p.55 抽出テキスト
Circulation. 2022;145:e895–e1032. DOI: 10.1161/CIR.0000000000001063 May 3, 2022 e949 CLINICAL STATEMENTS AND GUIDELINES CHARM (Candesartan in Heart failure-Assessment of Reduction in Mortality and morbidity) trials, candesartan reduced risk of cardiovascular death and HF hospitalization, the risk of first HF hospitalization, and the risk of recurrent HF hospitalization.5 In a subgroup of 520 patients with LVEF 44% to 49% in a post hoc analysis of TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist), spironolactone reduced the risk of the primary composite endpoint of cardiovascular death, HF hospitalization, or resuscitated sudden death, which was mostly caused by a reduction in cardiovascular mortality with spironolactone and among patients enrolled in North and South America.6 Spironolactone is preferred among HFmrEF patients with poorly controlled hypertension given previous evidence supporting its use for blood pressure management.1 Continuation of GDMT for patients with improved HFrEF and HFmrEF is important to reduce risk of recrudescent HF.4 Meta-analyses report diverse findings with neurohormonal antagonism in patients with HFmrEF, specifying benefit in certain subgroups, underlining the heterogeneity of this phenotype.2,9 Patients with HFmrEF should have repeat evaluation of LVEF to determine the trajectory of their disease process and should undergo testing as clinically indicated to diagnose conditions warranting disease-specific therapy (eg, CAD, sarcoidosis, amyloidosis). 7.6.2 HF With Improved Ejection Fraction Recommendation for HF With Improved Ejection Fraction Referenced studies that support the recommendation are summarized in the Online Data Supplements. COR LOE Recommendation 1 B-R 1. In patients with HFimpEF after treatment, GDMT should be continued to prevent relapse of HF and LV dysfunction, even in patients who may become asymptomatic.1 Synopsis Although GDMT can result in improvement in symptoms, functional capacity, LVEF, and reverse remodeling in patients with HFrEF,2 in most patients, LV function and structural abnormalities do not fully normalize, and symptoms and biomarker abnormalities may persist or reoccur. Many patients deemed to have recovered from HF with resolution of symptoms and improvement of LVEF and natriuretic peptide levels will relapse after withdrawal of GDMT.1 Resolution of symptoms and improvement in cardiac function and biomarkers after treatment does not reflect full and sustained recovery but, rather, remission, which requires treatment to be maintained.3 Stage C HF patients are defined as patients with structural heart disease with previous or current symptoms of HF. In those patients who do not improve (ie, patients who remain symptomatic or with LV dysfunction), GDMT should not only be continued but also optimized. Recommendation-Specific Supportive Text 1. In an open-label RCT,1 phased withdrawal of HF medications in patients with previous DCM—who were now asymptomatic, whose LVEF had improved from <40% to ≥50%, whose left ventricular enddiastolic volume (LVEDV) had normalized, and who had an NT-proBNP concentration <250 ng/L— resulted in relapse of cardiomyopathy and HF in 40% of the patients within 6 months. Relapse was defined by at least 1 of these: 1) a reduction in LVEF by >10% and <50%; 2) an increase in LVEDV by >10% and to higher than the normal range; 3) a 2-fold rise in NT-proBNP concentration and to >400 ng/L; or 4) clinical evidence of HF. Treatment was withdrawn successfully in only 50% of patients.1 Secondary analyses showed worsening Kansas City Cardiomyopathy Questionnaire scores, a substantial reduction in LVEF, and nonsignificant increases in NT-proBNP and LV volumes with withdrawal of HF medications. 7.7 Preserved EF (HFpEF) 7.7.1 HF With Preserved Ejection Fraction Recommendations for HF With Preserved Ejection Fraction* Referenced studies that support the recommendations are summarized in the Online Data Supplements. COR LOE Recommendations 1 C-LD 1. Patients with HFpEF and hypertension should have medication titrated to attain blood pressure targets in accordance with published clinical practice guidelines to prevent morbidity.1–3 2a B-R 2. In patients with HFpEF, SGLT2i can be beneficial in decreasing HF hospitalizations and cardiovascular mortality.4 2a C-EO 3. In patients with HFpEF, management of AF can be useful to improve symptoms. 2b B-R 4. In selected patients with HFpEF, MRAs may be considered to decrease hospitalizations, particularly among patients with LVEF on the lower end of this spectrum.5–7 2b B-R 5. In selected patients with HFpEF, the use of ARB may be considered to decrease hospitalizations, particularly among patients with LVEF on the lower end of this spectrum.8,9 2b B-R 6. In selected patients with HFpEF, ARNi may be considered to decrease hospitalizations, particularly among patients with LVEF on the lower end of this spectrum.10,11 3: No- Benefit B-R 7. In patients with HFpEF, routine use of nitrates or phosphodiesterase-5 inhibitors to increase activity or QOL is ineffective.12,13 *See Section 7.2, “Diuretics and Decongestion Strategies in Patients with HF,” and Section 10.2, “Management of Atrial Fibrillation (AF) in HF” for recommendations for use of diuretics and management of AF in HF. Downloaded from http://ahajournals.org by on October 7, 2026