With greater understanding of the impact of neuroendocrine stimulation on the adverse outcomes of heart failure, especially lethal arrhythmias and sudden cardiac death, focus has returned to the potential benefits of beta-adrenergic blockade. In patients with myocardial infarction and left ventricular (LV) dysfunction, particularly those prone to life-threatening arrhythmias, beta-blocker therapy has been associated with a lower incidence of arrhythmias and improved survival. Even in the absence of angiotensin-converting enzyme (ACE) inhibition, beta blockade has improved cardiac function and LV contractility in nonischemic heart failure, leading to a decrease in LV end-diastolic pressure and improved clinical status. Both the Metoprolol in Dilated Cardiomyopathy (MDC) trial and the Cardiac Insufficiency Bisoprolol Study (CIBIS) found beta blockade to be associated with decreased mortality rates in patients with nonischemic heart failure. Of the 3 large randomized mortality trials now under way, the Metoprolol CR/XL Randomized Intervention Trial in Heart Failure (MERIT-HF) is specifically designed to investigate the effects of beta blockade on total mortality when used as an adjunct to ACE inhibition in patients with ischemic or nonischemic heart failure. Unresolved issues to be addressed include whether(1) beta-blocker therapy in heart failure can improve survival and/or reduce the incidence of sudden cardiac death; (2) beta blockade is equally effective in ischemic and nonischemic heart failure; (3) any specific beta blocker may be better tolerated initially and cause fewer adverse effects; and (4) all beta blockers result in improved exercise tolerance and quality of life.

译文

随着对神经内分泌刺激对心力衰竭的不良后果(尤其是致命性心律不齐和心源性猝死)的影响有了更深入的了解,人们的注意力已经回到了β-肾上腺素能阻滞的潜在益处。在患有心肌梗塞和左心室(LV)功能障碍的患者中,尤其是那些容易危及生命的心律不齐的患者,β受体阻滞剂疗法与心律不齐的发生率较低和存活率提高相关。即使在没有血管紧张素转换酶(ACE)抑制的情况下,β阻滞剂也可改善非缺血性心力衰竭的心脏功能和左心室收缩能力,从而导致左心室舒张末期压力降低并改善临床状态。美托洛尔在扩张型心肌病(MDC)试验和心脏功能不全比索洛尔研究(CIBIS)中均发现,β阻滞剂与非缺血性心力衰竭患者的死亡率降低相关。在目前进行的3项大型随机死亡率试验中,美托洛尔CR / XL心力衰竭随机干预试验(MERIT-HF)是专门设计用于研究β受体阻滞剂作为患者ACE抑制的辅助药物时对总死亡率的影响缺血性或非缺血性心力衰竭。有待解决的尚未解决的问题包括:(1)心力衰竭中的β受体阻滞剂治疗是否可以提高生存率和/或减少心脏性猝死的发生率; (2)β受体阻滞剂在缺血性和非缺血性心力衰竭中均有效。 (3)任何特定的β受体阻滞剂最初可能耐受性更好,并且不良反应较少; (4)所有β受体阻滞剂均可改善运动耐力和生活质量。

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