Therapie der diastolischen Herzinsuffizienz (HFpEF/HFmrEF): Lichtstreifen am Horizont?

Zusammenfassung

Eine evidenzbasierte medikamentöse Therapie der diastolischen Herzinsuffizienz (HFpEF/HFmrEF) ist bislang, im Gegensatz zur systolischen Herzinsuffizienz (HFrEF), nicht etabliert. Die ESC-Leitlinien 2016 empfehlen als einzige Substanzklasse Diuretika zur Symptomverbesserung. Betablocker, ACE-Hemmer, Angiotensin-Rezeptor-Blocker zeigen keinen belegten Nutzen im Vergleich zu Placebo. Mit Mineralokortikoid-Rezeptor-Antagonisten (MRA), Angiotensin-Rezeptor-Neprilysin-Inhibitor (ARNI)und SGLT2-Inhibitoren stehen 3 unterschiedliche Wirkmechanismen zur Verfügung, die bei HFpEF/HFmrEF bezüglich Letalität und Morbidität in randomisierten kontrollierten Studien geprüft wurden oder werden. Die bisherigen Ergebnisse sind ambivalent, in einigen Aspekten aber ermutigend. Spironolacton wird im Focused Update 2017 der ACC/AHA-Leitlinie zur Symptomverbesserung bei HFpEF zurückhaltend empfohlen (IIb B). Die FDA hat im Januar 2021 Sacubitril/Valsartan zur Therapie der HFpEF/HFmrEF (EF unterhalb des Normalbereichs) zugelassen. Für die Therapie der ATTR-Amyloidose als seltene Ursache einer schweren Compliancestörung sind extrem kostenintensive Oligonukleotid-Substanzen verfügbar.

Abstract

An evidence-based pharmacological therapy of diastolic heart failure (HFpEF/HFmrEF) is, in contrast to systolic heart failure (HFrEF), not yet established. ESC guidelines recommend diuretics as the only drug option for relief of symptoms. Betablockers, ACE-inhibitors and angiotensin receptor blockers failed to show any benefit. Mineralocorticoid receptor antagonists (MRA), angiotensin receptor blocker/neprilysin inhibitor (ARNI) and SGLT2-inhibitors have been or are tested in randomized controlled trials leading to ambiguous, in part encouraging results. The Focused Update 2017 of the ACC/AHA guidelines recommends cautiously spironolactone for symptom relief in HFpEF (IIb B). In January 2021 the FDA approved Sacubitril/Valsartan for treatment of HFmrEF/HFpEF (EF below normal). For the treatment of ATTR amyloidosis, a rare cause of severe disorder of diastolic compliance, very expensive oligonucleotid drugs are available.

Was ist wichtig?

• Diastolische Herzinsuffizienz hat vielfältige Ursachen, unterschiedliche Pathomechanismen und Manifestationen.

• Prävention und/oder Therapie auslösender Erkrankungen (u.a. arterielle Hypertonie, Diabetes) sind essenziell. Diuretika sind symptomlindernd, eine zu starke Vorlastminderung muss jedoch vermieden werden wegen des Risikos einer überschießenden Schlagvolumenabnahme.

• Spironolacton wird im Focused Update der ACC/AHA-Leitlinie Herzinsuffizienz 2017 als im Einzelfall überlegenswert (IIb B) zur Morbiditätssenkung bei HFpEF empfohlen [1]. Sacubitril/Valsartan hat trotz ambivalenter Studienergebnisse im Januar 2021 eine FDA-Zulassung zur Therapie der HFpEF/HFmrEF (EF unterhalb des Normalbereichs) erhalten. SGLT2-Inhibitoren werden in laufenden Studien geprüft.

• Bei ATTR-Amyloidose steht mit Tafamidis ein für den hereditären Typ und den Wildtyp zugelassenes, kostenintensives Medikament zur Verfügung, das die Erkrankungsprogression verlangsamt.

Schlüsselwörter

HFpEF - HFmrEF - Mineralokortikoidrezeptorantangonist MRA - Angiotensinrezeptorblocker/Neprilysininhibitor ARNI - SGLT2-Inhibitoren - Tafamidis

Keywords

HFpEF - HFmrEF - mineralocorticoid receptor antagonist MRA - angiotensin receptor blocker/neprilysin inhibitor ARNI - SGLT2 inhibitor - tafamidis

Publication History

Article published online:
06 August 2021

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