为冠心病、风心病、肺心病及扩张型心肌病.随心功能级别的增加,利尿剂、洋地黄制剂、醛固酮拮抗剂、ACEI+β受体阻滞剂+醛固酮拮抗剂3药合用、利尿剂+洋地黄制剂+ACEI+β受体阻滞剂4药合用的应用比例增加;β受体阻滞剂以心功能美国纽约心脏病协会(NYHA)心功能分级Ⅱ级和Ⅲ级的患者应用多;ACEI在NYHA心功能分级Ⅲ级的患者应用多;血管紧张素Ⅱ受体拮抗剂(ARB)以NYHAⅢ级和Ⅳ级患者居多.结论 天津市部分医院老年心力衰竭住院患者的治疗药物以利尿剂、硝酸酯制剂和洋地黄制剂等为主;ACEI、β受体阻滞剂、ARB、醛固酮拮抗剂等药物的应用逐年代增加迅速.     

血管紧张素Ⅱ受体拮抗剂对心力衰竭患者的疗效

目的：探讨不能耐受血管紧张素转换酶抑制剂（ACEI）的慢性充血性心力衰竭（CHF）患者（NYHA分级Ⅲ～Ⅳ级,射血分数〈40％）血管紧张素Ⅱ受体拮抗剂（ARB）治疗和长期规律随访的效果。方法：前瞻性长期随访23例不能耐受ACEI的CHF患者接受ARB治疗和31例应用ACEI治疗患者的疗效,并比较两组患者的临床资料和ARB组生存患者治疗5年前后的临床资料。结果：（1）ARB组与ACEI组5年死亡率无明显差别（52．17％：48．39％,P〉0．05）;（2）ARB组中高龄、肌酐清除率（Ccr）降低的患者死亡率高（P〈0．01）;（3）ARB组中NYHA分级Ⅲ～Ⅳ级、射血分数〈40％的患者大多死于心力衰竭恶化（75％）,而猝死和明确死于室性心律失常的患者占死亡总数的25％;尽管规范地进行抗心力衰竭药物治疗。5年死亡率仍高达52．17％。长期接受ARB治疗的生存患者,其射血分数较治疗前明显增加[（32．5±1．6）％：（44．5±3．2）％,P〈0．01]、左心室舒张末期内径明显缩减[（66．3±2．0）％：（60．2±2．9）％,P〈0．05],NYHA分级显著改善（P〈0．05）。结论：部分不能耐受ACEI的CHF患者可能从ARB长期治疗中获益。     

Prognostic benefit of beta-blockers in patients not receiving ACE-Inhibitors.

AIMS: Beta-blockers (BBs) confer significant prognostic benefit in patients (pts) with systolic chronic heart failure (CHF). However, major trials have thus far studied BBs mainly in addition to ACE-Inhibitors or angiotensin receptor blockers (ARBs) as background therapy. The magnitude of the prognostic benefit of BBs in the absence of ACE-I or ARB has not as yet been determined. METHODS AND RESULTS: We performed a meta-analysis of all placebo-controlled BB studies in patients with CHF (n>200). Trials were identified via Medline literature searches, meeting abstracts, and contact with study organizations. Results for all-cause mortality and death or heart failure hospitalization were pooled using the Mantel-Haenszel (fixed effects) method. The impact of BB therapy on all-cause mortality in CHF, in the absence (4.8%) and presence (95.2%) of ACE-I (or ARB), was determined from six trials of 13 370 patients. The risk ratio (RR) for BBs vs. placebo was 0.73 [95% confidence interval (CI) 0.53-1.02] in the absence of ACE-I or ARB at baseline, compared with a RR of 0.76 (95% CI 0.71-0.83) in the presence of these agents. When ACE-Inhibitors were analysed in the same way (pre-BB), a RR of 0.89 (0.80-0.99) vs. placebo was observed in studies of >90 days. The impact of BB therapy on death or HF hospitalization in systolic CHF, in the absence and presence of ACE-I, was determined from three trials of 8988 patients. The RR for BBs vs. placebo was 0.81 (95% CI 0.61-1.08) in the absence of ACE-I or ARB at baseline, compared with a RR of 0.78 (95% CI 0.74-0.83) in the presence of these agents. When ACE-Is were analysed in the same way (pre-BB), a RR of 0.85 (95% CI 0.78-0.93) vs. placebo was observed in studies of >90 days. CONCLUSION: The magnitude of the prognostic benefit conferred by BBs in the absence of ACE-I appears to be similar to those of ACE-Is in systolic CHF. These data therefore suggest that either ACE-Is or BBs could be used as first-line neurohormonal therapy in patients with systolic CHF. Prospective studies directly comparing these agents are required to definitively address this issue.     

强化门诊随访对心力衰竭患者预后及依从性的影响

目的 评估强化门诊随访对慢性心力衰竭(心衰)患者预后及依从性的影响.方法 回顾分析333例心衰患者门诊诊治情况,按其是否定期于心衰门诊随访,分为强化门诊随访组(随访组)和常规治疗组(常规组).调查患者预后、药物治疗情况、生活质量和医疗费用.结果 随访组患者死亡与再住院率联合终点显著低于常规组(42.59%比66.67%,P<0.05);随访组患者死亡显著低于常规组(1.85%比14.35%,P<0.05);血管紧张索转换酶抑制剂/血管紧张素Ⅱ受体拮抗剂的处方率、达靶剂量率显著高于常规组(86.79%比40.54%,P<0.05;17.92%比8.65%,P<0.05);β受体阻滞剂处方率、达靶剂量率显著高于常规组(89.62%比46.49%,P<0.05;17.92%比1.62%,P<0.05).随访组患者生活质量较高(明尼苏达心衰生活质量问卷评分30.7比37.7,P<0.05),平均医疗费用节省3821.51元.结论 强化心衰门诊随访可以促进有循证医学证据的药物治疗,降低心衰患者的病死率和再入院率,改善生活质量并降低医疗费用.     

Impacto de los inhibidores de la enzima de conversión de la angiotensina y los antagonistas del receptor de la angiotensina II en la COVID-19 en una población occidental. Registro CARDIOVID

Introduction and objectivesCoronavirus disease (COVID-19) has been designated a global pandemic by the World Health Organization. It is unclear whether previous treatment with angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) affects the prognosis of COVID-19 patients. The aim of this study was to evaluate the clinical implications of previous treatment with ACEI/ARB on the prognosis of patients with COVID-19 infection.MethodsSingle-center, retrospective, observational cohort study based on all the inhabitants of our health area. Analyses of main outcomes (mortality, heart failure, hospitalization, intensive care unit [ICU] admission, and major acute cardiovascular events [a composite of mortality and heart failure]) were adjusted by multivariate logistic regression and propensity score matching models.ResultsOf the total population, 447 979 inhabitants, 965 patients (0.22%) were diagnosed with COVID-19 infection, and 210 (21.8%) were under ACEI or ARB treatment at the time of diagnosis. Treatment with ACEI/ARB (combined and individually) had no effect on mortality (OR, 0.62; 95%CI, 0.17-2.26; P = .486), heart failure (OR, 1.37; 95%CI, 0.39-4.77; P = .622), hospitalization rate (OR, 0.85; 95%CI, 0.45-1.64; P = .638), ICU admission (OR, 0.87; 95%CI, 0.30-2.50; P = .798), or major acute cardiovascular events (OR, 1.06; 95%CI, 0.39-2.83; P = .915). This neutral effect remained in a subgroup analysis of patients requiring hospitalization.ConclusionsPrevious treatment with ACEI/ARB in patients with COVID-19 had no effect on mortality, heart failure, requirement for hospitalization, or ICU admission. Withdrawal of ACEI/ARB in patients testing positive for COVID-19 would not be justified, in line with current recommendations of scientific societies and government agencies.     

A randomized trial of the efficacy of multidisciplinary care in heart failure outpatients at high risk of hospital readmission

OBJECTIVES: We sought to determine whether a multidisciplinary outpatient management program decreases chronic heart failure (CHF) hospital readmissions and mortality over a six-month period. BACKGROUND: Hospital admission for CHF is an important problem amenable to improved outpatient management. METHODS: Two hundred patients hospitalized with CHF at increased risk of hospital readmission were randomized to a multidisciplinary program or usual care. A study cardiologist and a CHF nurse evaluated each patient and made recommendations to the patient's primary physician before randomization. The intervention team consisted of a cardiologist, a CHF nurse, a telephone nurse coordinator and the patient's primary physician. Contact with the patient was on a prespecified schedule. The CHF nurse followed an algorithm to adjust medications. Patients in the nonintervention group were followed as usual. The primary outcome was the composite of the number of CHF hospital admissions and deaths over six months, compared by using a log transformation t test by intention-to-treat analysis. RESULTS: The median age of the study patients was 63.5 years, and 39.5% were women. There were 43 CHF hospital admissions and 7 deaths in the intervention group, as compared with 59 CHF hospital admissions and 13 deaths in the nonintervention group (p = 0.09). The quality-of-life score, percentage of patients on target vasodilator therapy and percentage of patients compliant with diet recommendations were significantly better in the intervention group. Cost per patient, in 1998 U.S. dollars, was similar in both groups. CONCLUSIONS: This study demonstrates that a six-month, multidisciplinary approach to CHF management can improve important clinical outcomes at a similar cost in recently hospitalized high-risk patients with CHF.