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akinohanayuki日記

自分が興味あることを書いています. 主に感染領域. 二次利用は自己責任でお願いします. 博士(薬学). 感染制御専門薬剤師.

心不全患者のスタチン使用

スタチンは謎です

 
ひと昔前の漢方のような
期待値が大きい薬剤です
 
そこで、振り返り…
 
まずは、心不全
 
以下、UpToDateより引用

 

Despite strong evidence of benefit for statins in most subsets of patients with established cardiovascular disease, two large randomized trials found no benefit from initiating statin therapy in patients with symptomatic systolic heart failure (ischemic or nonischemic) and a mean left ventricular ejection fraction ≤33 percent.
ちな、two large randomized trialsについては、下記を見て下さい。
 
 
軽度の心不全、左室駆出率35%未満
In patients with more than mild heart failure (HF) and a left ventricular ejection fraction less than 35 percent due to either ischemic heart disease or a nonischemic cardiomyopathy, we recommend not starting statin therapy (Grade 1B). This recommendation includes patients with a nonischemic cardiomyopathy who would have otherwise met criteria for initiation of statin therapy for the purpose of primary prevention.
 
Patients with mild heart failure and a left ventricular ejection fraction less than 35 percent should receive statin therapy according to standard indications.
 
another appropriate indication 
In patients already on a statin for another appropriate indication at the time they develop HF, we suggest continuing statin therapy (Grade 2B).
 
アテローム動脈硬化性心血管疾患またはLDLコレステロールレベル
In patients with diastolic HF, the decision to start statin therapy should be based upon other indications, such as the presence of atherosclerotic cardiovascular disease or LDL-cholesterol levels above guideline cutoffs.
 
 
2大トライアルをちょこっと
 
CORONA trial

N Engl J Med. 2007;357(22):2248.

P: 5011 patients (mean age 73 years) with New York Heart Association (NYHA) class II to IV ischemic systolic HF (mean left ventricular ejection fraction [LVEF] 31 percent) 
E:  rosuvastatin 
C:  placebo 
O:  
LDL levels (76 versus 138 mg/dL [1.96 versus 3.57 mmol/L]), and also had beneficial effects on HDL-C and triglycerides.
 
Despite these biochemical changes, there was no significant reduction in the primary composite outcome of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke (11.4 versus 12.3 percent with placebo, hazard ratio [HR] 0.92, 95% CI 0.83-1.02), 
 
or secondary outcomes such as cardiovascular mortality (9.3 versus 9.6 percent, HR 0.97), or coronary events (9.3 versus 10.0 percent, HR 0.92).
 
A post-hoc, subset analysis of the 3664 patients in whom baseline N-terminal pro B-type brain natriuretic peptide (NT-proBNP) levels.Patients in the lowest tertile of NT-proBNP (less than 103 pmol/L [868 pg/mL]), which is a marker for a better prognosis, had a significantly lower primary composite end point with statin therapy (HR 0.65, 95% CI 0.47-0.88). 
 
GISSI-HF trial   

Lancet. 2008;372(9645):1231.

P: 4574 patients (mean age 68 years) with ischemic or nonischemic NYHA class II to IV HF and a mean LVEF of 33 percent 
E: rosuvastatin 10 mg daily
C:  placebo
O:  
Serum LDL cholesterol fell from 122 to 89 mg/dL (3.16 to 2.31 mmol/L) after three years of rosuvastatin compared to no significant change with placebo.
At a median follow-up of 47 months, there was no significant difference in deaths from any cause (29 versus 28 percent with placebo), or in the combined end point of death or admission to the hospital for cardiovascular causes in both ischemic (HR 1.03) and nonischemic cardiomyopathy (HR 1.02).