PDF(Pubmed)
Abstract：
Modification of guideline-directed medical therapy (GDMT) in hospitalized patients with heart failure (HF) has not been extensively evaluated.
The community surveillance arm of the Atherosclerosis Risk in Communities Study identified 6959 HF hospitalizations from 2005-2011. Predictors of GDMT modification and survival were assessed using multivariable logistic regression and Cox proportional hazards models.
For 5091 hospitalizations, patient mean age was 75 years, 53% were female, 69% were white, and 81% had acute decompensated heart failure (ADHF). Regarding ejection fraction (EF), 31% of patients had HF with reduced EF (HFrEF), 24% had HF with preserved EF (HFpEF), and 44% were missing EF values. At admission, 52% of patients received angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs), 66% β-blockers (BBs), 9% aldosterone-receptor antagonists, 16% digoxin, 10% hydralazine, and 29% nitrates. Modification of GDMT occurred in up to 23% of hospitalizations. Significant predictors of GDMT initiation included ADHF and HFrEF; discontinuation of medications was observed with select comorbidities. In HFrEF, initiation of any GDMT was associated with reduced 1-year all-cause mortality (adjusted hazard ratio [HR] 0.41, 95% confidence interval [CI] 0.23-0.71) as was initiation of ACEI/ARBs, BBs, and digoxin. Discontinuation of any therapy versus maintaining GDMT was associated with greater mortality (HR 1.30, 95% CI 1.02-1.66). Similar trends were observed in HFpEF.
Our study suggests that GDMT initiation is associated with increased survival, and discontinuation of therapy is associated with reduced survival in hospitalized patients with HF. Future studies should be conducted to confirm the impact of GDMT therapy modification in this population.
The community surveillance arm of the Atherosclerosis Risk in Communities Study identified 6959 HF hospitalizations from 2005-2011. Predictors of GDMT modification and survival were assessed using multivariable logistic regression and Cox proportional hazards models.
For 5091 hospitalizations, patient mean age was 75 years, 53% were female, 69% were white, and 81% had acute decompensated heart failure (ADHF). Regarding ejection fraction (EF), 31% of patients had HF with reduced EF (HFrEF), 24% had HF with preserved EF (HFpEF), and 44% were missing EF values. At admission, 52% of patients received angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs), 66% β-blockers (BBs), 9% aldosterone-receptor antagonists, 16% digoxin, 10% hydralazine, and 29% nitrates. Modification of GDMT occurred in up to 23% of hospitalizations. Significant predictors of GDMT initiation included ADHF and HFrEF; discontinuation of medications was observed with select comorbidities. In HFrEF, initiation of any GDMT was associated with reduced 1-year all-cause mortality (adjusted hazard ratio [HR] 0.41, 95% confidence interval [CI] 0.23-0.71) as was initiation of ACEI/ARBs, BBs, and digoxin. Discontinuation of any therapy versus maintaining GDMT was associated with greater mortality (HR 1.30, 95% CI 1.02-1.66). Similar trends were observed in HFpEF.
Our study suggests that GDMT initiation is associated with increased survival, and discontinuation of therapy is associated with reduced survival in hospitalized patients with HF. Future studies should be conducted to confirm the impact of GDMT therapy modification in this population.
摘要：
在心力衰竭（HF）住院患者中指南指导的药物治疗（GDMT）的修改尚未得到广泛评估。
社区动脉粥样硬化风险研究的社区监测部门从2005-2011年确定了6959例HF住院。使用多变量逻辑回归和Cox比例风险模型评估GDMT修饰和生存的预测因子。
5091例住院,患者平均年龄为75岁,53%是女性，69%是白色的，81%患有急性失代偿性心力衰竭(ADHF)。关于射血分数（EF），31％的患者有HF降低EF（HFrEF），24%患有HF并保留EF（HFpEF），44％的人缺少EF值。入院时,52％的患者接受了血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂（ACEI/ARBs），66%β受体阻滞剂（BBs），9%醛固酮受体拮抗剂，16%地高辛,10%肼屈嗪,和29%的硝酸盐。GDMT的改变发生在高达23%的住院患者中。GDMT启动的重要预测因素包括ADHF和HFrEF；观察到药物停药并伴有选择性合并症。在HFrEF,任何GDMT的开始与1年全因死亡率降低相关(调整后的风险比[HR]0.41,95%置信区间[CI]0.23-0.71),BBs,还有地高辛.停止任何治疗与维持GDMT与更高的死亡率相关(HR1.30,95%CI1.02-1.66)。在HFpEF中观察到类似的趋势。
我们的研究表明GDMT启动与生存率增加有关，并且停止治疗与HF住院患者的生存率降低相关。未来的研究应该进行，以确认GDMT治疗改变对该人群的影响。
社区动脉粥样硬化风险研究的社区监测部门从2005-2011年确定了6959例HF住院。使用多变量逻辑回归和Cox比例风险模型评估GDMT修饰和生存的预测因子。
5091例住院,患者平均年龄为75岁,53%是女性，69%是白色的，81%患有急性失代偿性心力衰竭(ADHF)。关于射血分数（EF），31％的患者有HF降低EF（HFrEF），24%患有HF并保留EF（HFpEF），44％的人缺少EF值。入院时,52％的患者接受了血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂（ACEI/ARBs），66%β受体阻滞剂（BBs），9%醛固酮受体拮抗剂，16%地高辛,10%肼屈嗪,和29%的硝酸盐。GDMT的改变发生在高达23%的住院患者中。GDMT启动的重要预测因素包括ADHF和HFrEF；观察到药物停药并伴有选择性合并症。在HFrEF,任何GDMT的开始与1年全因死亡率降低相关(调整后的风险比[HR]0.41,95%置信区间[CI]0.23-0.71),BBs,还有地高辛.停止任何治疗与维持GDMT与更高的死亡率相关(HR1.30,95%CI1.02-1.66)。在HFpEF中观察到类似的趋势。
我们的研究表明GDMT启动与生存率增加有关，并且停止治疗与HF住院患者的生存率降低相关。未来的研究应该进行，以确认GDMT治疗改变对该人群的影响。
