Новые принципы лечения хронической сердечной недостаточности: феномен ингибиторов натрий-глюкозного котранспортера 2-го типа

Хроническая сердечная недостаточность  (ХСН) является одной из  важнейших проблем клинической кардиологии из-за высокой заболеваемости, частых госпитализаций и неблагоприятного прогноза больных. Достаточно неожиданно создававшиеся для лечения сахарного диабета ингибиторы натрий-глюкозного котранспортера 2-го типа (ИНГК2) дапаглифлозин и  эмпаглифлозин оказались эффективными средствами снижения риска неблагоприятного исхода у  пациентов с  ХСН, вошли в состав новой четырехкомпонентной терапии ХСН со сниженной фракцией выброса левого желудочка с классом рекомендаций I  и  уровнем доказательства А. Основанием для изменения клинических рекомендаций по  ХСН явились результаты крупных рандомизированных исследований DAPA-HF и EMPEROR-Reduced. Несмотря на очевидную клиническую выгоду, применения ИНГК2 при ХСН, механизмы наблюдаемых эффектов остаются предположительными и продолжают активно изучаться. В частности, в литературе обсуждается роль осмотического диуреза, снижения артериального давления и массы тела, увеличения продукции эритропоэтина, влияния на ремоделирование миокарда, модификации энергетического метаболизма сердца, ингибирования натрий-водородного обменника, аутофагии, влияния на  уровни лептина и  адипонектина. ИНГК2  присуще большинство качеств идеального средства для лечения ХСН со  сниженной фракцией выброса левого желудочка, в т. ч. единая доза без необходимости титрации, однократный прием в сутки, раннее позитивное влияние на  клинические исходы и  качество жизни, благоприятный профиль безопасности и  переносимости с  частотой серьезных побочных эффектов, не отличающийся от плацебо. При этом на выбор врачебной тактики могут повлиять особенности доказательной базы ИНГК2, в частности снижение сердечно-сосудистой и общей смертности в рандомизированном исследовании дапаглифлозина. 

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