Abstract:

Objective To retrospectively analyze the safety，efficacy of target dose candesartan in the treatment of chronic heart failure（CHF）and the factors affecting the target dose. Methods From March 2018 toDecember 2020，CHF patients with clinically stable NYHA Ⅱ - Ⅲ receiving candesartan in the outpatient departmentwere enrolled. Demographic data，drug combination therapy，echocardiographic parameters（UCG），NT-proBNP，serum creatinine and potassium were collected. According to the dose of candesartan，these patients were divided into candesartan target group（32 mg）and less than 32 mg group. Pair t-test was used to compare the difference of efficacy between groups before and after treatment. Logistic regression analysis was used to analyze the factors affecting candesartan to reach thetarget dose. Results A total of 79 patients were included in this study. The median follow-up time was 11 months. A total number of 40 patients（50.6%）reached the target dose of candesartan. The average candesartan dose of the other39 patients（49.4%）was 18.8±7.6 mg. A total of 60 patients with left ventricular ejection fraction（LVEF）less than 50% were included in this study（35 cases in the standard group and 25 cases in the substandard group）. After the candesartan treatment，the level of LVEF increase 30.7% significantly（P ＜ 0.001），and a significantly decrease of left ventricular end-diastolic diameter〔LVEDD，（67.7±9.3）mm vs（62.2±10.3）mm，P ＜ 0.01〕and left atrial diameter〔LAD，（46.2±7.3）mm vs（43.0±5.4）mm，P ＜ 0.05〕was observed in the target group. In the substandard group，LVEF increased by 15.1% comparing with the baseline（P ＜ 0.01），while the diameters of LVEDD and LAD were not significantly improved （P ＞ 0.05）. A total of 19 CHF patients with LVEF ≥ 50%（HFpEF）were included in this study. The diameters of LVEDD，LVEF，LAD，and the level of NT-proBNP improved after treatment but failed to reach the statistical significance（P ＞ 0.05）. Multivariate analysis showed that the etiology of dilated cardiomyopathy，LVEF ＜ 40% and high LAD diameter were the favorable factors for reaching the target dose of candisartan. The high level of NT-proBNP and the combined application of spironolactone negatively affected the dose reaching the standard. The diastolic blood pressure decreased significantly after treatment both in the standard group〔（83.4±12.4）mmHgvs（77.4±13.5）mmHg，P ＜ 0.05）〕and thenon-standard group〔（79.4±12.9）mmHg vs（74.2±13.1）mmHg，P ＜ 0.05）〕，while the systolic blood pressure did not decrease significantly（P ＞ 0.05）.1 patient was newly diagnosed of renal insufficiency in the standard group with creatinine of 115 μmol/L（normal value ＜ 104 μmol/L）and 4 in the substandard group（creatinine 143 μmol/L）. In the substandard group，the systolic blood pressure decreased below 90 mmHg in 1 patient. There was no hyperkalemia in both groups. Conclusion Thetarget dose of candesartan is more effective in the treatment of CHF，And the safety is satisfactory. A high level of NT-proBNPrather thana lowlevelof LVEF isthe limiting factor for candesartan toreach the targetdose

Key words:

Heartfailure, Candesartan, Compliancerate, Left ventricularejection fraction, Influencing factors

摘要：

目的 回顾性分析目标剂量坎地沙坦治疗慢性心力衰竭（chronic heart failure，CHF）的安全性、疗效以及影响药物达到目标剂量的因素。方法 选取 2018 年 3 月至 2020 年 12月在阜外华中心血管病医院门诊接受坎地沙坦治疗的临床症状稳定的 NYHA Ⅱ - Ⅲ级 CHF 患者，收集人口学资料、合并用药、超声心动图（echocardiographic parameters，UCG）指标、NT-proBNP、血肌酐和血钾。根据坎地沙坦用药情况分为坎地沙坦达标组（32 mg）和坎地沙坦不达标组（低于 32 mg），采用配对 t 检验比较各组治疗前后疗效差异，采用 Logistic 回归分析方法分析影响坎地沙坦达到目标剂量的因素。结果 共有 79 例CHF 患者纳入本研究，随访中位时间为 11 个月，其中坎地沙坦达标组 40 例（50.6%），不达标组 39 例 （49.4%），坎地沙坦应用平均剂量为（18.8±7.6）mg。本研究共纳入 60 例左心室射血分数（left ventricular ejection fraction，LVEF）＜ 50%（达标组 35 例，不达标组 25 例），达标组治疗前后 UCG 显示 LVEF 较 基 线 提 升 30.7%（P ＜ 0.001）， 左 室 舒 张 末 径（left ventricular end-diastolic diameter，LVEDD） 明 显 缩 小〔（67.7±9.3）mm 比（62.2±10.3）mm〕（P ＜ 0.01），左房内径（left atrial diameter，LAD）明显缩小〔（46.2±7.3）mm 比（43.0±5.4）mm，P ＜ 0.05）；不达标组 LVEF 较基线提升 15.1%（P ＜ 0.01），LVEDD、LAD 改善均不显著（P ＞ 0.05）。本研究纳入 LVEF ≥ 50%（HFpEF）的 CHF 患者共 19 例，治疗前后 LVEDD、LVEF、LAD、NT-proBNP 有所改善，但无统计学差异（P ＞ 0.05）。多因素分析结果表明，心衰病因为扩张型心肌病、LVEF ＜ 40%、大 LAD 是坎地沙坦达到目标剂量的有利因素 ；而NT-proBNP 水平高以及合并应用螺内酯影响剂量达标。安全性方面 ：达标组与不达标组治疗前后舒张压明显下降〔达标组 ：（83.4±12.4）mmHg 比 （77.4±13.5）mmHg（1 mmHg ＝ 0.133 kPa），不达标组（：79.4±12.9）mmHg 比（74.2±13.1）mmHg〕（P ＜ 0.05），收缩压无明显下降（P＞0.05）。达标组新发肾功能不全1例（115 μmol/L），不达标组新发4例（最高143 μmol/L）。 不达标组出现 1 例收缩压＜ 90 mmHg。两组均未出现高钾血症。结论 目标剂量坎地沙坦治疗 CHF 疗效显著、安全性良好。NT-proBNP 水平高而非 LVEF 低是限制坎地沙坦达到目标剂量的因素。 

关键词:

慢性心力衰竭 , 坎地沙坦 , 达标率 , 左室射血分数 , 影响因素